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McCann C, McCauley CO, Harkin D. Barriers and facilitators to opioid deprescribing among Advanced Nurse Practitioners: A qualitative interview study. J Adv Nurs 2024; 80:2500-2511. [PMID: 38082475 DOI: 10.1111/jan.15995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 05/12/2024]
Abstract
AIM To explore the experiences primary care Advanced Nurse Practitioners have had in relation to deprescribing opioids in chronic non-malignant pain. DESIGN A qualitative interview study. METHODS Primary care Advanced Nurse Practitioners were recruited from across the Northern Ireland GP Federations. Data collection for this study took place between April and June 2022. In total, 10 semi-structured online interviews were conducted. Interviews were audio and visually recorded, transcribed verbatim and interpreted using a thematic analysis framework. The COREQ criteria were used to guide the reporting of this study. RESULTS The Advanced Nurse Practitioners experienced several challenges associated with opioid deprescribing and the implementation of current chronic pain guidelines. The main barriers identified were difficulties engaging patients in deprescribing discussions, a lack of availability of supportive therapies and poor access to secondary care services. The barriers identified directly impacted on their ability to deliver best practice which resulted in a sense of professional powerlessness. CONCLUSION The experiences of the Advanced Nurse Practitioners demonstrate that opioid deprescribing in patients with chronic pain is challenging, and implementation of current chronic pain guidelines is difficult. IMPACT This study contributes to existing literature on the topic of reducing opioid prescribing and as far as the authors are aware, is the first study to examine the experiences of primary care advanced nurse practitioners in this context. These findings will be of interest to other primary care practitioners, and prescribers involved in the management of chronic non-malignant pain. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Piret EM, Milloy MJ, Voon P, Choi J, DeBeck K, Hayashi K, Kerr T. Denial of prescription pain medication among people who use drugs in Vancouver, Canada. Harm Reduct J 2024; 21:72. [PMID: 38549113 PMCID: PMC10979632 DOI: 10.1186/s12954-024-00956-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/03/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs. METHODS We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied. RESULTS Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates. CONCLUSIONS A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.
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Affiliation(s)
- Evelyne Marie Piret
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - M-J Milloy
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Pauline Voon
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - JinCheol Choi
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Kora DeBeck
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- School of Public Policy, Simon Fraser University, 515 West Hastings St, Vancouver, BC, V6B 5K3, Canada
| | - Kanna Hayashi
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Thomas Kerr
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Fischer B, Robinson T. The marked oscillatory pattern in prescription opioid utilization in Canada since 2000: Selected observations and questions for outcomes and policy. Pharmacoepidemiol Drug Saf 2024; 33:e5748. [PMID: 38158387 DOI: 10.1002/pds.5748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/30/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Benedikt Fischer
- Research and Graduate Studies, University of the Fraser Valley, Abbotsford, British Columbia, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Kaseweter K, Nazemi M, Gregoire N, Louw WF, Walsh Z, Holtzman S. Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era. BMC Health Serv Res 2023; 23:1131. [PMID: 37864210 PMCID: PMC10588239 DOI: 10.1186/s12913-023-10157-8] [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: 08/16/2022] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation. METHODS A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey. RESULTS The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options. CONCLUSIONS Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.
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Affiliation(s)
- Kimberley Kaseweter
- Department of Psychology, University of British Columbia, 3333 University Way, Kelowna, BC, V1V 1V7, Canada.
| | - Mark Nazemi
- Clinical and Wellbeing Solutions, Thrive Health Inc, 200 - 116 West Hastings Street, Vancouver, BC, V6B 1G8, Canada
| | - Nina Gregoire
- Department of Psychology, University of British Columbia, 3333 University Way, Kelowna, BC, V1V 1V7, Canada
| | - W Francois Louw
- Department of Family Practice, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
- Bill Nelems Pain and Research Centre, 309-2755 Tutt St, Kelowna, BC, V1Y 0G1, Canada
| | - Zach Walsh
- Department of Psychology, University of British Columbia, 3333 University Way, Kelowna, BC, V1V 1V7, Canada
| | - Susan Holtzman
- Department of Psychology, University of British Columbia, 3333 University Way, Kelowna, BC, V1V 1V7, Canada
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Cunningham D, Anastasio AT, Cochrane NH, Ryan SP, Bolognesi M, Seyler TM. Opioid Legislation Decreases Opioid Prescribing in Total Knee Arthroplasty. Orthopedics 2022; 46:142-150. [PMID: 36508483 DOI: 10.3928/01477447-20221207-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this study was to evaluate the impact of opioid-limiting legislation on perioperative opioid prescriptions in total knee arthroplasty. The hypothesis was that opioid legislation has reduced opioid prescription filling above levels anticipated by national trends. This study retrospectively evaluated opioid prescription filling for all patients undergoing total knee arthroplasty in a commercially available insurance database between 2010 and 2018 (n=1,068,764). Initial discharge and 90-day cumulative oxycodone 5-mg equivalents filled were tabulated. Opioid prescription filling was evaluated over time and between states with and without opioid-limiting legislation using analysis of variance and multivariable linear and logistic regression. States with and without opioid legislation had significant reductions in initial and cumulative opioid prescription filling volume (all P<.001). However, the magnitude of this reduction was larger in states with opioid legislation. Legislation targeting duration and volume had the largest impact on initial post-act opioid prescription filling volume compared with states without legislation in an estimated "pre-act" time frame. Legislation targeting duration and volume and no specific target had the largest impact on cumulative post-act opioid prescription filling volume. States without legislation still had large, significant reductions in filling volume, but the magnitude was not as great as in states with opioid legislation. States with and without opioid legislation had significant decreases in initial and cumulative opioid prescription filling volume. However, the magnitude of reduction was larger in states that enacted legislation. Younger age, pre-operative opioid use, and higher comorbidity burden were associated with greater opioid use postoperatively. [Orthopedics. 202x;4x(x):xx-xx.].
