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Russell C, Ashley J, Ali F, Bozinoff N, Corace K, Marsh DC, Mushquash C, Wyman J, Zhang M, Lange S. Examining inequities in access to opioid agonist treatment (OAT) take-home doses (THD): A Canadian OAT guideline synthesis and systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104343. [PMID: 38554565 DOI: 10.1016/j.drugpo.2024.104343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 01/08/2024] [Accepted: 01/30/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. METHODS This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. RESULTS A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. CONCLUSIONS This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada, M5S 1A8.
| | - Jenna Ashley
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1
| | - Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St., Toronto, Ontario, Canada, M5T 1R8; Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Canada, M5G1V7
| | - Kim Corace
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, Canada, K1H 8M5; Substance Use and Concurrent Disorders Program, The Royal Ottawa Mental Health Center, 1145 Carling Avenue, Ottawa, Ontario, Canada, K1Z 7K4; University of Ottawa Institute of Mental Health Research, The Royal Ottawa Mental Health Center, 1145 Carling Avenue, Ottawa, Ontario, Canada, K1Z 7K4
| | - David C Marsh
- NOSM University, 935 Ramsey Lake Road, Sudbury, Ontario, Canada, P3E 2C6; ICES North, 56 Walford Road, Sudbury, Ontario, Canada, P3E 2H3; Health Science North Research Institute, 56 Walford Road, Sudbury, Ontario, Canada, P3E 2H3
| | - Christopher Mushquash
- Department of Psychology, Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1, Canada
| | - Jennifer Wyman
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Canada, M5G1V7; Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Maria Zhang
- Pharmacy Services, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada, M6J 1H4; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Canada, M5S 3M2
| | - Shannon Lange
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada, M5S 1A8; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St., Toronto, Ontario, Canada, M5T 1R8; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, Canada, M5T 1R8
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Treacy J, Morrato EH, Horne R, Wolf MS, Bakhai A, Wilson MC, Lightowler M, Guerler S, Jokinen J. Behavioral Science: Enhancing Our Approach to the Development of Effective Additional Risk Minimization Strategies. Drug Saf 2024:10.1007/s40264-024-01420-w. [PMID: 38594553 DOI: 10.1007/s40264-024-01420-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Abstract
Additional risk minimization strategies may be required to assure a positive benefit-risk balance for some therapeutic products associated with serious adverse drug reactions/risks of use, without which these products may be otherwise unavailable to patients. The goals of risk minimization strategies are often fundamentally to influence the behavior of healthcare professionals (HCPs) and/or patients and can include appropriate patient selection, provision of education and counselling, appropriate medication use, adverse drug reaction monitoring, and adoption of other elements to assure safe use, such as pregnancy prevention. Current approaches to additional risk minimization strategy development rely heavily on information provision, without full consideration of the contextual factors and multi-level influences on patient and HCP behaviors that impact adoption and long-term adherence to these interventions. Application of evidence-based behavioral science methods are urgently needed to improve the quality and effectiveness of these strategies. Evidence from the fields of adherence, health promotion, and drug utilization research underscores the value and necessity for using established behavioral science frameworks and methods if we are to achieve clinical safety goals for patients. The current paper aims to enhance additional risk minimization strategy development and effectiveness by considering how a behavioral science approach can be applied, drawing from evidence in understanding of engagement with pharmaceutical medicines as well as wider public health interventions for patients and HCPs.
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Affiliation(s)
| | - Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
| | - Robert Horne
- Spoonful of Sugar Ltd, University College London Business Company, Brighton and Hove, UK
| | - Michael S Wolf
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ameet Bakhai
- The Royal Free and University College Medical School, London, UK
| | | | - Mark Lightowler
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Science, King's College London, London, UK
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de Kleijn L, Jansen-Groot Koerkamp EAW, van der Kooij I, Veen M, Rijkels-Otters HJBM, Koes BW, Chiarotto A. Exploring the facilitators and barriers in opioid deprescribing for non-cancer pain treatment experienced by general practitioners: A qualitative study. Eur J Pain 2024. [PMID: 38287911 DOI: 10.1002/ejp.2243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 01/09/2024] [Accepted: 01/15/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Guidelines recommend opioid deprescribing in patients on long-term opioid treatment for chronic non-cancer pain. This study aims to explore facilitators and barriers in opioid deprescribing among general practitioners in the Netherlands. In addition, this study aims to identify possibilities for improvement regarding opioid deprescribing in primary care. METHODS Focus group discussions with Dutch General practitioners were held by two skilled moderators. The focus group discussions were transcribed verbatim and analysed using MAXQDA software. Three independent reviewers searched for overarching themes using thematic analysis with an inductive approach. Discussions were organized until data saturation was reached. RESULTS Twenty-two general practitioners participated in four focus group discussions. Five main themes emerged from the data: (1) patient-centred care; (2) ensuring proper pain management (3) dilemmas and hardships in dealing with opioid use disorder; (4) the competency gap; (5) needs and possibilities to improve opioid deprescribing in primary care. The first theme addresses the main facilitators in opioid tapering. The following three themes emerged as main barriers in opioid deprescribing. The fifth theme identified possibilities for change. CONCLUSIONS This study indicates the importance of intrinsic motivation and a tailored approach to deprescribe opioids in patients with chronic pain on long-term opioid treatment. Identified barriers include struggles in pain management, challenges caused by opioid use disorder, insufficient capacities such as time constraints and lack of skills. Recommendations for improvement involve enhanced collaboration with healthcare professionals in primary and secondary care, provision of practical tools and assurance of sufficient time. SIGNIFICANCE This focus group study among 22 Dutch general practitioners elucidates the complexities of opioid deprescribing and reveals pivotal themes such as patient-centred care, pain management challenges, and competency gaps. The findings underscore the crucial role of intrinsic motivation and that of a tailored approach in opioid deprescribing, while demonstrating how a lack in effective pain treatments, practical capacities and challenges caused by opioid dependence, impede opioid deprescribing. By uncovering these complexities, this study aims to inform future deprescribing strategies.
