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Jansen-Groot Koerkamp EAW, Weesie YM, Heringa M, Hek K, Blom JW, Numans ME, van Dijk L, Bouvy ML. General practitioners' and community pharmacists' beliefs and practices on opioids for non-malignant pain. Eur J Pain 2024. [PMID: 38923637 DOI: 10.1002/ejp.2304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND In Europe, opioid use has surged, largely due to prescriptions for chronic non-malignant pain (CNMP). General practitioners (GPs) and community pharmacists (CPs) play a major role in opioid prescribing for non-malignant pain. Exploring their personal beliefs and practices might reveal underlying mechanisms to identify measures that could halt the further escalation of opioid use. METHODS Guided by the health belief model, a survey was designed and distributed nationwide to examine the practices and beliefs of GPs and CPs in the domains: threats, benefits, barriers and self-efficacy. The results of GPs and CPs were compared at the statement level using chi-square analysis. RESULTS Of 214 GPs and 212 CPs who completed the survey, the majority agreed that too many opioids are used in the treatment of chronic non-malignant pain (66.8% GPs and 66.5% CPs). Furthermore, they were concerned about the addictive potential of opioids (83.1% GPs and 71.7% CPs). In general, both professions have concerns about opioid use. GPs report a slightly higher degree of self-efficacy and perceive fewer benefits from opioids in treating CNMP. GPs and CPs valued the recommended measures to reduce opioid prescribing, yet less than half actively implement these strategies in their clinics. CONCLUSION GPs and CPs believe that opioids are being used too frequently to treat CNMP. However, both professions lack the actions to improve opioid-related care. GPs and CPs require education, collaboration and tools to implement guidelines on non-malignant pain and opioids. SIGNIFICANCE This study, guided by the health belief model, reveals that general practitioners and community pharmacists have serious concerns about opioid use in chronic non-malignant pain. Despite shared concerns, both professions differ in their beliefs about opioid benefits and perceived self-efficacy. Both professions have in common that they value recommended measures to reduce opioid prescribing. Also, they both struggle to implement strategies, emphasizing the urgent need for education, collaboration and tools to align practices with guidelines on non-malignant pain and opioids.
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Affiliation(s)
- E A W Jansen-Groot Koerkamp
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Y M Weesie
- Pharmaceutical Care, Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - M Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - K Hek
- Pharmaceutical Care, Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - J W Blom
- Department Public Health and Primary Care of the Leiden University Medical Center, Leiden, The Netherlands
| | - M E Numans
- Department Public Health and Primary Care of the Leiden University Medical Center, Leiden, The Netherlands
| | - L van Dijk
- Pharmaceutical Care, Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
- Department of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - M L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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2
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Arthur J, Edwards T, Lu Z, Amoateng MD, Koom-Dadzie K, Zhu H, Long J, Do KA, Bruera E. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic cancer pain. Support Care Cancer 2024; 32:121. [PMID: 38252311 DOI: 10.1007/s00520-024-08323-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE Data indicates that clinicians might be under-prescribing opioids for patients with chronic cancer pain, and this could impact adequate pain management. Few studies have sought to understand healthcare provider (HCP) perceptions and practices regarding the prescription of opioids for chronic cancer pain. We assessed HCP perceptions and practices regarding opioid prescription for patients with chronic cancer pain since the onset of the COVID-19 pandemic. METHODS An anonymous cross-sectional survey was conducted among 186 HCPs who attended an opioid educational event in April 2021 and 2022. RESULTS Sixty-one out of 143 (44%) opioid prescribers reported reluctance to prescribe opioids for chronic cancer pain. In a multivariate logistic model, younger participants (log OR - 0.04, 95% CI - 0.085, - 0.004; p = 0.033) and pain medicine clinicians (log OR - 1.89, CI - 3.931, - 0.286; p = 0.034) were less reluctant, whereas providers who worry about non-medical opioid use were more reluctant to prescribe opioids (log OR 1.58 95% CI 0.77-2.43; p < 0.001). Fifty-three out of 143 (37%) prescribers had experienced increased challenges regarding opioid dispensing at pharmacies, and 84/179 (47%) of all respondents reported similar experience by their patients. Fifty-four out of 178(30%) were aware of opioid-related harmful incidents to patients or their families, including incidents attributed to opioid misuse by a household or family member. CONCLUSION A considerable number of opioid prescribers were reluctant to prescribe opioids for patients with chronic cancer pain. Many reported challenges regarding dispensing of opioids at the pharmacies. These may be unintended consequences of policies to address the opioid crisis. Future measures should focus on addressing regulatory barriers without undermining the gains already made to combat the opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Magdelene Doris Amoateng
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Kwame Koom-Dadzie
