Opioid Analgesics Prescription to End-of-Life Cancer Patients: Characteristics,Attitudes,and Practices of French General Practitioners

Abstract

Background:

Pain management, especially at the end of life, varies depending on the prescriber's characteristics and attitudes. Little is known about the practices of general practitioners (GPs) regarding end-of-life management for patients with cancer.

Objectives:

To provide an overview of the characteristics associated with GPs' attitudes and practices regarding opioids prescribing and to explore GPs' perceived role and difficulties in managing end-of-life care for patients with cancer.

Design:

A cross-sectional study (December 2015 to March 2016).

Subjects and Analyses:

Data were collected from a representative sample of 376 GPs in southeastern France recruited to participate in a survey on medical practices and opinions regarding cancer patient management. Descriptive analyses and multivariate logistic regressions were conducted to study the characteristics, attitudes, and practices associated with GPs' opioids prescribing attitudes.

Results:

Almost 97% of GPs stated that they prescribe opioids to end-of-life cancer patients. Among these, 77% said that they prescribe opioids on their own initiative, while 23% declared doing so in coordination with a specialist team. Female GPs, GPs working in solo practices, and GPs reporting more difficulties in managing end-of-life cancer patients were significantly less likely to prescribe opioids on their own initiative.

Conclusion:

Our results suggest that GPs' characteristics and practices influence the prescribing attitudes at the end of life. Given the dearth of studies on this topic, further research is recommended to better understand the impact of GPs' characteristics on their prescriptive attitudes. The possible interactions between patients' and physicians' characteristics—in particular gender—should also be investigated.

Introduction

Pain is a key symptom that has a significant impact on the quality of life and well-being in patients with cancer.¹ The subjective and multidimensional nature of cancer pain (CP), including its physical, social, psychological, and spiritual components,² make its assessment and management especially challenging.³ The most commonly used guidelines to relieve this symptom were established by the World Health Organization (WHO) and comprise a three-step “ladder” approach: nonopioids or step I analgesics for mild pain, weak opioids or step II analgesics for moderate pain, and strong opioids or step III analgesics for severe pain.⁴ Morphine, a strong opioid, is considered to be the standard opioid and the first-choice drug for moderate to severe CP relief,^5,6 especially for end-of-life pain.⁷ However, the international literature reveals that pain is often inadequately controlled and remains undertreated in cancer patients, particularly at the end of life.^8–11

CP management is a multidimensional problem since both the assessment of CP and its response to management can be affected by the patient, the healthcare professional, and the interaction between the two.² Physicians play a key role in CP management. Nevertheless, lack of knowledge concerning pain management,^12–14 inadequate assessment of pain, reluctance to prescribe opioids, and fear of patient addiction may constitute barriers to effective pain relief.^2,15,16 Moreover, distrust toward pain medication may be more marked in specific contexts such as end-of-life situations because of the significant emotional burden placed on physicians and patients and family members.^7,17

The management of end-of-life cancer patients has been the subject of numerous studies in recent years. Yet, while the subject has been widely investigated in specialized settings, less is known about the daily practices of general practitioners (GPs). In France, GPs are now among the key professionals involved in the management of cancer patients¹⁸—including at the end of life, given that a majority of patients prefer to end their days at home.¹⁹ This justifies our interest in studying the role of GPs in managing pain, in end-of-life situations.

According to the French guidelines for CP management, GPs are responsible for the evaluation and management of pain.²⁰ However, at both the French²⁰ and international levels,^21,22 it is recommended to request an additional diagnostic and/or therapeutic advice from a specialist team, especially when managing severe forms of pain. The French High Health Authority nevertheless allows GPs to prescribe strong opioids to cancer patients without consulting a specialist team²³ (i.e., multidisciplinary team for the evaluation and treatment of chronic pain comprising neurologist, oncologist, psychiatrist, and other specialists).^24,25

In practice, strong opioid prescriptions in France must be made on secure prescription forms (i.e., prescriptions using natural white watermarked paper, preprinted mentions in blue, and so on²⁶) and the duration of treatment cannot exceed 28 days.²⁷ Other opioids (e.g., oxycodone, fentanyl) besides morphine may be prescribed, especially when the side effects of morphine no longer make it possible to maintain effective daily doses.