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Affiliation(s)
- Loes de Kleijn
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Elsemiek A W Jansen-Groot Koerkamp
- SIR Institute for Pharmacy Practice and Policy, Leiden, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Iris van der Kooij
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mario Veen
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Biesiada AM, Ciałkowska-Rysz A, Mastalerz-Migas A. Opioid Treatment in Primary Care: Knowledge and Practical Use of Opioid Therapy. Healthcare (Basel) 2024; 12:217. [PMID: 38255104 PMCID: PMC10815125 DOI: 10.3390/healthcare12020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Primary care physicians play a key role in initiating opioid therapy. However, knowledge gaps in opioid use and pain management are significant barriers to providing optimal care. This research study aims to investigate the educational needs of primary care physicians regarding opioid therapy and opioid use in pain management. METHODS A computer-assisted web interview (CAWI) protocol was used to collect data from primary care physicians. Drug selection criteria, knowledge of opioid substitutes and dosage, and practical use of opioid therapy were evaluated. RESULTS While 84% of participating physicians (724 respondents) reported initiating opioid treatment, only a minority demonstrated accurate opioid dosage calculations. Significant discrepancies between physicians' self-perceived knowledge and their clinical skills in opioid prescribing and pain management were observed. In total, 41% of physicians incorrectly indicated dose conversion rates for tramadol (the most frequently used drug according to 65% of responders). CONCLUSIONS Targeted educational programs are essential to bridge the knowledge gap and increase physicians' competence in pain management. The proper self-assessment of one's own skills may be the key to improvement. Further research should focus on developing specialized educational courses and decision-support tools for primary care physicians and examining the impact of interprofessional pain management teams on patient outcomes.
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Affiliation(s)
- Aleksander Michał Biesiada
- Family Physician Office S&M Ltd., 31-123 Krakow, Poland
- Polish Society of Family Medicine, 51-141 Wroclaw, Poland
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Guilcher SJT, Cimino SR, Tadrous M, McCarthy LM, Riad J, Tricco AC, Hagens S, Lien J, Tharmalingam S, Gomes T. Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review. J Med Internet Res 2023; 25:e49173. [PMID: 38153776 PMCID: PMC10784986 DOI: 10.2196/49173] [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: 05/24/2023] [Revised: 08/31/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted. OBJECTIVE This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations. METHODS A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach. RESULTS Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors. CONCLUSIONS This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.
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Affiliation(s)
- Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie R Cimino
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Jessica Riad
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Andrea C Tricco
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | | | | | | | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, 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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Hernandez-Ceron N, Gilani F, Hurava I, Kain NA, Ashworth N. Cross-sectional study of rapid tapering of opioid prescriptions following medical regulatory intervention in Alberta from 2013 to 2020. BMJ Open 2023; 13:e070066. [PMID: 37857542 PMCID: PMC10603432 DOI: 10.1136/bmjopen-2022-070066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE To determine if inappropriate tapering/discontinuation of opioids to Alberta patients occurred from mid-2013-2020, as unintended consequences of prescribing guidelines, regulations and policies in response to the North American opioid crisis. DESIGN A population-based, repeated cross-sectional time-series study. SETTING Alberta, Canada. PARTICIPANTS Residents of Alberta, Canada aged 18 and older who received an opioid dispense from a community pharmacy from 2013 to 2020. MAIN OUTCOME MEASURES The prevalence of potential rapid tapering was measured at a given date (reference day), enveloped by a data window. Dose changes were measured as oral morphine equivalents (OME) per patient, at multiple time points ('data window' around a reference day). Chronic recipients were identified, and their prescriptions were contrasted 90 days before and after the reference day to measure OME/day changes. RESULTS Approximately 9000 dispenses (totalling ~6 million OME) per day were analysed from 2013 to 2020. The total number of opioid recipients was highly cyclic in nature (peaking in winter). The number of chronic opioid recipients remained somewhat stable from ~70K in 2013 to ~86K at the end of 2020. The number of chronic high and very high dose recipients presented a significant decrease after 2017. Approximately 11%-12% of chronic high-dose recipients experienced potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. For chronic very high dose recipients, approximately 11.5% experience potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. Potential discontinuation remained constant and the interventions did not have a significant impact on the trend. CONCLUSION The evidence suggests that changes in prescribing guidelines were not associated with an increase of rapid opioid tapering/discontinuation in Alberta.
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Affiliation(s)
- Nancy Hernandez-Ceron
- Analytics, Innovation & Research, College of Physicians and Surgeons, Edmonton, Alberta, Canada
| | - Fizza Gilani
- Analytics, Innovation & Research, College of Physicians and Surgeons, Edmonton, Alberta, Canada
| | - Iryna Hurava
- Analytics, Innovation & Research, College of Physicians and Surgeons, Edmonton, Alberta, Canada
| | - Nicole Allison Kain
- Analytics, Innovation & Research, College of Physicians and Surgeons, Edmonton, Alberta, Canada
- University of Alberta, Edmonton, Alberta, Canada
| | - Nigel Ashworth
- Analytics, Innovation & Research, College of Physicians and Surgeons, Edmonton, Alberta, Canada
- University of Alberta, Edmonton, Alberta, Canada
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Kithulegoda N, Chu C, Tadrous M, Bean T, Salach L, Regier L, Bevan L, Burton V, Price D, Ivers N, Desveaux L. Academic detailing to improve appropriate opioid prescribing: a mixed-methods process evaluation. CMAJ Open 2023; 11:E932-E941. [PMID: 37848255 PMCID: PMC10586496 DOI: 10.9778/cmajo.20210050] [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: 10/19/2023] Open
Abstract
BACKGROUND Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing. METHODS In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing. RESULTS Physicians receiving academic detailing (n = 238) achieved a greater reduction in opioid prescribing than matched controls (n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change. INTERPRETATION The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing.