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Hongxu Zhu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - James Long
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Kim-Anh Do
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
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Abdel Shaheed C, Ivers R, Vizza L, McLachlan A, Kelly PJ, Blyth F, Stanaway F, Clare PJ, Thompson R, Lung T, Degenhardt L, Reid S, Martin B, Wright M, Osman R, French S, McCaffery K, Campbell G, Jenkins H, Mathieson S, Boogs M, McMaugh J, Bennett C, Maher C. Clinical Observation, Management and Function Of low back pain Relief Therapies (COMFORT): A cluster randomised controlled trial protocol. BMJ Open 2023; 13:e075286. [PMID: 37989377 PMCID: PMC10668201 DOI: 10.1136/bmjopen-2023-075286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/04/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Low back pain (LBP) is commonly treated with opioid analgesics despite evidence that these medicines provide minimal or no benefit for LBP and have an established profile of harms. International guidelines discourage or urge caution with the use of opioids for back pain; however, doctors and patients lack practical strategies to help them implement the guidelines. This trial will evaluate a multifaceted intervention to support general practitioners (GPs) and their patients with LBP implement the recommendations in the latest opioid prescribing guidelines. METHODS AND ANALYSIS This is a cluster randomised controlled trial that will evaluate the effect of educational outreach visits to GPs promoting opioid stewardship alongside non-pharmacological interventions including heat wrap and patient education about the possible harms and benefits of opioids, on GP prescribing of opioids medicines dispensed. At least 40 general practices will be randomised in a 1:1 ratio to either the intervention or control (no outreach visits; GP provides usual care). A total of 410 patient-participants (205 in each arm) who have been prescribed an opioid for LBP will be enrolled via participating general practices. Follow-up of patient-participants will occur over a 1-year period. The primary outcome will be the cumulative dose of opioid dispensed that was prescribed by study GPs over 1 year from the enrolment visit (in morphine milligram equivalent dose). Secondary outcomes include prescription of opioid medicines, benzodiazepines, gabapentinoids, non-steroidal anti-inflammatory drugs by study GPs or any GP, health services utilisation and patient-reported outcomes such as pain, quality of life and adverse events. Analysis will be by intention to treat, with a health economics analysis also planned. ETHICS AND DISSEMINATION The trial received ethics approval from The University of Sydney Human Research Ethics Committee (2022/511). The results will be disseminated via publications in journals, media and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12622001505796.
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Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rowena Ivers
- Graduate School of Medicine, University of Wollongong, Sydney, New South Wales, Australia
| | - Lisa Vizza
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Stanaway
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip James Clare
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Prevention Research Collaboration, University of Sydney, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Thomas Lung
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences College of Pharmacy, Arkansas, Arkansas, USA
| | - Michael Wright
- Centre for Health Economics Research Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rawa Osman
- Quality Use of Medicines (QUM) Connect, Sydney, New South Wales, Australia
| | - Simon French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- School of Psychology, University of Queensland, Queensland, Queensland, Australia
| | - Hazel Jenkins
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Monika Boogs
- Painaustralia Consumer Advisory Group, Canberra, ACT, Australia
| | - Jarrod McMaugh
- Pharmaceutical Society of Australia, Canberra, ACT, Australia
| | - Carol Bennett
- Alliance for Gambling Reform, National, Victoria, Australia
- College of Arts and Social Sciences, The Australian National University, Canberra, ACT, Australia
- Department of Health, Therapeutic Goods Administration National Medicines Scheduling Advisory Committee, Canberra, ACT, Australia
- Faculty of Health Science, University of Canberra, Canberra, ACT, Australia
| | - Christopher Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
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Willman AS. Chronic non-cancer pain training and practice-based small group learning in defence primary healthcare. BMJ Mil Health 2021; 168:243. [PMID: 33664090 DOI: 10.1136/bmjmilitary-2021-001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Antony Sean Willman
- Academic Department of General Practice, Royal Defence Medical College, Birmingham, UK
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Roper KL, Jones J, Rowland C, Thomas-Eapen N, Cardarelli R. Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment. PATIENT EDUCATION AND COUNSELING 2021; 104:585-594. [PMID: 32958306 PMCID: PMC7921200 DOI: 10.1016/j.pec.2020.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/21/2020] [Accepted: 08/26/2020] [Indexed: 05/29/2023]
Abstract
OBJECTIVE A mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care. METHODS Two focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks. RESULTS CP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive. CONCLUSION Patients' understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies. PRACTICE IMPLICATIONS These findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.
