Why we still prescribe so many opioids: A qualitative study on barriers and facilitators to prescribing guideline implementation

Authors

DOI:

https://doi.org/10.5055/jom.2021.0622

Keywords:

clinical guidelines, opioid stewardship, multidisciplinary implementation, pain medicine, focus groups

Abstract

Introduction: Opioid prescribing occurs within almost every healthcare setting. Implementation of safe, effective opioid stewardship programs represents a critical but daunting challenge for medical leaders. This study sought to understand the barriers and aids to the routine use of clinical guidelines for opioid prescribing among healthcare professionals and to identify areas in need of additional education for prescribing providers, pharmacists, and nurses.

Methods: Data collection and analysis in 2018-2019 employed a team of two trained facilitators who conducted 20 focus groups using a structured facilitation guide to explore operational, interpersonal, and patient care-related barriers to best practice adherence. Each professional group was interviewed separately, with similar care settings assigned together. Invitation to participate was based on a sampling methodology representing emergency, medical specialty, primary care, and surgical practice settings.

Results: Key concerns among all groups reflected the inadequacy of available tools for staff to appropriately assess and treat patients’ pain. Tools and technology to support safe opioid prescribing were also cited as a barrier by all three professional groups. All groups noted that prescribers tend to rely upon default settings within the electronic medical record when issuing prescriptions. Both pharmacists and prescribers cited time and scheduling as a barrier to adherence.

Conclusions: In spite of significant regulatory and public policy efforts to address the opioid crisis, healthcare organizations face significant challenges to improve adherence to best practice prescribing guidelines. These findings highlight several facilitators for change which could boost opioid stewardship initiatives to focus on critical systems’ factors for improvement.

Author Biographies

Kathryn W. Zavaleta, MHSA

Department of Management Engineering and Consulting, Mayo Clinic, Rochester, Minnesota

Lindsey M. Philpot, PhD, MPH

Department of Medicine, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota

Julie L. Cunningham, PharmD, RPh

Department of Pharmacy, Mayo Clinic, Rochester, Minnesota

Halena M. Gazelka, MD

Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

Holly L. Geyer, MD

Department of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota

Denise L. Rismeyer, MSN, RN, NPD-BC

Department of Nursing, Mayo Clinic, Rochester, Minnesota

Amber M. Stitz, DNP, APRN, ACNS-BC

Department of Nursing and Practice Optimization and Acceleration, Mayo Clinic, Rochester, Minnesota

Casey M. Clements, MD, PhD

Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota

References

Hah JM, Bateman BT, Ratliff J, et al.: Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesth Analg. 2017; 125(5): 1733-1740.

Thiels CA, Anderson SS, Ubl DS, et al.: Wide variation and overprescription of opioids after elective surgery. Ann Surg. 2017; 266(4): 564-573.

Badreldin N, Grobman WA, Chang KT, et al.: Opioid prescribing patterns among postpartum women. Am J Obstet Gynecol. 2018; 219(1): 103.e101-103.e108.

Buono K, Brueseke T, Wu J, et al.: Evaluation of opioid prescriptions after urogynecologic surgery within a large health care organization: How much are we prescribing? Female Pelvic Med Reconstr Surg. 2019; 25(2): 125-129.

Ziegelmann MJ, Joseph JP, Glasgow AE, et al.: Wide variation in opioid prescribing after urological surgery in tertiary care centers. Mayo Clin Proc. 2019; 94(2): 262-274.

Howard R, Fry B, Gunaseelan V, et al.: Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019; 154(1): e184234.

Bartels K, Mayes LM, Dingmann C, et al.: Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One. 2016; 11(1): e0147972.

Toye F, Seers K, Tierney S, et al.: A qualitative evidence synthesis to explore healthcare professionals’ experience of prescribing opioids to adults with chronic non-malignant pain. BMC Fam Pract. 2017; 18(1): 94.