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Affiliation(s)
- Natasha Kithulegoda
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.
| | - Cherry Chu
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Tupper Bean
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Lena Salach
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Loren Regier
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Lindsay Bevan
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Victoria Burton
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - David Price
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Laura Desveaux
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
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9
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Hammaker K, Weathington N, Maroon J, Tang LW, Donohue B, Yehuda R, Ford KM, Figura M, Kelmendi B, Tan B, Cook MW, Factor SD, Lagano L, Driscoll HP, Howe AS, Cho EG, Rabin DM. An answered call for aid? Cannabinoid clinical framework for the opioid epidemic. Harm Reduct J 2023; 20:110. [PMID: 37587466 PMCID: PMC10428550 DOI: 10.1186/s12954-023-00842-6] [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: 09/13/2022] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND The opioid crisis continues in full force, as physicians and caregivers are desperate for resources to help patients with opioid use and chronic pain disorders find safer and more accessible non-opioid tools. MAIN BODY The purpose of this article is to review the current state of the opioid epidemic; the shifting picture of cannabinoids; and the research, policy, and current events that make opioid risk reduction an urgent public health challenge. The provided table contains an evidence-based clinical framework for the utilization of cannabinoids to treat patients with chronic pain who are dependent on opioids, seeking alternatives to opioids, and tapering opioids. CONCLUSION Based on a comprehensive review of the literature and epidemiological evidence to date, cannabinoids stand to be one of the most interesting, safe, and accessible tools available to attenuate the devastation resulting from the misuse and abuse of opioid narcotics. Considering the urgency of the opioid epidemic and broadening of cannabinoid accessibility amidst absent prescribing guidelines, the authors recommend use of this clinical framework in the contexts of both clinical research continuity and patient care.
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Affiliation(s)
- Krista Hammaker
- Northeast Ohio Medical University, 4209 St Rt 44, PO Box 95, Rootstown, OH, 44272, USA
| | - Nathaniel Weathington
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 200 Delafield Rd, Ste 2040, Pittsburgh, PA, 15215, USA
| | - Joseph Maroon
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 1218 Scaife Hall, 3550 Terrace St, Pittsburgh, PA, 15261, USA
| | - Lawton W Tang
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Huntington Hospital, 100 West California Blvd, Pasadena, CA, 91105, USA
| | - Brian Donohue
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 1300 Oxford Dr, Bethel Park, PA, 15102, USA
| | - Rachel Yehuda
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Kenneth M Ford
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Institute for Human and Machine Cognition (IHMC), 40 South Alcaniz, Pensacola, FL, 32502, USA
| | - Myro Figura
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of California Los Angeles, 757 Westwood Plaza, Ste 3325, Los Angeles, CA, 90095-7403, USA
| | - Ben Kelmendi
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Yale University, 300 George St, Ste 901, New Haven, CT, 06511, USA
| | - Belinda Tan
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- People Science, Inc, 3870 Del Amo Blvd, Unit 507, Torrance, CA, 90503, USA
| | - Matthew W Cook
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- BioReset Medical, 3803 S Bascom Ave, Ste 203, Campbell, CA, 95008, USA
| | - Steven D Factor
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Abington Neurological Associates, 1151 Old York Rd, Ste 200, Abington, PA, 19001, USA
| | - Laura Lagano
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
| | | | - Adam S Howe
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Albany Medical Center, 23 Hackett Blvd, MC-108, Albany, NY, 12208, USA
| | - EunBit G Cho
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
| | - David M Rabin
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA.
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10
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McCleary N, Laur C, Presseau J, Dobell G, Lam JM, Gushue S, Hagel K, Bevan L, Salach L, Desveaux L, M. Ivers N. Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231206569. [PMID: 37936967 PMCID: PMC10624081 DOI: 10.1177/26334895231206569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. Method We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Results Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). Conclusions The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.
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Affiliation(s)
- Nicola McCleary
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Gail Dobell
- Health System Performance & Support, Ontario Health, Toronto, Canada
| | - Jonathan M.C. Lam
- Health System Performance & Support, Ontario Health, Toronto, Canada
| | - Sharon Gushue
- Population Health & Prevention, Ontario Health, Toronto, Canada
| | - Katie Hagel
- Centre for Effective Practice, Toronto, Canada
| | | | - Lena Salach
- Centre for Effective Practice, Toronto, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Noah M. Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
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11
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Bell LV, Fitzgerald SF, Flusk D, Poulin PA, Rash JA. Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research. Can J Pain 2023; 7:2156331. [PMID: 36874229 PMCID: PMC9980668 DOI: 10.1080/24740527.2022.2156331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy. Aim The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature. Methods Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded. Results Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation). Conclusions Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.
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Affiliation(s)
- Louise V Bell
- Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Sarah F Fitzgerald
- Department of Psychology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - David Flusk
- Discipline of Anesthesia, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Patricia A Poulin
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Psychology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua A Rash
- Department of Psychology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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12
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McEwen V, Esterlis MM, Lorello RG, Sud A, Englesakis FM, Bhatia A. A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain. Can J Pain 2023; 7:2145940. [PMID: 36874231 PMCID: PMC9980640 DOI: 10.1080/24740527.2022.2145940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction/Aim Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain. Methods The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted. Results The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs. Discussion/Conclusions This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.