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Affiliation(s)
- Karen L Roper
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA.
| | - Jarred Jones
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Courtney Rowland
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Neena Thomas-Eapen
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Roberto Cardarelli
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
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6
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Arthur J, Edwards T, Lu Z, Hui D, Fellman B, Bruera E. Health Care Provider Attitudes, Beliefs, and Perceived Confidence in Managing Patients With Cancer Pain and Nonmedical Opioid Use. J Pain Symptom Manage 2021; 61:128-135.e6. [PMID: 32645456 PMCID: PMC9990526 DOI: 10.1016/j.jpainsymman.2020.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Health care provider education is an effective strategy to improve knowledge and competencies in opioid-prescribing practices. However, there are very few studies regarding this among providers of patients with cancer pain and nonmedical opioid use (NMOU). The aim of our study was to assess participants' attitudes, beliefs, and self-perceived confidence in caring for patients with cancer pain and NMOU before and after attending an opioid educational seminar on the use and nonmedical use of opioids in patients with cancer. METHODS An anonymous cross-sectional survey was conducted among health care providers who attended an opioid educational event in April 2018 and May 2019. RESULTS The overall response rate was 63% (129 of 206). Approximately 72% of participants had concerns about NMOU in patients with cancer, 69% felt that such patients are frequently underdetected, and 63% felt that cancer pain is frequently undertreated. At baseline, only 23% reported adequate knowledge and 35% reported confidence in caring for patients with cancer with NMOU-related issues. Among those who completed both the preseminar and postseminar surveys, these numbers improved significantly at the end of the seminar (26% vs. 71% and 43% vs. 84%, respectively; all P < 0.001). CONCLUSION Most health care providers expressed concerns about underdetection of NMOU and undertreatment of pain among patients with cancer. Many self-reported knowledge and confidence deficits in caring for patients with cancer with NMOU. Seminar participation was associated with an increase in the number of participants with self-perceived knowledge and confidence. Future studies are needed to ascertain the impact of such opioid educational events on patient care practices.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA.
| | - Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
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Trudeau KJ, Hildebrand C, Garg P, Chiauzzi E, Zacharoff KL. A Randomized Controlled Trial of the Effects of Online Pain Management Education on Primary Care Providers. PAIN MEDICINE 2018; 18:680-692. [PMID: 28034967 DOI: 10.1093/pm/pnw271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective To improve pain management practices, we developed an online interactive continuing education (CE) program for primary care providers (PCPs). This program follows the flow of clinical decision-making through simulated cases at critical pain treatment points along the pain treatment continuum. Design A randomized controlled trial was conducted to test the efficacy of this program. Participants were randomized to either the experimental condition or the control condition (online, text-based CE program). Subjects A total of 238 primary care providers were recruited through hospitals, professional newsletters, and pain conferences. Results Participants in both conditions reported significantly improved scores on knowledge (KNOW-PAIN 50), attitudes (CAOS), and pain practice behaviors (PPBS) scales over the four-month study. The experimental condition showed significantly greater change over time on the tamper-resistant formulations (TRFs) of opioids and dosing CAOS subscale compared with the control condition. Post hoc comparisons suggested that participants in the experimental condition were less likely to endorse use of opioid TRFs over time compared with the control condition. Exploratory analyses for potential moderators indicated a significant three-way interaction with time, condition, and discipline (i.e., physician vs other) for the impediments and concerns attitudes subscale and the early refill behaviors subscale. Post hoc comparisons indicated that physicians in the experimental condition exhibited the greatest change in attitudes and the nonphysicians exhibited the greatest change in reported behaviors in response to requests for early refills. Conclusions Findings suggest online CE programs may positively impact PCPs' knowledge, attitudes, and pain practice behaviors but provide minimal evidence for the value of including interactivity.
