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Physicians Who Don’t Keep Medical Knowledge Current More Likely to Over-Prescribe Opioids for Back Pain


Researchers from Harvard University and the American Board of Internal Medicine found better test-takers wrote less pain pill prescriptions

Philadelphia, PA, July 1, 2021 – During a period of growing concern over addiction to opioids and a shift in recommended guidelines, physicians with higher clinical knowledge scores on the ABIM Maintenance of Certification (MOC) exam wrote fewer opioid prescriptions (especially high dose, long-use prescriptions, such as Oxycontin) for back pain than those who scored lower on the exam, according to a recent study by researchers from the American Board of Internal Medicine (ABIM) and Harvard School of Public Health.

Published on July 1, 2021 in JAMA Open, the study of 10,246 mid-career general internists suggests that those who scored higher on the exam may have been more aware of guideline changes that warned against dangers surrounding the over-prescription of opioids (such as OxyContin) for musculoskeletal pain, and reduced prescriptions accordingly.

The study notes that doctors cut back prescribing between 2015-2017 (when the opioid epidemic was declared a public health emergency, and opioid prescription guidelines shifted). Fifty-two thousand Americans died from drug overdoses in 2015, and 64,000 more died the following year.

From 2009-2017, opioids were prescribed in 21.6% of 55,387 new onset low back pain office visits, a clinical scenario targeted because guidelines advise explicitly against opioids as first-line therapy. Between 2015-2017, when information about the scope of the opioid epidemic became known and guidelines changed, physicians who scored in the top versus bottom quartile on ABIM’s MOC exam were 20 percent less likely to prescribe opioids. There was little difference in opioid prescribing by physician exam performance from 2009-2014, before the guidelines changed. Researchers concluded the higher the score on the exam, the fewer opioid prescriptions for new onset lower back pain complaints were written.

“As the ugly head of the opioid crisis re-emerges, this paper reminds us of the crucial role that primary care physicians play in terms of prescribing opioids, and how responsiveness to guideline changes is contingent on keeping current with medical knowledge advocated by organizations, such as ABIM, through their MOC exam,” said Bradley M Gray, PhD, lead author on the study and ABIM Senior Health Services researcher.

Michael Barnett, MD, from the Harvard T.H. Chan School of Public Health, senior author on the study said, “our study reinforces that physicians with greater clinical knowledge were more likely to change their behavior to match evolving clinical guidelines around opioid prescribing. Yet, even physicians who scored in the top quartile of ABIM’s exam prescribed opioids at disappointingly high rates given that they are not first-line therapy for back pain. This finding suggests that more targeted interventions are also required.”

In addition to this study, researchers from Harvard, the Mayo Clinic and ABIM recently published a study in BMJ Open that showed patients treated by physicians who score well on diagnostic related questions on the ABIM MOC exam, were at significantly lower risk for death, ED and hospitalization after a visit at risk for diagnostic error. “Taken together these studies tell us that a well written standardized exam can tell you a lot about a physician,” Dr. Gray said.

ABIM Board Certified Doctors Make a Difference
Internists and subspecialists who earn and maintain board certification from the American Board of Internal Medicine (ABIM) differentiate themselves every day through their specialized knowledge and commitment to continual learning in service of their patients. Established as an independent nonprofit more than 80 years ago, ABIM continues to be driven by doctors who want to achieve higher standards for better care in a rapidly changing world. Visit ABIM's blog to learn more and follow ABIM on Facebook, Twitter and Instagram. ABIM is a member of the American Board of Medical Specialties.