Pain patients who take opioids can't get in the door at over half of primary care clinics

Stigma against long-term users of prescription opioids, likely related to the prospect of taking on a patient who might have an opioid use disorder or addiction, appears to play a role, the University of Michigan research suggests.

Simulated patients who said their doctor or other primary care provider had retired were more likely to be told they could be accepted as new patients, compared with those who said their provider had stopped prescribing opioids to them for an unknown reason.

The U-M primary care provider and health care researcher who led the new study, Pooja Lagisetty, M.D., M.Sc., hopes that her team's new findings published in the journal Pain could help primary care clinics look at their practices regarding existing or prospective new patients.

"We need to make sure we're training prescribers and their teams in addressing the systemic biases that this research highlights," says Lagisetty, a general internal medicine physician at Michigan Medicine, U-M's academic medical center. "We shouldn't even be thinking about the reason that patients are giving when they seek to access care.

"Even if you think that someone is using opioids for a reason other than pain, or that long-term opioids are not an effective pain care strategy, those are exactly the patients we in primary are should be seeing," she adds. "Restricting their primary care access limits their ability to engage in pain-focused care and potentially addiction-focused care."

It also worsens stigma, she says, by suggesting that people using opioids for pain are more worthy of receiving care than those who may have addiction.

She and her colleagues had seen signs of stigma against patients on long-term opioids for non-cancer pain in a previous study that used the "secret shopper" technique to call clinics in Michigan. But the new study takes that to a new level, with data from 452 clinics in nine states.

Each clinic responded to two calls, separated by time, from a female caller who asked if the clinic was taking new patients, said she was covered by a major insurer in the area, and said she had been taking opioids for years for pain. Depending on the call, she then either said that her last provider had retired or stopped prescribing opioids, leading her to seek a new primary care clinic and asking if their providers would potentially continue to prescribe opioids after a visit.

All of the clinics included in the study said they were taking new patients, but when the patient mentioned wanting to receive opioids, 43% of the clinics said they were no longer willing to schedule the appointment.

"This suggests that many clinics are likely just shutting their door to any patient needing an opioid prescription despite the reason for needing a new provider," says Lagisetty, who is also a member of the U-M Institute for Healthcare Policy and Innovation. "Clinics often stated to the patient that this was due to new policies, fear of legal ramifications, or administrative burdens."

She adds that barriers to treating opioid addiction in a primary care setting, including the special training needed to prescribe buprenorphine and the added support needed to help patients receiving medications for opioid use disorder, may have contributed to this. Recent signs that the federal requirements may be relaxed could help change this, but only if primary care providers receive help and training in providing this kind of care.

Nearly one-third (32%) of the clinics said they would schedule the patient for an appointment and the primary care provider would potentially continue to prescribe opioids, no matter which scenario the patient gave.

But the remaining 25% of clinics gave mixed signals when called twice. In those clinics, patients had nearly 2 times the likelihood of getting scheduled if their prior physician had retired as compared to those who said their last doctor had stopped prescribing for unknown reasons.

"In these cases, where clinics gave different answers depending on the scenario presented, it is harder to argue that stigma around opioid use, pain, and addiction is not playing a role in clinic decision-making," says Lagisetty.