Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

BMJ Qual Saf. 2022 May;31(5):340-352. doi: 10.1136/bmjqs-2021-013503. Epub 2021 Nov 1.


Background: Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.

Methods: Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014-2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.

Results: 7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.

Conclusions: Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

Keywords: medical education; pain; pharmacoepidemiology.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Analgesics, Opioid / therapeutic use
  • Canada
  • Chronic Pain* / drug therapy
  • Clinical Competence
  • Cohort Studies
  • Drug Prescriptions
  • Female
  • Humans
  • Male
  • National Health Programs
  • Physicians*
  • Practice Patterns, Physicians'
  • United States


  • Analgesics, Opioid