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Affiliation(s)
| | | | | | - Emil Chiauzzi
- PatientsLikeMe, Inc, Cambridge, Massachusetts, MA, USA
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Les modalités de prescription d’analgésiques opiacés par les médecins de l’Hôtel-Dieu de France de Beyrouth. Encephale 2016; 42:511-516. [DOI: 10.1016/j.encep.2016.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 11/23/2022]
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9
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Kennedy MC, Henman MC, Cousins G. General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study. PHARMACY 2016; 4:E15. [PMID: 28970388 PMCID: PMC5419349 DOI: 10.3390/pharmacy4010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 12/28/2022] Open
Abstract
Chronic non-malignant pain (CNMP) is commonly managed by General Practitioners (GPs) in primary care. Analgesics are the mainstay of CNMP management in this setting. Selection of medications by GPs may be influenced by micro factors which are relevant to the practice setting, meso factors which relate to the local or regional environment or macro factors such as those arising from national or international influences. The aim of this study is to explore influences on GP practises in relation to pain management for older adults with CNMP. Semi-structured interviews were conducted with 12 GPs. Transcripts were organised using the Framework Method of Data Management while an applied thematic analysis was used to identify the themes emerging from the data. Clinical considerations such as the efficacy of analgesics, adverse effects and co-morbidities strongly influence prescribing decisions. The GPs interviewed identified the lack of guidance on this subject in Ireland and described the impact of organisational and structural barriers of the Irish healthcare system on the management of CNMP. Changes in practice behaviours coupled with health system reforms are required to improve the quality and consistency of pharmacotherapeutic management of CNMP in primary care.
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Affiliation(s)
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, St. Stephens Green, Dublin , Ireland.
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10
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Blake H, Leighton P, van der Walt G, Ravenscroft A. Prescribing opioid analgesics for chronic non-malignant pain in general practice - a survey of attitudes and practice. Br J Pain 2015; 9:225-32. [PMID: 26526705 DOI: 10.1177/2049463715579284] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study replicates a previous postal survey of general practitioners (GPs) to explore whether attitudes to opioid prescribing have changed at a time when the number of opioid prescriptions issued in primary care has increased. METHODS With permission, a 57-item survey instrument previously utilised with GPs in the South-west of England was circulated to 214 GPs in city-centre practices in the East Midlands. The survey instrument included items relating to practice context, prescribing patterns and attitudes about analgesic medication, perceived prescribing frequency and reluctance to prescribe. RESULTS Responses were received from 94 GPs (45%). Almost three-quarters (72.7%) of GPs reported that they sometimes or frequently prescribed strong opioids for chronic non-cancer pain. Over two-thirds (67.8%) reported that they were sometimes or frequently reluctant to prescribe strong opioids for chronic non-cancer pain. No significant relationships were observed between perceived frequency of prescribing and a range of demographic factors; however, concerns about 'physical dependence', 'long-term commitment to prescribing' and 'media reports' were associated with less frequent reported prescribing of, and greater reluctance to prescribe, strong opioids. DISCUSSION Given the national trend for increased opioid prescriptions, it is unsurprising that more frequent self-reported prescribing is reported here; however, increased frequency does not translate into less reluctance about prescribing. The effectiveness of strong opioids for chronic pain is recognised, but concerns about addiction, dependence and misuse inform a reluctance to use strong opioids. These juxtapositions highlight a continued need for clearer understanding of GPs' perceptions of strong opioids and point to the potential benefit of dedicated guidelines or specialist education and training to address their uncertainties.