The increase in opioids prescribing in France over the last few decades^28,29 may reflect better acceptance of opioids among GPs. In this regard, our hypothesis was that almost all GPs in our study would be prone to prescribe opioids. The issue, then, was to determine whether they did so on their own or after conferring with a specialist team.

Objectives

This study aimed to identify GPs' attitudes and practices regarding the prescription of opioids to end-of-life cancer patients. It also sought to explore GPs' perceived role and difficulties in managing end-of-life cancer patients.

Methods

Population

The survey was conducted as part of a national panel designed to regularly collect data on French private GPs' medical practices, working conditions, and opinions regarding public health regulatory policies. The research design of the panel has been detailed elsewhere.^30,31 Between November 2013 and March 2014, GPs were randomly selected from the Ministry of Health's exhaustive database of health professionals in France. The sample was stratified for gender, age, workload (obtained from the reimbursement database of the National Health Insurance Fund), and density of city of practice. Among the 1229 eligible GPs, working in southeastern France, 40% completed the inclusion questionnaire and committed to participating in a telephone interview every six months, without knowing the topic in advance. The National Authority for Statistical Information (Commission Nationale de l'Information Statistique) approved the panel (ref: no. 82/H030).

The present study on the management of end-of-life cancer patients was conducted between December 2015 and March 2016. Physicians working in southeastern France still eligible at the end of 2015 (n = 475) were invited to participate. Those who died, retired, moved, or were absent for a long time were deemed no longer eligible to participate in the survey.

Procedure and questionnaire

Physician volunteers were surveyed using computer-assisted telephone interviews.

In addition to sociodemographic data and professional characteristics of GPs, the KABP (Knowledge, Attitude, Beliefs, and Practices) questionnaire collected information on GPs' training in oncology, participation in palliative or oncological care networks, and sources for cancer-related information. The questionnaire gathered information on GPs' attitudes and practices regarding the prescription of opioids to end-of-life cancer patients (i.e., Do you prescribe opioids to your end-of-life cancer patients? [1] Yes, on my own initiative; [2] Yes, in coordination with a specialist team; or [3] Never). Note that this question was rather general with no distinction regarding dosage forms (e.g., injectable versus oral opioids). Questionnaire also collected information on whether GPs' patients rejected morphine due to its long-term side effects (i.e., Have your patients rejected morphine due to its long-term side effects?). Other questions dealt with GPs' perceived role and difficulties in different aspects of cancer patient management (i.e., pain management, psychological support to patients, social support, end-of-life care, and psychological support to families), and in particular at the end of life (i.e., pain management, management of other symptoms, psychological support to patients, and psychological support to families). GPs were also asked about their participation (recommended but not obligatory) in oncology multidisciplinary consultation meeting where specialist physicians decide on the individual treatment plans for patients with cancer. Finally, GPs were asked how many new cancer patients they had seen in 2015.

Statistical analyses

Weighting method

To ensure that the regional sample of the survey is representative of all private GPs working in southeastern France weighting adjustment was conducted regarding four characteristics: gender; age; the density of GPs in the city of practice³²; and the number of office consultations and house calls made between December 2011 and November 2012.

Variables

Dependent variable: attitudes/practices regarding opioids prescription oppose GPs who prescribe opioids on their own initiative to those who prescribe opioids in coordination with a specialist team.

Explanatory variables: a score was constructed by adding together the answers to four questions concerning GPs' perceived difficulties in managing end-of-life cancer patients. The higher the score, the more the GPs' perceived difficulties were important. Another score was constructed by adding together the answers to five questions concerning GPs' perceived role in managing cancer patients. The higher the score, the more the GP considered that he/she had an important role to play. In both cases, scores were not computed when at least one answer was missing. Cronbach's alpha tests were carried out to assess internal consistency for both constructed scores, a value of alpha ranging between 0.7 and 0.95 was considered as acceptable.³³ Moreover, we constructed indicator variables by incorporating information on GPs' practice schedule, opinion on morphine side effects, and training in oncology.

