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

Kathryn W. Zavaleta, MHSA, Lindsey M. Philpot, PhD, MPH, Julie L. Cunningham, PharmD, RPh, Halena M. Gazelka, MD, Holly L. Geyer, MD, Denise L. Rismeyer, MSN, RN, NPD-BC, Amber M. Stitz, DNP, APRN, ACNS-BC, Casey M. Clements, MD, PhD


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.


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

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