Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Letter from a licensing body and group education reduced prescribing of regulated analgesics

ACP J Club. 1996 July-Aug;125:25. doi:10.7326/ACPJC-1996-125-1-025

Source Citation

Anderson JF, McEwan KL, Hrudey WP. Effectiveness of notification and group education in modifying prescribing of regulated analgesics. Can Med Assoc J. 1996 Jan 1;154:31-9.



To determine whether notification of excessive prescribing of regulated analgesics alone or in combination with a 1-day course on pain management will reduce the rate of prescribing by physicians.


Randomized controlled trial with 6-month follow-up.


Primary care practices in British Columbia, Canada.


136 physicians had prescribing rates for regulated analgesics that were 2 standard deviations higher than the provincial mean. 54 of the top 100 prescribers were randomly selected; follow-up data were available for 49 prescribers (mean age 52 y, 100% men, mean years from graduation 26 y).


18 physicians were allocated to receive a standard letter from the College of Physicians and Surgeons of British Columbia that informed them of their prescribing status; they were also invited to attend a 1-day workshop on pain management. Topics included chronic low-back disability and narcotic dependency as a complication of chronic pain management. The format included lectures, case studies, and discussion groups. 18 physicians received only the letter from the college, and 18 physicians who received no feedback on their prescribing status acted as controls.

Main outcome measures

Mean total number of prescriptions written for regulated analgesics for 6 months before and 6 months after the intervention.

Main results

The mean number of prescriptions for regulated analgesics written in the 6 months before the intervention was 100 for physicians in the education group, 115 for physicians in the notification group, and 116 for physicians in the control group. In the 6 months after the intervention, the mean number of prescriptions written was 66, 86, and 120, respectively. The 33% reduction in prescribing in the education group and the 25% reduction in the notification group both differed from the control group (P < 0.01 for both groups) but did not differ from each other.


Physicians who were notified by the licensing body of their excessive prescribing status for restricted analgesics reduced their rate of prescribing in the next 6 months.

Source of funding: British Columbia Ministry of Health and Ministry Responsible for Seniors.

For article reprint: Dr. J.F. Anderson, Provincial Medical Advisor, Adult Clinical and Addictions Services Branch, British Columbia Ministry of Health and Ministry Responsible for Seniors, 3rd Floor, 1810 Blanshard Street, Victoria, British Columbia V8T 4J1, Canada. FAX 604-952-0808.


All the physicians in this study by Anderson and colleagues were registered with the Triplicate Prescribing Program (TPP) of the College of Physicians and Surgeons of British Columbia. In this program, regulated analgesics cannot be prescribed without permission of the TPP, and every year a few physicians in British Columbia lose their prescribing privileges. Would the results of this study have been the same if a licensing authority had not been involved, and what can we conclude about the value of the educational intervention?

Some evidence exists that feedback to physicians about their individual prescribing patterns in a nonregulatory setting can increase compliance with protocols (1), but in this study the lack of significant difference between the 2 intervention groups showed that it was the threat of loss of privileges and not the educational intervention that was effective in changing behavior. The results make it difficult to draw firm conclusions about the value of the educational intervention, but the experience in Britain where financial incentives and penalties were used to contain prescribing costs suggests that the effects observed in the short term are not sustained over time (2). It may be that potentially threatening interventions have shorter-term effects than educational interventions. This, and the observation that the education group showed the greater reduction in prescribing volume, leaves open the possibility that a longer follow-up would reveal important differences between the interventions of coercion and education.

Nicky Britten, MA, MSc
United Medical and Dental School of Guy's and St. Thomas' HospitalsLondon, England, UK


1. Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Mem Fund Q. 1989;67:268-317.

2. Stewart-Brown S, Surender R, Bradlow J, Coulter A, Doll H. The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme. BMJ. 1995;311:1543-7.