Open Access Open Access  Restricted Access Subscription or Fee Access

How opioid prescribing policies influence primary care clinicians’ treatment decisions and conversations with patients with chronic pain

Elizabeth C. Danielson, PhD, Christopher A. Harle, PhD, Sarah M. Downs, MPH, Laura Militello, MA, Olena Mazurenko, MD, PhD

Abstract


Objective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.

Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.

Results: Opioid prescribing policies influenced clinicians’ treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).

Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.


Keywords


chronic pain, opioid prescribing policies, treatment decisions, primary care

Full Text:

PDF

References


Abuse S: Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality. Substance Abuse and Mental Health Services Administration, 2019.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645.

Traylor C: Center for Medicare and Medicaid services. CMCS informational bulletin: Medicaid strategies for non-opioid pharmacologic and non-pharmacologic chronic pain management. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib022219.pdf. Updated February 22, 2019. Accessed November 4, 2020.

Dowell D, Haegerich T, Chou R: No shortcuts to safer opioid prescribing. N Engl J Med. 2019; 380(24): 2285-2287.

Bohnert AS, Guy GP Jr, Losby JL: Opioid prescribing in the United States before and after the centers for disease control and prevention's 2016 opioid guideline. Ann Intern Med. 2018; 169(6): 367-375.

Wilson N: Drug and opioid-involved overdose deaths—United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020; 69(Suppl. 1): 38-46.

Kroenke K, Alford DP, Argoff C, et al.: Challenges with implementing the centers for disease control and prevention opioid guideline: A consensus panel report. Pain Med. 2019; 20(4): 724-735.

Centers for Disease Control and Prevention website: CDC advises against misapplication of the guideline for prescribing opioids for chronic pain. Available at https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guidelineprescribing-opioids.html. Updated April 24, 2019. Accessed August 23, 2020.

Health Professionals for Patients in Pain: Professionals call on the CDC to address misapplication of its guideline on opioids for chronic pain through public clarification and impact evaluation. Available at https://dontpunishpainrally.com/wp-content/Flyer-Files/CPP%20News%20Source/Professionals%20Call%20on%20CDC%20to%20Address%20Misapplication%20of%20Guidelines.PDF. Updated March 6, 2019. Accessed August 23, 2020.

Food and Drug Administration: FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. Food and drug administration website. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuationopioid-pain-medicines-and-requires-label-changes. Updated April 9, 2019. Accessed August 23, 2020.

Kennedy LC, Binswanger IA, Mueller SR, et al.: “Those conversations in my experience don't go well”: A qualitative study of primary care provider experiences tapering long-term opioid medications. Pain Med. 2018; 19(11): 2201-2211.

Militello LG, Anders S, Downs SM, et al.: Understanding how primary care clinicians make sense of chronic pain. Cogn Tech Work. 2018; 20(4): 575-584.

Harle CA, DiIulio J, Downs SM, et al.: Decision-centered design of patient information visualizations to support chronic pain care. Appl Clin Inform. 2019; 10(04): 719-728.

Harle CA, Apathy NC, Cook RL, et al.: Information needs and requirements for decision support in primary care: An analysis of chronic pain care. AMIA Annu Symp Proc. 2018; 2018: 527-534.

Militello LG, Hurley RW, Cook RL, et al.: Primary care clinicians’ beliefs and strategies for managing chronic pain in an era of a national opioid epidemic. J Gen Intern Med. 2020; 35: 3542-3547.

Python Releases for Windows: Available at https://www.python.org/downloads/windows/. Updated 2019. Accessed October 1, 2020.

Vaismoradi M, Turunen H, Bondas T: Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013; 15(3): 398-405.

DeSantis L, Ugarriza DN: The concept of theme as used in qualitative nursing research. West J Nurs Res. 2000; 22(3): 351-372.

Campbell JN: APS 1995 presidential address. Pain Forum. 1996; 5(1): 1-92.

Baker DW: History of the joint commission's pain standards: Lessons for today's prescription opioid epidemic. JAMA. 2017; 317(11): 1117-1118.

Davis CS, Lieberman AJ, Hernandez-Delgado H, et al.: Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review. Drug Alcohol Depend. 2019; 194: 166-172.

Heins SE, Frey KP, Alexander GC, et al.: Reducing high-dose opioid prescribing: State-level morphine equivalent daily dose policies, 2007–2017. Pain Med. 2020; 21(2): 308-316.

Association ISM: Indiana pain management prescribing final rule. Indiana state medical association website. Available at https://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf. Updated October 25, 2016. Accessed August 26, 2020.

Indiana State Medical Association website: Opioid prescribing requirements. 844 IAC 5-6-8 drug monitoring testing. Available at https://www.ismanet.org/pdf/FinalRule102516.pdf. Updated August 22, 2016. Accessed August 26, 2020.

Henry SG, Paterniti DA, Feng B, et al.: Patients’ experience with opioid tapering: A conceptual model with recommendations for clinicians. J Pain. 2019; 20(2): 181-191.

Mark TL, Parish W: Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 2019; 103: 58-63.

Oliva EM, Bowe T, Manhapra A, et al.: Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: Observational evaluation. BMJ. 2020; 368: m283.

James JR, Scott JM, Klein JW, et al.: Mortality after discontinuation of primary care-based chronic opioid therapy for pain: A retrospective cohort study. J Gen Intern Med. 2019; 34(12): 2749-2755.

Indiana State Medical Association: A comparison of the CDC opioid prescribing guidelines for chronic pain and the Indiana opioid prescribing rule. Indiana state health department website. Available at: https://www.in.gov/isdh/files/31_Comparison%20of%20CDC%20v.%20Indiana%20Rx%20Guidelines.pdf. Accessed October 20, 2020.

Indiana State Medical Association website: Opioid prescribing requirements. 844 ICA 5-6-7 INSPECT report. Available at https://www.ismanet.org/pdf/FinalRule102516.pdf. Updated October 7, 2014.

Sekhon R, Aminjavahery N, Davis CN Jr, et al.: Compliance with opioid treatment guidelines for chronic non-cancer pain (CNCP) in primary care at a veterans affairs medical center (VAMC. Pain Med. 2013; 14(10): 1548-1556.

Xierali IM, Nivet MA: The racial and ethnic composition and distribution of primary care physicians. J Health Care Poor Underserved. 2018; 29(1): 556-570.

Association of American Medical Colleges: Active physicians by sex and specialty. 2015. Available at https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sexand-specialty-2015. Accessed February 24, 2021.

Association of American Medical Colleges: Active physicians by age and specialty. 2015. Available at https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-ageand-specialty-2015. Accessed February 24, 2021.




DOI: https://doi.org/10.5055/jom.2021.0684

Refbacks

  • There are currently no refbacks.