Ebbert JO, Philpot LM, Clements CM, et al.: Attitudes, beliefs, practices, and concerns among clinicians prescribing opioids in a large academic institution. Pain Med. 2018; 19(9): 1790-1798.

Thiels CA, Hanson KT, Cima RR, et al.: From data to practice: Increasing awareness of opioid prescribing data changes practice. Ann Surg. 2018; 267(3): e46-e47.

Cushman PA, Liebschutz JM, Hodgkin JG, et al.: What do providers want to know about opioid prescribing? A qualitative analysis of their questions. Subst Abus. 2017; 38(2): 222-229.

Desveaux L, Saragosa M, Kithulegoda N, et al.: Understanding the behavioural determinants of opioid prescribing among family physicians: A qualitative study. BMC Fam Pract. 2019; 20(1): 59.

Kilaru AS, Gadsden SM, Perrone J, et al.: How do physicians adopt and apply opioid prescription guidelines in the emergency department? A qualitative study. Ann Emerg Med. 2014; 64(5): 482-489.

Penm J, MacKinnon NJ, Connelly C, et al.: Emergency physicians’ perception of barriers and facilitators for adopting an opioid prescribing guideline in Ohio: A qualitative interview study. J Emerg Med. 2019; 56(1): 15-22.

Krebs EE, Bergman AA, Coffing JM, et al.: Barriers to guideline-concordant opioid management in primary care—A qualitative study. J Pain. 2014; 15(11): 1148-1155.

Spitz A, Moore AA, Papaleontiou M, et al.: Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: A qualitative study. BMC Geriatr. 2011; 11: 35.

Hagemeier NE, Tudiver F, Brewster S, et al.: Interprofessional prescription opioid abuse communication among prescribers and pharmacists: A qualitative analysis. Subst Abus. 2018; 39(1): 89-94.

Gazelka HM, Clements CM, Cunningham JL, et al.: An institutional approach to managing the opioid crisis. In Paper presented at Mayo Clinic Proceedings, 2020.

Dowell D, Compton WM, Giroir BP: Patient-centered reduction or discontinuation of long-term opioid analgesics: The HHS guide for clinicians. JAMA. 2019; 322(19): 1855-1856.

Rubin R: HHS guide for tapering or stopping long-term opioid use. JAMA. 2019; 322(20): 1947-1947.

Wanzer MB, Wojtaszczyk AM, Kelly J: Nurses’ perceptions of physicians’ communication: The relationship among communication practices, satisfaction, and collaboration. Health Commun. 2009; 24(8): 683-691.

Philpot LM, Barnes SA, Brown RM, et al.: Barriers and benefits to the use of patient outcome measures in routine clinical care: A qualitative study. Am J Med Qual. 2018; 33(4): 359-364.

Breivik EK, Björnsson GA, Skovlund E: A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain. 2000; 16(1): 22-28.

Hadland SE, Kertesz SG: Opioid deaths in Ontario, Canada. United Kingdom: British Medical Journal Publishing Group, 2018b; 362: k3537. DOI: 10.1136/bmj.k3537.

The Joint Commission, LD.04.03.13 EP 1 (Effective January 1, 2018): Pain assessment and management standards. Program-specific standards. Available at https://www.jointcommission.org/en/resources/patient-safety-topics/pain-management-standards-for-accredited-organizations/. Accessed September 5, 2020.

Published

03/01/2021

How to Cite

Zavaleta, MHSA, K. W., L. M. Philpot, PhD, MPH, J. L. Cunningham, PharmD, RPh, H. M. Gazelka, MD, H. L. Geyer, MD, D. L. Rismeyer, MSN, RN, NPD-BC, A. M. Stitz, DNP, APRN, ACNS-BC, and C. M. Clements, MD, PhD. “Why We Still Prescribe so Many Opioids: A Qualitative Study on Barriers and Facilitators to Prescribing Guideline Implementation”. Journal of Opioid Management, vol. 17, no. 2, Mar. 2021, pp. 115-24, doi:10.5055/jom.2021.0622.