A double agency problem? Opioid prescribing and guideline adherence in general practice

Policymakers introduce policy tools such as guidelines to motivate physicians to act in their interest. If these interests do not align with patients’ demands, then physicians may face a double agency problem. Such a problem may arise with opioids, which are often highly demanded by patients, while authorities encourage restrictive use. This study uncovers whether physicians’ patient-oriented and society-oriented altruistic motivations relate to filled opioid prescriptions and responses to a new clinical guideline on opioid prescribing. We combine unique survey data on Danish general practitioners’ (GPs’) altruistic motivations with rich register data on filled opioid prescriptions and patient and practice characteristics. First, we use linear regression models to estimate the association between GPs’ altruistic motivations and filled opioid prescriptions prior to the guideline. Second, we employ difference-in-differences (DiD) models to estimate how GPs’ altruistic motivations relate to responses to the guideline. Prior to the guideline, we find that opioid dosages are higher for patients enlisted with more patient-oriented GPs. Similarly, among patients using opioids long-term, being enlisted with more patient-oriented GPs increases the likelihood of filled opioid prescriptions including short-acting opioids. Our DiD-estimates reveal that, following the new guideline, filled opioid prescriptions are more guideline-adherent when patients are enlisted with more societyoriented GPs. This knowledge may help policymakers who seek to motivate physicians to prescribe in adherence with guidelines.