Statistics

Data were summarized using percentages for categorical variables and mean (SD) for continuous data. First, we compared the distribution of GPs' sociodemographic and professional characteristics between prescribers and nonprescribers. Second, we conducted univariate logistic regression analyses to determine the characteristics (gender, age), attitudes, and practices associated with GPs' prescription of opioids to end-of-life cancer patients. Variables significantly associated with a p < 0.20 in univariate analyses were selected for the multivariate model. Final regression model was selected by forward stepwise selection procedure (probability threshold = 20%, probability of staying in the model = 5%). All analyses were performed using STATA version 12 (STATA Corp, College Station, TX).

Results

Sample selection

Overall, 376 GPs were surveyed (with a participation rate of 82.0%), and 361 (95.9%) answered questions concerning the prescription of opioids to end-of-life cancer patients. Among them, only 2.7% have declared that they never prescribe opioids. When comparing prescribers and nonprescribers baseline characteristics, no statistical differences were observed. Indeed, nonprescribers were subsequently excluded from the analyses. Final analyzed sample included 351 GPs.

Sample characteristics

Sociodemographic and professional characteristics of opioids prescribers are detailed in Table 1: 29.7% of GPs were women; mean age was 56.5 years; and 20.5% of them think that “Patients who use morphine for their CP reject it due to its long-term side effects” whereas 68.8% disagreed with this statement and 10.7% neither agreed nor disagreed (Table 2).

Table 1.

Sociodemographic and Professional Characteristics of Southeastern France General Practitioners Who Prescribe Opioids

	n = 351
Gender (%)
Female	29.7
Male	70.3
Age at interview, mean (SD)	56.5 (9.1)
Density of GPs in the city of practice^a (%)
Low	9.8
Intermediate	64.7
High	25.5
2012 workload (%)
Low	32.5
Intermediate	49.3
High	18.2
Type of practice (%)
Solo (or individual practice)	47.5
Group practice, other type of practice^b	52.5
Practice schedule^** (%)
Full private practice	93.0
Part-time private practice	5.1
Private practice with part-time hospital practice	1.9
Place of practice
Urban	95.6
Rural	4.4
No. of terminally ill cancer patients receiving home care in the two years preceding the survey^*** (%)
<10	73.7
10–19	20.2
20 or more	6.1
No. of new cancer patients seen in 2015^** (%)
0–10	64.1
More than 10	35.9

Density indicator for the number of GPs in every city, expressed as a percentage variation from the French national averagez

Mainly centers that bring together several GPs endorsed by the regional health agencies.

Missing data or no response: ^** ≥1% and <10%, ^*** ≥10%.

GPs, general practitioners.

Table 2.

Attitudes and Practices of Southeastern France General Practitioners Regarding End-of-Life Cancer Management

	n = 351
Prescribe opioids (%)
On their own initiative	77.0
In coordination with a specialist team	23.0
Have already participated in a MCM for cancer patients^a (%)
Yes	14.0
No	86.0
“Patients reject morphine due to its long-term side effects”^* (%)
Agree	20.5
Neither agree nor disagree	10.7
Disagree	68.8
Member of cancer or palliative care network (%)
Yes	6.0
No	94.0
Occasional practice of homeopathy or acupuncture^* (%)
Yes	20.6
No	79.4
Have a referral specialist for advice on pain management^* (%)
Yes	76.7
No	23.3
Training in oncology^* (%)
Complementary diploma or training related to oncology and continuing oncological training sessions (at least one over the last 5 years).	11.2
Complementary diploma or training related to oncology only	2.0
Continuing oncological training sessions only	54.5
None	32.3
Sources of information for cancer care:
Specialists (oncologists and hematologists)^** (%)	89.6
National medical literature^** (%)	76.4
National good practice guidelines^** (%)	52.3
Regional good practice guidelines^** (%)	51.5
International medical literature ^** (%)	21.3

Meetings at which specialists from different disciplines engage in formal discussions over diagnostic and therapeutic strategies in oncology.