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Affiliation(s)
- Virginia McEwen
- Chronic Pain Management Program, St. Joseph's Care Group, Thunder Bay, ON, Canada.,Interventional Pain Service, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada.,Clinical Sciences Division, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
| | | | - R Gianni Lorello
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, University Health Network - Toronto Western Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Wilson Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Humber River Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - F Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Anuj Bhatia
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, University Health Network - Toronto Western Hospital, Toronto, ON, Canada
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13
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Poulin PA, Shergill Y, Grebowicz A, Almeida I, Cantave R, MacLeod B, Larocque T, Garstin D, Fitzgerald SF, Rash JA. Extension for Community Healthcare Outcomes (ECHO) Chronic Pain & Opioid Stewardship in Northwestern Ontario: A Thematic Analysis of Patient Cases. Can J Pain 2022; 6:211-224. [DOI: 10.1080/24740527.2022.2126754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Patricia A. Poulin
- St Joseph’s Care Group, Project ECHO Chronic Pain & Opioid Stewardship, Thunder Bay, ON, Canada
- Department of Psychology, Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Faculty of Medicine, Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Yaadwinder Shergill
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Adrian Grebowicz
- St Joseph’s Care Group, Project ECHO Chronic Pain & Opioid Stewardship, Thunder Bay, ON, Canada
- Northern Ontario School of Medicine, Lakehead University, Thunder Bay, ON, Canada
| | - Inês Almeida
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Psychology, ISCTE – Instituto Universitário de Lisboa, Lisbon, Portugal
| | - Rosemee Cantave
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bryan MacLeod
- St Joseph’s Care Group, Project ECHO Chronic Pain & Opioid Stewardship, Thunder Bay, ON, Canada
- St. Joseph’s Care Group, Chronic Pain Management Program, Thunder Bay, ON, Canada
| | - Tim Larocque
- St Joseph’s Care Group, Project ECHO Chronic Pain & Opioid Stewardship, Thunder Bay, ON, Canada
| | - Donna Garstin
- St Joseph’s Care Group, Project ECHO Chronic Pain & Opioid Stewardship, Thunder Bay, ON, Canada
| | - Sarah F. Fitzgerald
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Joshua A. Rash
- School of Social Sciences, Memorial University of Newfoundland, St. John’s, NL, Canada
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14
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A qualitative interview study of GPs' experiences of prescribing opioid medication for chronic pain. BJGP Open 2022; 6:BJGPO.2022.0085. [PMID: 36216370 PMCID: PMC9904793 DOI: 10.3399/bjgpo.2022.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses. AIM To explore GPs' experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice. DESIGN & SETTING Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales. METHOD Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach. RESULTS Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions. CONCLUSION Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely.
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15
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King LK, Krystia O, Waugh EJ, MacKay C, Stanaitis I, Stretton J, Weisman A, Ivers NM, Parsons JA, Lipscombe L, Hawker GA. Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework. OSTEOARTHRITIS AND CARTILAGE OPEN 2022; 4:100299. [PMID: 36474789 PMCID: PMC9718241 DOI: 10.1016/j.ocarto.2022.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/05/2022] [Accepted: 07/26/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM. Design We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines. Results Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences). Conclusions We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.
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Affiliation(s)
- Lauren K. King
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Owen Krystia
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Esther J. Waugh
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Crystal MacKay
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Ian Stanaitis
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | | | - Alanna Weisman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Noah M. Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Department of Community and Family Medicine, University of Toronto, Toronto, ON, Canada
| | - Janet A. Parsons
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Applied Health Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital – Unity Health Toronto, Toronto, ON, Canada
| | - Lorraine Lipscombe
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Gillian A. Hawker
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
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16
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Patey AM, Fontaine G, Francis JJ, McCleary N, Presseau J, Grimshaw JM. Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions. Psychol Health 2022; 38:766-794. [PMID: 35839082 DOI: 10.1080/08870446.2022.2100887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.
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Affiliation(s)
- Andrea M. Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jillian J. Francis
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola McCleary
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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17
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Bathia NS, McAskill RE, Hancox JE, Knaggs RD. Collaboration between adult patients and practitioners when making decisions about prescribing opioid medicines for chronic non-cancer pain in primary care: a scoping review. Br J Pain 2022; 16:119-126. [PMID: 35111320 PMCID: PMC8801689 DOI: 10.1177/20494637211025560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Long-term opioid therapy (>12 months) is not effective for improving chronic non-cancer pain and function. Where patients are not experiencing pain relief with long-term opioids, the opioid should be tapered and discontinuation considered. Practitioners may find it challenging to tell patients experiencing pain that they are better off reducing or not taking medicines that do not help. This review aims to ascertain what is published about: (1) the interaction and (2) the nature of the relationship between practitioners and patients when prescribing opioids for chronic non-cancer pain in primary care. METHOD A scoping review of English-language qualitative, quantitative or mixed-method studies in databases including: MEDLINE, Embase, PsycINFO, AMED, BNI, CINALH EMCARE and HMIC. The identified papers were reviewed to provide a descriptive summary of the literature. RESULTS The review identified 20 studies. The studies used a range of methods including interviews, focus groups, audio and video recordings of clinical consultations, telephone survey and data from patient records. One study reported that researchers had engaged with a patient advisory group to guide their research. Patients expressed the importance of being treated as individuals, not being judged and being involved in prescribing decisions. Practitioners expressed difficulty in managing patient expectations and establishing trust. Opioid risk and practitioner suspicion shape opioid prescribing decisions. There is a paucity of literature about how precisely practitioners overcome interactional challenges and implement personalised care in practice. CONCLUSION The studies in this review ascertain that practitioners and patients often find it challenging to achieve shared decisions in opioid review consultations. Effective communication is essential to achieve good clinical practice. Collaborative research with PPI partners should be aimed at identifying communication practices that support practitioners to achieve shared decisions with patients when reviewing opioids for chronic non-cancer pain.
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Affiliation(s)
- Nirlas Shantilal Bathia
- NHS Nottingham and Nottinghamshire CCG, Nottingham, UK,Nirlas Shantilal Bathia, NHS Nottingham and Nottinghamshire CCG, Nottingham NG1 6GN, UK.
