The rate at which physicians prescribed opioids fell by 4.6% between 2015 and 2017 compared with 2009 through 2011. The decline in prescribing was seen in physicians who scored highest on the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) examination, according to the results of a study published in JAMA Network.

Given the risks associated with opioids and the change in guidance that began around 2015, the researchers wanted to explore why opioid prescription rates remain high. The authors hypothesized that physicians with greater clinical knowledge would stay more up-to-date on these guidelines and therefore respond to guideline changes.

The authors used the ABIM board certification database to identify general internal medicine physicians who had taken an MOC examination between 2008 and 2016. The researchers then linked those physicians to Medicare claims for lower back pain visits that took place during the year after those physicians’ examinations. After applying exclusion criteria, the study included 55,387 visits and 10,246 physicians.

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Of all the included visits, 6697 (12.1%) involved patients from rural ZIP codes. The study population was 75.8% White, and 67.1% of participants were women. The mean age was 76.2 years. The study did not report any other race/ethnicity demographics.

Physicians prescribed opioids after 11,978 (21.6%) visits for low back pain; 9759 (81.5%) of these prescriptions were of high dosage or long duration. Physicians in the highest knowledge quartile showed a statistically significant 4.4 percentage point (95% CI, -6.8 to -2.0 percentage point) decrease in adjusted prescribing when the early (2009-2011) and the late (2015-2017) periods were compared. Prescribing rates among lower-scoring physicians did not change significantly.

Because the study was limited to Medicare fee-for-service claims, it may not generalize to other populations. The researchers also cannot say whether the same results would apply to other clinical situations where opioids are more commonly prescribed. Unobserved confounding between examination performance and opioid prescribing could have biased results.

“Our findings suggest that performance on a knowledge examination is associated with clinically meaningful prescribing behavior,” the researchers concluded. “Physicians who score well on these examinations may be more responsive to changes in standards of care. However, continued prescribing of [opioids of high dosage or long duration] by physicians who scored high on the MOC examination suggests that general knowledge-based interventions, although helpful, may not be sufficient to address opioid overprescribing.”


Gray BM, Vandergrift JL, Weng W, Lipner RS, Barnett ML. Clinical knowledge and trends in physicians’ prescribing of opioids for new onset back pain, 2009-2017. JAMA Netw Open. Published online July 1, 2021. doi:10.1001/jamanetworkopen.2021.15328