Missing data or no response: ^*<1%, ^** ≥1% and <10%, ^*** ≥10%.

MCM, multidisciplinary consultation meeting.

Perceived role and difficulties

Table 3 details GPs' perceived role in managing cancer patients. More than 80% of GPs described their role in managing pain, managing end-of-life care, providing psychological support to patients, and providing psychological support to relatives as important or very important. GPs also perceived their role in providing social support as important, but to a lesser degree (67.6%).

Table 3.

Perceived Role of Southeastern France General Practitioners in Managing Cancer Patients

GPs' perceived role (%)	Slightly important	Fairly important	Important	Very important	Missing responses
Pain management	1.9	11.2	32.1	54.6	0.2
Psychological support to patient	1.1	6.0	27.0	65.9	0.0
Social support to patient	11.4	20.4	41.1	26.5	0.6
End-of-life management	2.0	5.8	25.9	65.9	0.4
Psychological support to relatives	2.4	11.8	37.7	46.8	1.3

	Mean (SD)	Min	Max	Cronbach's alpha	Missing (%)
Score of perceived role in cancer patient management	16.7 (2.7)	5	20	0.7	2.1

Table 4 presents GPs' perceived difficulties in managing end-of-life cancer patients. More than half of GPs reported important to very important difficulties in managing pain and other symptoms (57.2% and 56.5% respectively). Difficulties in providing psychological support to patients and to their relatives were more shared among respondents (65.0% and 65.8%, respectively).

Table 4.

Perceived Difficulties of Southeastern France General Practitioners in Providing Care to End-of-Life Patients

GPs' perceived difficulties (%)	Very important	Important	Slightly important	Not important	Missing responses
Pain management	11.1	46.1	29.1	12.8	0.9
Management of other symptoms	6.6	49.9	33.5	8.0	2.0
Psychological support to patient	14.6	50.4	25.1	8.5	1.4
Psychological support to relatives	14.1	51.7	24.9	7.9	1.4

	Mean (SD)	Min	Max	Cronbach's alpha	Missing (%)
Score of perceived difficulties in end-of-life management	10.6 (2.6)	4	16	0.8	2.3

Opioids prescription

According to our data, 77% of GPs stated that they prescribe opioids to suffering end-of-life cancer patients on their own initiative, while 23% declared that they do so in coordination with a specialist team. Univariate analyses (Table 5) showed that female GPs and GPs working in solo practices were less likely to prescribe opioids on their own initiative. Similarly, a lower workload in 2012, a lower number of new cancer patients in 2015, the occasional practice of homeopathy or acupuncture, a lower score of perceived role in managing cancer care, and a higher score of perceived difficulties in managing end-of-life care were all associated with lower rates of prescription on one's own initiative.

Table 5.

Univariate and Multivariate Logistic Regressions Results

	Prescription on one's own initiative ^a
	Univariate OR [95% CI]	p	Multivariate aOR^c [95% CI]	p
Sociodemographic characteristics
Gender: women	0.46 [0.28–0.77]	0.003	0.51 [0.28–0.95]	0.035
Age at interview^b	0.99 [0.97–1.02]	0.833	0.99 [0.96–1.03]	0.662
Professional characteristics
2012 workload^b
Low	1		1
Intermediate	2.20 [1.28–3.78]	0.004	1.39 [0.75–2.60]	0.295
High	2.58 [1.14–5.81]	0.022	1.16 [0.46–2.93]	0.757
Type of practice
Group practice, other type of practice	1		1
Solo (or individual practice)	0.45 [0.27–0.74]	0.002	0.42 [0.23–0.75]	0.004
No. of new cancer patients seen in 2015
0–10	1		1
More than 10	1.71 [1.26–2.33]	0.001	1.63 [1.17–2.28]	0.004
Attitudes and practices
Score of perceived difficulties in end-of-life management	0.89 [0.81–0.99]	0.026	0.83 [0.73–0.93]	0.002
Score of perceived role in cancer patient management	1.17 [1.08–1.29]	0.000	1.15 [1.04–1.27]	0.007

Prescription of opioids in coordination with a specialist team was used as the reference category in the logistic regressions.

