Christina Mattina

As the opioid crisis continues across the United States, researchers are highlighting one potential solution: strengthening physician education on best prescribing practices. The suggestion is based on findings that physicians who attended a top-ranked medical school wrote far fewer opioid prescriptions than those who attended less rigorous schools.

The continually rising overdose death toll led the White House’s opioid commission to recommend in an interim report that President Donald Trump take the uncommon step of declaring the crisis a national emergency. Trump  he would refrain from doing so for now, but mentioned a number of tactics he intended to implement, including stronger law enforcement and more prevention campaigns aimed at youth.

One recommendation in the interim report, to “mandate prescriber education initiatives with the assistance of medical and dental schools across the country,” was bolstered by the results of a working paper recently published by the National Bureau of Economic Research. The study explored the potential role of physician education as a determinant of opioid prescribing rates.

Using prescribing data and medical school rankings, the researchers found that graduation from a higher-ranked medical school was associated with prescribing fewer opioids. For example, general practitioners from the lowest ranked medical schools in the United States wrote an average of 550 opioid prescriptions annually, which is more than 3 times the average amount of 180 prescriptions written by those who attended Harvard Medical School, the top school.

Not only did physicians from higher ranked medical schools write the fewest prescriptions among all physicians who prescribed opioids, they were also less likely to prescribe the drugs at all. Less than two-thirds (65%) of physicians schooled at Harvard wrote at least 1 opioid prescription in any given year from 2006 to 2014, compared with nearly 80% of physicians who attended the lowest ranked medical schools.

Considering this inverse association between medical school rank and opioid prescribing, the study authors theorized some explanations for this relationship. Their analyses indicated that the prescribing gradient persisted after controlling for specialty and practice location, suggesting that the relationship reflects differences in training on appropriate opioid prescribing across schools.

The study authors noted that adoption of unified opioid curricula has been haphazard, citing a review that found no standards for opioid prescribing education in the curricula of all 4 medical schools in Massachusetts—including Harvard Medical School. Furthermore, just 28% of ranked and 43% of unranked US medical schools had pledged by fall 2016 that they would update their curriculum to incorporate the CDC’s recent opioid prescribing guidelines.

These findings will be important for the FDA to consider as it is “actively exploring the question of whether, in the future, there should be mandatory provider education” on safe opioid prescribing, as FDA Commissioner Scott Gottlieb, MD, announced in his remarks before the agency’s July meeting on opioids. Such a requirement could make opioid training more uniform across schools and potentially diminish the prescribing disparities observed in the current study.

“Since variations in opioid prescribing have contributed to deaths due to the current opioid epidemic, training aimed at reducing prescribing rates among the most liberal prescribers—who disproportionately come from the lowest ranked medical schools—could possibly have large public health benefits,” the study concluded.



One thing I did not see mentioned is how long the lower amount of opiate prescribing lasts into a physicians career.  Drug seekers beat us up to prescribe more, complaining of pain, using a variety of manipulative tactics.  As a whole, I think physicians are more empathetic and sympathetic than other professions in terms of how we deal with those under our care.  Addicts are smart, they know this and know how to prey on it.  There’s no mention in this study of how long after medical school these results were obtained.  Residents fresh out of school often do not have their own DEA# and cannot prescribe without getting their attending physician (who has a DEA#) to co-sign their prescriptions.  Clearly if these respondents were within their first 3 years of graduation, they were likely still residents; any other result would be unlikely.  This may be an article regarding “shape-shifting of blame” that really doesn’t add much new information to what we already know!

Dr. Raymond Oenbrink
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