| | | | - Jennie E Hancox
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Roger D Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
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18
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Punwasi R, de Kleijn L, Rijkels-Otters JBM, Veen M, Chiarotto A, Koes B. General practitioners' attitudes towards opioids for non-cancer pain: a qualitative systematic review. BMJ Open 2022; 12:e054945. [PMID: 35105588 PMCID: PMC8808445 DOI: 10.1136/bmjopen-2021-054945] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Worldwide the use of opioids, both doctor-prescribed and illicit, has increased. In most countries, opioids are first prescribed by general practitioners (GPs). Identifying factors that influence GPs' opioid prescription decision-making may help reduce opioid misuse and overuse. We performed a systematic review to gain insight into GP attitudes towards opioid prescription and to identify possible solutions to promote changes in the field of primary care. DESIGN AND SETTING Systematic review of qualitative studies reporting GPs' attitudes towards opioid use in non-cancer pain management. METHODS We searched Embase, Medline, Web of Science Core Collection, Cochrane, PsychInfo, Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Google Scholar. Two independent reviewers selected studies based on prespecified eligibility criteria. Study quality was evaluated with the Critical Appraisal Skills Programme checklist, and their results were analysed using thematic analysis. Quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. RESULTS We included 14 studies. Four themes were established using thematic analyses: (1) GPs caught in the middle of 'the opioid crisis'; (2) Are opioids always bad? (3) GPs' weighing scale, taking patient-related and therapeutic relationship-related factors into account; and (4) GPs' sense of powerlessness-lack of alternatives, support by specialists and lack of time in justifying non-prescriptions. CONCLUSION GP attitudes towards opioid prescribing for non-cancer pain are subject to several GP-related, patient-related and therapeutic relationship-related factors. Raising GP and patient awareness on the inefficacy of opioids in chronic non-cancer pain management and providing non-opioid alternatives to treat chronic pain might help to promote opioid reduction in primary care. More research is needed to develop practical guidelines on appropriate opioid prescribing, tapering off opioid use and adopting effective communication strategies. PROSPERO REGISTRATION NUMBER CRD42020194561.Cite Now.
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Affiliation(s)
- Rani Punwasi
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - L de Kleijn
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - J B M Rijkels-Otters
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - M Veen
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Bart Koes
- Department of General Practice, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
- Centre for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
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19
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Cross AJ, Buchbinder R, Mathieson S, Bourne A, Maher CG, Lin CWC, O'Connor DA. Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: a systematic review with qualitative evidence synthesis using the Theoretical Domains Framework. BMJ Qual Saf 2022; 31:387-400. [DOI: 10.1136/bmjqs-2021-014186] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022]
Abstract
BackgroundUnderstanding barriers and enablers to monitoring and deprescribing opioids will enable the development of tailored interventions to improve both practices.ObjectiveTo perform a qualitative evidence synthesis of the barriers and enablers to monitoring ongoing appropriateness and deprescribing of opioids for chronic non-cancer pain (CNCP) and to map the findings to the Theoretical Domains Framework (TDF).MethodsWe included English-language qualitative studies that explored healthcare professional (HCP), patient, carer and the general public’s perceptions regarding monitoring and deprescribing opioids for CNCP. We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO from inception to August 2020. Two authors independently selected the studies, extracted the data, assessed the methodological quality using the Critical Appraisal Skills Programme, and assessed the confidence in the findings using GRADE CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research). We used an inductive approach to synthesis of qualitative data and mapped identified themes to TDF domains.ResultsFrom 6948 records identified we included 21 studies, involving 209 HCPs and 330 patients. No studies involved carers or the general public. Five barrier themes were identified: limited alternatives to opioids, management of pain is top priority, patient understanding, expectations and experiences, prescriber pressures, and reluctance to change. Four enabler themes were identified: negative effects of opioids and benefits of deprescribing, clear communication and expectations for deprescribing, support for patients, and support for prescribers. 16 barrier and 12 enabler subthemes were identified; most were graded as high (n=15) or moderate (n=9) confidence. The TDF domains ‘beliefs about consequences’, ‘environmental context and resources’, ‘social influences’ and ‘emotion’ were salient for patients and HCPs. The domains ‘skills’ and ‘beliefs about capabilities’ were more salient for HCPs.ConclusionFuture implementation interventions aimed at monitoring and deprescribing opioids should target the patient and HCP barriers and enablers identified in this synthesis.PROSPERO registration numberCRD42019140784.
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20
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Ravishankar P, Barksdale E, Winkelman RD, Kavanaugh MD, Pelle DW, Benzel EC, Mroz TE, Steinmetz MP. Follow-up: the change in postoperative opioid prescribing after lumbar decompression surgery following a state-level prescribing reform. J Neurosurg Spine 2022:1-2. [PMID: 34996041 DOI: 10.3171/2021.10.spine211209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Edward Barksdale
- 1School of Medicine, Case Western Reserve University, Cleveland; and
| | | | | | - Dominic W Pelle
- 2Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edward C Benzel
- 2Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Thomas E Mroz
- 2Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio
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21
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Martins D, Khuu W, Tadrous M, Greaves S, Sproule B, Bozinoff N, Juurlink DN, Mamdani MM, Paterson JM, Gomes T. Impact of changes in opioid funding and clinical policies on rapid tapering of opioids in Ontario, Canada. Pain 2022; 163:e129-e136. [PMID: 34326293 PMCID: PMC8675054 DOI: 10.1097/j.pain.0000000000002420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 10/26/2022]
Abstract
ABSTRACT Reports have emerged of abrupt tapering among recipients of long-term prescription opioids to conform new prescribing guidelines. We conducted a population-based, repeated cross-sectional time-series study among very high-dose (≥200 MME) opioid recipients in Ontario, Canada, to examine changes in the monthly prevalence of rapid tapering from 2014 to 2018, defined as recipients experiencing either a ≥50% reduction in daily doses or abrupt discontinuation sustained for 30 days. Interventional autoregressive integrated moving average models were used to test for significant changes following key guidelines and drug policies and programs. A sensitivity analysis examined rapid tapering sustained for 90 days. The monthly prevalence of rapid tapering events was stable from January 2014 to September 2016 (average monthly prevalence: 1.4%) but increased from 1.4% in October 2016 to 1.8% in April 2017 (P = 0.001), coincident with Ontario's Fentanyl Patch-for-Patch Return Program implementation. Transient spikes in the prevalence of rapid tapering also occurred 2 months after Ontario's delisting of publicly funded high-strength opioids and the release of updated Canadian Opioid Prescribing Guideline for Chronic Pain, reaching 2.3% in March 2017 and July 2017, respectively. However, this prevalence decreased to 1.2% in December 2018 (P < 0.0001). Although the prevalence of abrupt opioid discontinuation was lower, similar trends were observed. Our sensitivity analysis examining long-lasting rapid tapering found similar trends but lower prevalence, with no changes in complete discontinuation. These temporary increases in rapid tapering events highlight the need for improved communication and evidence-based resources for prescribers to minimize negative consequences of evolving policies and guidelines.