Variables not selected by the stepwise procedure and forced in the multivariate logistic regression.

All the variables presented in Tables 1 and 2 were tested, and only those significant at a threshold of 20% were used to carry out the multivariate logistic regression.

The multivariate logistic regression was carried out on n = 328 GPs.

aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.

In the multivariate analysis (Table 5), after adjustment for age and workload in 2012, female GPs (adjusted odds ratio [aOR]: 0.51; [95% confidence interval (CI) 0.28–0.95]), GPs working in solo practices (aOR: 0.42; [95% CI 0.23–0.75]), and GPs reporting more difficulties in managing end-of-life cancer patients (aOR: 0.83; [95% CI 0.73–0.93]) were less likely to prescribe opioids on their own initiative. By contrast, GPs with higher numbers of new cancer patients in 2015 (aOR: 1.63; [95% CI 1.17–2.28]) and GPs who declared having an important role to play in all aspects of cancer patient management were more likely to do so (aOR: 1.15; [95% CI 1.04–1.27]).

Discussion

Main findings

In our study, almost all GPs reported prescribing opioids to their end-of-life cancer patients, but one quarter reported not doing so on their own initiative. Moreover, female GPs, GPs working in solo practices, GPs who perceived their role in cancer care as less important, and GPs who reported difficulties in managing end-of-life care were less likely to prescribe opioids on their own initiative. While a majority of GPs considered their role in end-of-life care to be very important, more than half reported significant difficulties in various aspects of end-of-life cancer patient management.

Limitations of the study

The present study has several limitations. Opioids prescription may be overestimated due to a social desirability bias linked to the self-reported nature of the questionnaire. GPs' reliance on specialist team may also be overestimated, either because GPs included the prolongation of preexisting prescriptions in the category of reliance or because they preferred to select this option than to report nonprescriptive attitudes. Moreover, analyses based on cross-sectional data dealing with opinions and practices must be interpreted cautiously, as they rely solely on the declarations of respondents. In view of this, our study should be considered exploratory rather than conclusive.

Characteristics associated with GPs' prescriptive attitudes

Almost 97% of GPs in our study stated that they prescribe opioids. This confirms our hypothesis that the majority of GPs are prone to prescribe opioids in end-of-life situations. A comparable result was reported in a study among French GPs, 98% of whom were found to prescribe strong opioids in palliative care when nonopioid and weak opioid analgesics are no longer effective.³⁴

While GPs' long reluctance to prescribe opioids has been well documented in the medical literature,^35,36 GP practices have been changing in recent years, in particular, with a view to improving pain management and end-of-life care.^37,38 Our data may reflect the increasing acceptance of opioids among GPs. However, we do not have any information on the adequacy of the prescriptions made. Our findings should be interpreted with caution, especially since the association between the rise in opioids prescription and the growing harm caused by opioid misuse has been reported in at least one study.³⁹

In our study, three out of four GPs initiated opioids prescription on their own, whereas the remaining GPs did so after consulting a specialist team. However, GPs who prescribe opioids on their own initiative do not necessarily select the appropriate prescription. Moreover, GPs who request advice from a specialist team may be truly manifesting reluctance toward opioids, or, on the contrary, they may be looking to ensure adequate pain treatment to avoid opioids misuse.

