Authors Reply:—We appreciate Dr. Rastegar’s observation that the focus of his opioid prescribing has changed over time and agree that this raises an intriguing question. While we know of no empiric evidence to support or refute the association between greater experience and use of a decision making framework that focuses on addiction, we fully agree that decision-making frameworks may not be static. In fact, we suspect that many physicians may have changed the focus of their pain treatment relatively recently. Approximately 20 years ago, pain specialists argued that the risk of addiction should not prevent the use of prescription opioids to manage chronic pain, and there was a shift in clinical consensus in favor of using opioids for pain. Consequently, rates of opioid prescribing increased dramatically,1,2 and there were substantial increases in drug-related emergency room visits, admissions to addiction treatment, and deaths from drug overdose.3,4,5 If greater experience is associated with an addiction-oriented decision making framework, as Dr. Rastegar suggests, one potential explanation is that physicians’ practice patterns during this time shifted in response to these patterns of opioid use and potential negative sequelae. However, any finding of an association between experience and opioid prescribing behavior may be limited by opportunity bias, as more experienced physicians may be more likely to have encountered situations in which opioid prescribing led to negative outcomes for either them or their patients. Indeed, several of the participants in our study who focused on minimizing the risk of addiction did so because of negative past experiences. However, in contrast to Dr. Rastegar, none of the participants in our study described changes in their own personal decision-making framework as a result of greater clinical experience.

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