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Affiliation(s)
- Diana Martins
- Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | | | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women’s College Hospital Research Institute, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Beth Sproule
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nikki Bozinoff
- ICES, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - David N. Juurlink
- ICES, Toronto, ON, Canada
- The Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Muhammad M. Mamdani
- Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - J. Michael Paterson
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tara Gomes
- Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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22
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Opioid Prescription Following Coronary Artery Bypass Grafting in the United States: A Call to Action. Ann Thorac Surg 2021; 114:1534-1537. [PMID: 34871575 DOI: 10.1016/j.athoracsur.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 11/20/2022]
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23
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Milner KA, DeNisco SM, Greer AE. Opioid Prescribing for Chronic Pain in Federally Qualified Health Centers Post–Centers for Disease Control and Prevention Guidelines. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Alderson SL, Farragher TM, Willis TA, Carder P, Johnson S, Foy R. The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis. PLoS Med 2021; 18:e1003796. [PMID: 34606504 PMCID: PMC8489725 DOI: 10.1371/journal.pmed.1003796] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care. METHODS AND FINDINGS A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate. CONCLUSIONS Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.
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Affiliation(s)
- Sarah L. Alderson
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Tracey M. Farragher
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
| | - Thomas A. Willis
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Paul Carder
- West Yorkshire Research and Development, National Health Service Bradford Districts Clinical Commissioning Group, Bradford, United Kingdom
| | - Stella Johnson
- West Yorkshire Research and Development, National Health Service Bradford Districts Clinical Commissioning Group, Bradford, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
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Effect of COVID-19 on management of patients with low back pain in the emergency department. Australas Emerg Care 2021; 25:154-160. [PMID: 34261620 PMCID: PMC8264562 DOI: 10.1016/j.auec.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 12/29/2022]
Abstract
Background Patients presenting to Emergency Department (ED) with non-specific low back pain can receive more unnecessary, intensive and costly care than is recommended. The COVID-19 pandemic has provided an unprecedented opportunity to examine how health systems prioritise necessary care that provides clear benefits to patients. The purpose of this study was to examine the impact of COVID-19 on care of low back pain in the ED. Methods We performed a retrospective analysis of electronic medical record data on care for low back pain from three public hospitals in Sydney. We included patients diagnosed with spinal conditions who presented between March and May in 2019 and in 2020. Outcomes were the total number of patients presenting with spinal conditions to ED, the proportion diagnosed with non-specific low back pain, and the proportion receiving potentially unnecessary aspects of care (ambulance use, imaging, opioids, hospital admissions). We calculated relative risk with 95% CIs and examined plots with locally weighted smoothed curves. Results Presentations for spinal conditions over a three-month period to three EDs reduced from 694 in 2019 to 475 in 2020 (31% reduction, 95% CI = 26%–37%). The proportion of patients diagnosed with non-specific low back pain (83% in 2019 vs 86% in 2020), or receiving potentially unnecessary care were similar in 2019 and 2020 (Imaging = 25% vs 25%; Opioids = 54% vs 56%; Admitted = 18% vs 20%; pathology test = 24% vs 23%). The proportion of patients arriving by ambulance was higher during the pandemic; 29% in 2019 vs 41% in 2020 (RR = 1.39, 95% CI = 1.19–1.63). Conclusions ED presentations for low back pain associated with spinal conditions decreased substantially during the COVID-19 pandemic. Use of potentially unnecessary aspects of care did not change or increased during the pandemic.
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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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AlRuthia Y, Alhazzani H, Alhindi G, Alarfaj M, Almutairi L, Alanazi M, Alokili K, Alanazi N, Alodaibi F, Alwhaibi M, Bashatah AS, Asiri Y, Alsanawi H. Predictors of Opioid Prescription Among a Sample of Patients with Acute Musculoskeletal Pain at a Tertiary Care Hospital in Saudi Arabia. J Pain Res 2020; 13:2929-2936. [PMID: 33235491 PMCID: PMC7678505 DOI: 10.2147/jpr.s276630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background Musculoskeletal pain is one of the most complex and debilitating types of pain. Although different pharmacologic treatments are available, very few studies have explored the predictors for opioid analgesics prescription to manage this type of pain. Objective The aim of this study was to explore the predictors for opioid prescription in patients with acute musculoskeletal pain in Saudi Arabia. Methods This was a single-center, retrospective chart review of adult patients (≥18 yrs.) with an acute nociceptive musculoskeletal pain at a university-affiliated medical center in Riyadh, Saudi Arabia. Cancer patients and those with chronic neuropathic pain were excluded. Patients’ age, gender, number of comorbidities, duration of pain management, number of clinic visits for pain, and Numeric Pain Rating Scale (NPRS) scores at rest and with normal activities were collected. Multiple logistic regression was conducted to examine the relationship between the type of musculoskeletal pain and the prescription of opioid analgesics controlling for NPRS score on activity, age, gender, number of comorbidities, duration of pain treatment, and number of clinic visits for pain. Results The mean age of the 227 patients, who met the inclusion criteria, was 39 years and 68% of them were male. Sixty-three percent of the patients were prescribed opioid analgesics, and 61% of them had shoulder pain, 29% had back pain, and 10% had lower extremity pain (eg, hip, thigh, lower leg, knee, ankle, and foot pain). Tramadol was the most commonly prescribed opioid analgesic (82%), followed by codeine (13%). Ninety-seven percent of patients who were prescribed non-opioid analgesics had shoulder pain. Patients with shoulder pain had lower odds of receiving opioid analgesics (OR=0.019, P<0.0001, 95% CI=0.004–0.081) in comparison to their counterparts who had lower extremity or back pains. Moreover, the higher the pain score on activity was, the higher odds of receiving opioid analgesics (OR=1.317, P<0.0001, 95% CI=1.029–1.685). Conclusion Future studies should explore the impact of different opioid prescribing policies to improve the quality of patient care and reduce the unnecessary prescribing of opioids for patients with non-cancer musculoskeletal pain.