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Affiliation(s)
- Holly Blake
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham, UK
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11
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Song J, Foell J. An exploration of opioid medication management for non-malignant pain in primary care. Br J Pain 2015; 9:181-9. [PMID: 26516575 DOI: 10.1177/2049463715574111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present study aimed to explore how prescription of opioid medication for chronic non-malignant pain (CNMP) is managed in primary care. We used audit as a research tool, and one general practitioner (GP) practice in West London acted as an exemplar. Of the practice population with CNMP, 1% had repeat prescription of at least 12 months duration for opioid analgesics at the time of data collection. These 1% are on highly controlled opioids. Our study showed the following: (1) long-term opioid prescription appears to follow a fluctuating course as opposed to staying the same; (2) we found that medication reviews were done in most cases (85.7%), but the quality of the process is difficult to assess and ascertain; and (3) we identified two incidences where opioid contract was implemented. In both cases, contracts were used as a last chance warning for patients who were already problematic, suggesting that opioid contracts served as a disciplinary tool rather than a preventative measure. Our findings highlight a need for a more structured and specific review of analgesic medication, and a need for a simple and effective way to identify patients at high risk of developing problematic use, to ensure better monitoring and early presentations.
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Affiliation(s)
- Jia Song
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
| | - Jens Foell
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
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12
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Saunders KW, Shortreed S, Thielke S, Turner JA, LeResche L, Beck R, Von Korff M. Evaluation of Health Plan Interventions to Influence Chronic Opioid Therapy Prescribing. Clin J Pain 2015; 31:820-829. [PMID: 25621426 PMCID: PMC4620063 DOI: 10.1097/ajp.0000000000000159] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Evaluate health plan interventions targeting physician chronic opioid therapy (COT) prescribing. MATERIALS AND METHODS In 2006, Group Health's (GH) Integrated Group Practice (IGP) initiated diverse interventions targeting COT prescriber norms and practices. In 2010, the IGP implemented a COT guideline, including a mandated online course for physicians managing COT. These interventions were not implemented in GH's network practices. We compared trends in GH-IGP and network practices for 2006 to 2012 in the percent of patients receiving COT and their opioid dose. We compared physician beliefs before versus after the mandated course and precourse to postcourse changes in COT dosing for IGP physicians who took the course. RESULTS From 2006 to 2012, mean (SE) daily opioid dose among IGP COT patients (intervention setting) declined from 74.1 mg (1.9 mg) morphine equivalent dose (MED) to 48.3 mg (1.0 mg) MED. Dose changes among GH network COT patients (control setting) were modest-88.2 mg (5.0 mg) MED in 2006 to 75.7 mg (2.3 mg) MED in 2012. Among physicians taking the mandated course in 2011, we observed precourse to postcourse changes toward more conservative opioid prescribing beliefs. However, COT dosing trends did not change precourse to postcourse. DISCUSSION Following initiatives implemented to alter physician prescribing practices and norms, mean opioid dose prescribed to COT patients declined more in intervention than control practices. Physicians reported more conservative beliefs regarding opioid prescribing immediately after completing an online course in 2011, but the course was not associated with additional reductions in mean daily opioid dose prescribed by physicians completing the course.