Unlike what has been described in the literature, no difference in attitudes toward opioids prescription were found in our study between prescribers and nonprescribers, a finding mainly due to the low number of nonprescribers. Differences in prescriptive attitudes—that is, prescribing opioids on one's own initiative or in coordination with a specialist team—were associated instead with different types of prescribers—that is, female versus male GPs and GPs working in solo practices versus GPs working in group practices. The question, then, was whether the characteristics of these two types of prescribers corresponded to those described in the literature between prescribers and nonprescribers.^40–42

On the one hand, female GPs in our study were found to initiate prescription on their own less often than male GPs. The influence of gender on prescriptive attitudes is not so clear-cut in the literature: Some studies report that female physicians are more likely to prescribe analgesics,^43,44 whereas others find the opposite to be true.^41,42,45 In addition, other studies⁴⁶ suggest that female GPs are less likely to change their prescription habits. Differences in attitudes toward opioids prescription may become more marked as a growing number of women have entered medical school in the last few decades.^47,48 More generally, the predominance of female GPs may lead to changes in the management of chronic pain.

On the other hand, we found that GPs working in solo practices were less likely to prescribe opioids without requesting advice from a specialist team. The scientific literature provides contrasting evidence on the effectiveness of group practices compared with solo practices.^49,50 Some authors found greater adherence to clinical guidelines recommendations in group practices,⁵¹ whereas others found no difference.⁵² In addition, studies suggest that GPs working in group practices are more successful at managing chronic and acute pain than those working in solo practices.⁵³ In this regard, our findings may reflect a network effect, whereby GPs from the same group benefit from the networks and expertise of their colleagues and can therefore discuss the cases of their respective patients without needing consulting a specialist team.

In our study, we also explored GPs' perceived role in several aspects of cancer care. We found that GPs were significantly involved in cancer management. These results are in line with those reported in the literature,^54,55 and may reflect the greater involvement of GPs in supportive care in cancer following the recommendations of the last French cancer plan (2014–2019).⁵⁶ Specifically, GPs in our study reported playing an important role in the management of pain and in the provision of social and psychological support to patients and their relatives. GPs were also found to value their role in end-of-life accompaniment, contrary to what has been reported in other studies,^57,58 where GPs considered palliative care to be the responsibility of the palliative care team.

Finally, nearly two thirds of surveyed GPs were found to face difficulties in providing end-of-life care, and this despite the fact that most declared themselves to be significantly involved in all aspects of cancer care. This suggests that end-of-life care may be one problematic aspect of cancer management among GPs. In particular, GPs reported facing greater difficulties in providing psychological support than in managing somatic symptoms. Providing psychological support to relatives was also found to be one of the most difficult aspects of end-of-life care.³⁴ Moreover, in our study, more than half of GPs faced significant difficulties in managing CP, despite the fact that a high proportion prescribed opioids and/or had a referral specialist who could provide them with advice on pain management.

Conclusions and Implications for Practice

Almost all GPs surveyed in our study were prone to prescribe opioids to end-of-life cancer patients. However, frequent prescription of opioids and prescription of the drugs on one's own initiative do not necessarily reflect adequate pain management.

Our findings shed light on the factors associated with GPs' prescription of opioids. In view of these findings, future training should focus on: (1) determining the appropriate prescription of opioids; (2) identifying the circumstances in which specialist advice may be of value, in a context of scarce guidelines on CP management at the end of life; and (3) developing the skills and attitudes needed for effective communication with end-of-life patients regarding both symptom assessment and psychological care. In addition, our study emphasizes the need for further research to better understand the impact of GPs' characteristics on their prescriptive attitudes. The possible interactions between patients' and physicians' characteristics—particularly gender—should also be investigated.

Footnotes

Acknowledgments

The authors of this study thank the French League against cancer “Ligue contre le cancer” for the doctoral fellowship and all the private general practitioners who agreed to participate in the survey.

The National Authority for Statistical Information (Commission Nationale de l'Information Statistique) approved the Panel (ref: no. 82/H030).

The study was funded by the Directorate for Research, Studies, Assessment, and Statistics of Ministry of Health (French acronym DREES), the French Ministry of Social Affairs and Health, the National Institute for prevention and health education (French acronym INPES), the National Institute for Health and Medical Research (French acronym Inserm), and the IReSP. The DREES and INPES, funding agencies of the study, played a supporting role in the study design and result analysis; the ORS PACA-UMR-SESSTIM ensured scientific coordination of the study.

Author Disclosure Statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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