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Affiliation(s)
- Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hawazin Alhazzani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ghaida Alhindi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Maryam Alarfaj
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Lama Almutairi
- Department of Pharmacy, King Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Miteb Alanazi
- Department of Pharmacy, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Khaulah Alokili
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nouf Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alodaibi
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Adel S Bashatah
- Department of Nursing Education and Administration, College of Nursing, King Saud University, Riyadh, Saudi Arabia
| | - Yousif Asiri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hisham Alsanawi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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A Population Study of Prescribed Opioid-based Pain Reliever Use among Individuals with Mood and Anxiety Disorders in Canada. Drug Alcohol Depend 2020; 216:108229. [PMID: 32841813 PMCID: PMC7939522 DOI: 10.1016/j.drugalcdep.2020.108229] [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: 04/06/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the context of the ongoing North American overdose crisis, a clear understanding of opioid prescription and usage trends is important. Although individuals with mood and/or anxiety disorders are a sub-population at increased risk of developing substance use disorders, they have been identified as more likely to receive opioid prescriptions. The primary objective of this study was to investigate differences in prescribed opioid-based pain reliever use between Canadians with and without diagnosed mood and/or anxiety disorders. METHODS We utilized data from the 2015-2016 Canadian Community Health Survey (CCHS), a population-based, cross-sectional survey. We examined self-reported diagnoses of mood and/or anxiety disorders and self-reported prescribed opioid-based pain reliever use. Logistic regression modeling was used to estimate the unadjusted and adjusted odds of prescribed opioid-based pain reliever use associated with mood and/or anxiety disorders. RESULTS Our study sample had 2,810 individuals. The prevalence of mood and/or anxiety disorders and prescribed opioid use was 11.7% and 14.6%, respectively. Individuals diagnosed with mood and/or anxiety disorders were more likely to use prescribed opioid-based pain relievers compared with individuals without these diagnoses (OR = 2.36, 95% CI = 1.64, 3.41), even after adjustment for age, sex, total household income, cultural/racial background, and chronic pain (AOR= 1.78, 95% CI= 1.23, 2.58). CONCLUSIONS Our findings suggest that mood and/or anxiety disorders were positively associated with prescribed opioid-based pain reliever use. Future research should investigate potential unmet healthcare needs among individuals with these conditions, as mood and/or anxiety disorders may be modifiable risk factors.
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Warner NS, Finnie D, Warner DO, Hooten WM, Mauck KF, Cunningham JL, Gazelka H, Bydon M, Huddleston PM, Habermann EB. The System Is Broken: A Qualitative Assessment of Opioid Prescribing Practices After Spine Surgery. Mayo Clin Proc 2020; 95:1906-1915. [PMID: 32736943 DOI: 10.1016/j.mayocp.2020.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To elucidate factors that influence opioid prescribing behaviors of key stakeholders after major spine surgery, with a focus on barriers to optimized prescribing. METHODS In-person semi-structured interviews were performed with 20 surgical and medical professionals (January 23, 2019 to June 11, 2019) at a large academic medical center, including resident physicians, midlevel providers, attending physicians, and clinical pharmacists. Interviews centered on perceptions of postoperative prescribing practices were coded and analyzed using a qualitative inductive approach. RESULTS Several unique themes emerged. First, wide interprovider variation exists in the perceived role of opioid prescribing guidelines. Second, there are important relationships between clinical experience, time constraints, and postoperative opioid prescribing. Third, opioid tapering is a major area of inconsistency. Fourth, there are serious challenges in managing analgesic expectations, particularly in those with chronic pain. Finally, there is currently no process to facilitate the hand-off or transition of opioid prescribing responsibility between surgical and primary care teams, which represents a major area for practice optimization efforts. CONCLUSION Despite increased focus on postoperative opioid prescribing, there remain numerous areas for improvement. The development of tools and processes to address critical gaps in postoperative prescribing will be essential for our efforts to reduce long-term opioid use after major spine surgery and improve patient care.
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Affiliation(s)
- Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Dawn Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Halena Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Roberson PNE, Cortez G, Trull LH, Lenger K. In Their Own Words: How Opioids Have Impacted the Lives of "Everyday" People Living in Appalachia. JOURNAL OF APPALACHIAN HEALTH 2020; 2:26-36. [PMID: 35769637 PMCID: PMC9150495 DOI: 10.13023/jah.0204.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction The opioid epidemic is ravaging people, families, and communities in Appalachia. However, limited research has examined how "everyday" people (e.g., not chronic pain patients, not medical professionals) living in these communities how opioids have impacted their lives. Objective Identify the perception of the opioid epidemic on individuals, families, and communities from people living in region most impacted regions. Methods Patients were recruited at Remote Area Medical clinics throughout Central and Southern Appalachia to complete interviews online (N = 169) or over the phone (N = 26), including one open-ended question about how opioids have impacted their lives. Results Using the qualitative method content analysis, several themes were identified, including both the positive and negative impact of opioids from the online interviews. Additionally, resiliency was found to be a common theme and a theme not often emphasized by scholars and the media. These themes also highlight the importance of social support in these communities. Further, in the phone interviews, we were able to replicate the themes, and an additional theme was identified: Systemic Cause of Opioids. Conclusion Opioid intervention must be comprehensive and include the cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must harness the existing resiliency and social support in these communities to effectively combat the opioid crisis in Appalachia. Otherwise, opioids will remain the insider and further insulate Appalachian communities from systemic recovery.