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Affiliation(s)
| | | | - Stephen Thielke
- Departments of Psychiatry and Behavioral Sciences
- Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center
| | - Judith A Turner
- Departments of Psychiatry and Behavioral Sciences
- Rehabilitation Medicine
- Anesthesiology and Pain Medicine
| | | | - Randi Beck
- Department of Physical Medicine and Rehabilitation, Group Health, Seattle, WA
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Jamison RN, Scanlan E, Matthews ML, Jurcik DC, Ross EL. Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial. PAIN MEDICINE 2015; 17:99-113. [DOI: 10.1111/pme.12871] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Robert N. Jamison
- Psychiatry
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Elizabeth Scanlan
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Michele L. Matthews
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Dylan C. Jurcik
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Edgar L. Ross
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
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14
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Ringwalt C, Roberts AW, Gugelmann H, Skinner AC. Racial disparities across provider specialties in opioid prescriptions dispensed to medicaid beneficiaries with chronic noncancer pain. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:633-40. [PMID: 25287703 PMCID: PMC5012901 DOI: 10.1111/pme.12555] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Chronic pain affects both psychological and physical functioning, and is responsible for more than $60 billion in lost productivity annually in the United States. Although previous studies have demonstrated racial disparities in opioid treatment, there is little evidence regarding disparities in treatment of chronic noncancer pain (CNCP) and the role played by physician specialty in these disparities. DESIGN A retrospective cohort study. SETTING We analyzed North Carolina Medicaid claims data, from July 1, 2009 to May 31, 2010, to examine disparities by different provider specialties in beneficiaries' dispensed prescriptions for opioids. SUBJECTS The population included white and black North Carolina Medicaid beneficiaries with CNCP (N = 75,458). METHODS We used bivariate statistics and logistic regression analysis to examine race-based discrepancies in opioid prescribing by physician specialty. RESULTS Compared with white beneficiaries with CNCP (N = 49,197), black beneficiaries (N = 26,261) were less likely (odds ratio [OR] 0.91 [confidence interval {CI}: 0.88-0.94]) to fill an opioid prescription. Our hypothesis was partially supported: we found that race-based differences in beneficiaries' dispensed opioid prescriptions were more prominent in certain specialties. In particular, these differences were most salient among patients of specialists in obstetrics and gynecology (OR 0.78 [CI: 0.67-0.89]) and internal medicine (OR 0.86 [CI: 0.79-0.92]), as well as general practitioners/family medicine physicians (OR 0.91 [CI: 0.85-0.97]). CONCLUSIONS Our findings suggest that, in our study population, black beneficiaries with CNCP are less likely than whites to fill prescriptions for opioid analgesics as a function of their provider's specialty. Although race-based differences in patients filling opioid prescriptions have been noted in previous studies, this is the first study that clearly demonstrates these disparities by provider specialty.
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Affiliation(s)
- Chris Ringwalt
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | - Andrew W. Roberts
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Hallam Gugelmann
- California Poison Control System, San Francisco Division, University of California at San Francisco and Veterans Affairs Medical Center, San Francisco
| | - Asheley Cockrell Skinner
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics in the School of Medicine, University of North Carolina at Chapel Hill
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15
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Turk DC, Dansie EJ, Wilson HD, Moskovitz B, Kim M. Physicians' Beliefs and Likelihood of Prescribing Opioid Tamper-Resistant Formulations for Chronic Noncancer Pain Patients. PAIN MEDICINE 2014; 15:625-36. [DOI: 10.1111/pme.12352] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Seamark D, Seamark C, Greaves C, Blake S. GPs prescribing of strong opioid drugs for patients with chronic non-cancer pain: a qualitative study. Br J Gen Pract 2013; 63:e821-8. [PMID: 24351498 PMCID: PMC3839391 DOI: 10.3399/bjgp13x675403] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 07/03/2013] [Accepted: 08/06/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) is common in the UK. GPs manage most patients with such pain. Previous research has suggested that prescribing is influenced by patient and doctor factors, but less is known about the decision- making process involved in prescribing opioid drugs for CNCP. AIM To describe the factors influencing GPs' prescribing of strong opioid drugs for CNCP. Design and setting Semi-structured interviews and a focus group of a purposive sample of GPs from a range of practice settings including male and female GPs with experience of prescribing strong opioids. METHOD Transcripts of interviews and a focus group were analysed using qualitative research methodology (thematic analysis). RESULTS GPs described prescribing opioid drugs for patients with CNCP as being different from treating cancer related pain. GPs followed accepted stepwise approaches in their prescribing for CNCP. They reported difficulty in assessing the level of pain and concern over duration of use of strong opioids and their possible side effects, tolerance, and addiction. Variation in reported practice was observed, which may be linked to experience and significant events. CONCLUSION GPs in this study demonstrated a thoughtful attitude towards prescribing strong opioids for CNCP. They were aware of the difficulties of long-term strong opioid prescription. Only a few GPs had had specific training in chronic pain management and this may explain some of the variation in practice reported. GPs may benefit from training in pain assessment and long-term management of patients with CNCP.