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Singh V, Tang A, Bieganowski T, Anil U, Macaulay W, Schwarzkopf R, Davidovitch RI. Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty. World J Orthop 2022; 13:703-713. [PMID: 36159616 PMCID: PMC9453274 DOI: 10.5312/wjo.v13.i8.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines.
AIM To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.
METHODS We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.
RESULTS There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15.
CONCLUSION All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - Alex Tang
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - William Macaulay
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, United States
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Makhinson M, Seshia SS, Young GB, Smith PA, Stobart K, Guha IN. The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'? J Eval Clin Pract 2021; 27:1033-1043. [PMID: 33760335 DOI: 10.1111/jep.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis. METHODS The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential. RESULTS The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables. LIMITATIONS The analysis suggests associations not causality. CONCLUSION The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.
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Affiliation(s)
- Michael Makhinson
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at the University of California, Los Angeles, California, USA.,Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Shashi S Seshia
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gordon Bryan Young
- Clinical Neurological Sciences and Medicine (Critical Care), Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada.,Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Preston A Smith
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kent Stobart
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Indra Neil Guha
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Development and Initial Evaluation of Psychometric Properties of a Pain Competence Assessment Tool (PCAT). THE JOURNAL OF PAIN 2021; 23:398-410. [PMID: 34583019 DOI: 10.1016/j.jpain.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022]
Abstract
Competency-based education is now considered the best approach for pain educational programs provided for pre and postgraduate healthcare providers (HCPs). To demonstrate learners' progression, an assessment tool that aligns with this educational approach and targets different HCPs is needed. A Pain Competence Assessment Tool (PCAT) was developed based on the pain management core competencies that align with the International Association for the Study of Pain interprofessional pain curriculum. The PCAT is an online competency-based assessment tool for HCPs that consists of 5 case scenarios followed by 17 key-feature questions. HCPs and trainees completed the PCAT through a series of studies to assess its psychometric properties. The preliminary evaluation suggested that the PCAT had adequate content validity. Apart from 6 questions, the PCAT questions demonstrated homogeneity and acceptable reliability, and substantial stability. No ceiling or floor effect was found. A significant difference was detected between the HCPs' and trainees' scores. The PCAT scores strongly correlated with other variables reflecting different competence levels. The PCAT scores showed significant changes in the baseline scores compared to scores after attending an educational intervention. The PCAT offers a first-of-its-kind tool for assessing HCPs' competence (ie, knowledge and its application) in managing chronic pain. Future research is needed for further validation and adaptation of the PCAT. PERSPECTIVE: The Pain Competence Assessment Tool (PCAT) offers a first-of-its-kind tool for assessing clinicians' core competencies that overlap between different professions and support the clinicians' capacity to successfully manage chronic pain in the real world focusing on the patient-centered perspective rather than the profession-specific perspective.
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Goodwin J, Kirkland S. Barriers and facilitators encountered by family physicians prescribing opioids for chronic non-cancer pain: a qualitative study. HEALTH PROMOTION AND CHRONIC DISEASE PREVENTION IN CANADA-RESEARCH POLICY AND PRACTICE 2021; 41:182-189. [PMID: 34164970 DOI: 10.24095/hpcdp.41.6.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Harms caused by prescription opioid analgesics (POAs) have been identified as a major international public health concern. Recent statistics show rising numbers of opioid-related deaths across Canada. However, Canadian family physicians appear to have inadequate resources to safely and effectively prescribe opioid analgesics to treat chronic non-cancer pain (CNCP). METHODS We completed a qualitative study of the barriers and facilitators to safe and effective prescribing of opioid analgesics for CNCP through semi-structured interviews with eight family physicians in Nova Scotia. Thematic analysis was used to identify the barriers and facilitators. RESULTS Family physicians identified challenges in prescribing opioid analgesics for CNCP: the complexity of CNCP management, addictions risks and prescribing tools, physician training, the physician-patient relationship, prescription monitoring and control, and systemic factors. CONCLUSION Family physicians described themselves as inadequately supported in their prescribing of opioid analgesics for CNCP and could benefit from an integrated and coordinated approach to prescriber support.
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Affiliation(s)
- Joshua Goodwin
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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