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Carland JE, Elhage T, Baysari MT, Stocker SL, Marriott DJE, Taylor N, Day RO. Would they trust it? An exploration of psychosocial and environmental factors affecting prescriber acceptance of computerised dose-recommendation software. Br J Clin Pharmacol 2020; 87:1215-1233. [PMID: 32691902 DOI: 10.1111/bcp.14496] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/14/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Dose-prediction software can optimise vancomycin therapy, improving therapeutic drug monitoring processes and reducing drug toxicity. Success of software in hospitals may be dependent on prescriber uptake of software recommendations. This study aimed to identify the perceived psychosocial and environmental barriers and facilitators to prescriber acceptance of dose-prediction software. METHODS Semi-structured interviews, incorporating prescribing scenarios, were undertaken with 17 prescribers. Participants were asked to prescribe the next maintenance dose of vancomycin for a scenario(s) and then asked if they would accept a recommendation provided by a dose-prediction software. Interviews further explored opinions of dose-prediction software. Interview transcripts were analysed using an inductive approach to identify themes and the Theoretical Domains Framework was used to synthesise barriers and facilitators to software acceptance. RESULTS When presented with software recommendations, half of the participants were comfortable with accepting the recommendation. Key barriers to acceptance of software recommendations aligned with 2 Theoretical Domains Framework domains: Knowledge (uncertainty of software capability) and Beliefs about Consequences (perceived impact of software on clinical outcomes and workload). Key facilitators aligned with 2 domains: Beliefs about Consequences (improved efficiency) and Social Influences (influence of peers). A novel domain, Trust, was identified as influential. CONCLUSION Prescribers reported barriers to acceptance of dose-prediction software aligned with limited understanding of, and scepticism about, software capabilities, as well as concerns about clinical outcomes. Identification of key barriers and facilitators to acceptance provides essential information to design of implementation strategies to support the introduction of this intervention into the workplace.
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Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Tania Elhage
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
| | - Melissa T Baysari
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Natalie Taylor
- Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia.,School of Medical Sciences, University of NSW, Kensington, NSW, Australia
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Percy ED, Hirji S, Cote C, Laurin C, Atkinson L, Kiehm S, Malarczyk A, Harloff M, Bozso SJ, Buyting R, Fatehi Hassanabad A, Guo MH, Jaffer I, Lodewyks C, Tam DY, Tremblay P, Légaré JF, Cook R, Kaneko T, Pelletier MP. Variability in opioid prescribing practices among cardiac surgeons and trainees. J Card Surg 2020; 35:2657-2662. [PMID: 32720337 DOI: 10.1111/jocs.14885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. METHODS A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. RESULTS Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. CONCLUSIONS Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.
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Affiliation(s)
- Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claudia Cote
- Division of Cardiac Surgery, Dalhousie Medical School, Halifax, Canada
| | - Charles Laurin
- Division of Cardiac Surgery, Université Laval, Quebec, Canada
| | - Logan Atkinson
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Spencer Kiehm
- Department of Medical Education, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Ryan Buyting
- Department of Medicine, Dalhousie Medical School, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | | | - Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada
| | - Iqbal Jaffer
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Carly Lodewyks
- Section of Cardiac Sciences, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Tremblay
- Division of Cardiac Surgery, Dalhousie Medical School, Halifax, Canada
| | - Jean-François Légaré
- Department of Medicine, Dalhousie Medical School, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | - Richard Cook
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc P Pelletier
- Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Busse JW, Juurlink D, Buckley DN, Guyatt GH. Response to "understanding the behavioural determinants of opioid prescribing among family physicians: a qualitative study". BMC FAMILY PRACTICE 2020; 21:109. [PMID: 32534565 PMCID: PMC7293785 DOI: 10.1186/s12875-020-01187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/10/2020] [Indexed: 11/21/2022]
Abstract
The 2017 Canadian opioid Guideline made both strong recommendations, indicating that all or almost all fully informed patients would choose the recommended course of action, and weak recommendations, in which different choices are appropriate for individual patients based on their values and preferences. The Guideline’s recommendation to taper legacy patients prescribed high-dose opioid therapy is weak, and mandatory tapering is expressly discouraged.
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Affiliation(s)
- Jason W Busse
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, HSC-2V9, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.
| | - David Juurlink
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room G1 57, Toronto, ON, M4N 3M5, Canada
| | - D Norman Buckley
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, MDCL-2104, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Gordon H Guyatt
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, HSC-2V9, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
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Perceptions and Impact of the 2017 Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain: A Cross-Sectional Study of Canadian Physicians. Pain Res Manag 2020; 2020:8380171. [PMID: 32148601 PMCID: PMC7048936 DOI: 10.1155/2020/8380171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/25/2019] [Indexed: 12/21/2022]
Abstract
Background Physician adherence to guideline recommendations for the use of opioids to manage chronic pain is often limited. Objective In February 2018, we administered a 28-item online survey to explore perceptions of the 2017 Canadian guideline for opioid therapy and chronic noncancer pain and if physicians had altered practices in response to recommendations. Results We invited 34,322 Canadian physicians to complete our survey, and 1,128 responded for a response rate of 3%; 687 respondents indicated they prescribed opioids for noncancer pain and answered survey questions about the guideline and their practice. Almost all were aware of the guideline, 94% had read the document, and 89% endorsed the clarity as good or excellent. The majority (86%) felt the guideline was feasible to implement, but 66% highlighted resistance by patients, and 63% the lack of access to effective nonopioid treatment as barriers. Thirty-six percent of respondents mistakenly believed the guideline recommended mandatory tapering for patients using high-dose opioid therapy (≥90 mg morphine equivalent per day), and 58% felt they would benefit from support for opioid tapering. Seventy percent of respondents had changed practices to align with guideline recommendations, with 51% engaging some high-dose patients in opioid tapering and 43% reducing the number of new opioid starts. Conclusion There was high awareness of the 2017 Canadian opioid guideline among respondents, and preliminary evidence that recommendations have changed practice to better align with the evidence. Ongoing education is required to avoid the misunderstanding that opioid tapering is mandatory, and research to identify effective strategies to manage chronic noncancer pain is urgently needed.
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