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Affiliation(s)
| | | | - Colin Greaves
- University of Exeter medical School (Primary Care), Exeter, UK
| | - Susan Blake
- Honiton Research Practice, Honiton, Devon, UK
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McCracken LM, Boichat C, Eccleston C. Training for general practitioners in opioid prescribing for chronic pain based on practice guidelines: a randomized pilot and feasibility trial. THE JOURNAL OF PAIN 2011; 13:32-40. [PMID: 22112421 DOI: 10.1016/j.jpain.2011.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Revised: 08/03/2011] [Accepted: 09/22/2011] [Indexed: 11/16/2022]
Abstract
UNLABELLED This study is a pilot and feasibility study that compares 2 training experiences to improve appropriate opioid prescribing for chronic pain. Both training conditions included education in relation to opioid guidelines. Following education, 1 condition included training aimed at improving psychological flexibility and the other included training in practical knowledge and skills related to pain management. Eighty-one general practitioners (GPs) took part in the study, each having been randomly assigned to 1 of the training conditions. It proved easy to recruit GPs to the training. Overall, GPs demonstrated increased knowledge of opioid prescribing for chronic pain and decreases in concerns related to prescribing following training. However, there were no changes observed in reported prescribing practices or in secondary measures of well-being. There were also no significant differences between the training conditions, other than a greater increase in intention to use prescribing guidelines in the psychological flexibility condition. Feasibility and acceptability of the training methods were generally rated high. The psychological flexibility condition was rated higher than the comparison condition in terms of interest and satisfaction. Finally, processes of psychological flexibility before and after training significantly correlated with measures of GP well-being, providing partial support for the relevance of these processes as a focus in GP training. PERSPECTIVE A training intervention for GPs including education on opioid guidelines for chronic pain and psychological flexibility training increased knowledge of prescribing and reduced concerns but did not change prescribing behavior or well-being. The training was highly acceptable to GPs but may have been too short to produce other effects.
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Affiliation(s)
- Lance M McCracken
- Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, United Kingdom.
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Rosser BA, McCracken LM, Velleman SC, Boichat C, Eccleston C. Concerns about medication and medication adherence in patients with chronic pain recruited from general practice. Pain 2011; 152:1201-1205. [PMID: 21376463 DOI: 10.1016/j.pain.2011.01.053] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 11/17/2022]
Abstract
This study examines the concerns and beliefs about medication reported by patients with nonmalignant chronic pain encountered within general practice. Two hundred thirty-nine patients with chronic pain took part in this research. Patients completed the Pain Medication Attitudes Questionnaire, a measure of patient concerns and beliefs relating to addiction, withdrawal, side effects, mistrust in doctors, perceived need of medication, scrutiny from others, and tolerance. The data revealed that patient concerns and beliefs predicted general medication nonadherence. In addition, concerns were related to the direction of nonadherence: overuse of medication was related to increased perceived need for medication and greater concern over side effects; underuse was related to decreased concerns over withdrawal and increased mistrust in the prescribing doctor. Analyses also indicated that patient attitudes and concerns about medication were more predictive of nonadherence than both level of pain and the reported frequency of experienced side effects. This research contributes to the increasing evidence that patient attitudes and beliefs about pain medication are associated with adherence behavior. Training general practitioners to identify and address these concerns may reduce concerns, improve adherence, and facilitate the doctor-patient relationship.
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Affiliation(s)
- Benjamin A Rosser
- Bath Centre for Pain Research, University of Bath, Bath, UK Bath Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, UK
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Abstract
Sufentanil is a highly potent synthetic opioid that is approximately 1000-fold more potent than morphine and up to tenfold more potent than fentanyl. It is most commonly used by anesthesiologists to provide intraoperative analgesia. Although sufentanil is not yet approved for chronic pain management, it is being explored for chronic pain therapy. Owing to its physical properties, high potency, high lipid solubility, high therapeutic index and short duration of action, sufentanil has the potential to provide effective analgesia via multiple routes of administration. The superior pharmacokinetics of sufentanil make it ideal for treatment of breakthrough pain via the sublingual/buccal and nasal routes. Similarly, the transdermal route of sufentanil administration should provide analgesia for a prolonged period. The adverse effects of sufentanil are similar to those of other opioids that are commonly used for chronic pain management (e.g., fentanyl and morphine). Future research is necessary to define the role of sufentanil in the treatment of chronic pain.
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Affiliation(s)
- Girish P Joshi
- University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
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