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Barriers to Guideline-Concordant Opioid Management in Primary Care—A Qualitative Study

  • Erin E. Krebs
    Correspondence
    Address reprint requests to Erin E. Krebs, MD, MPH, Department of Medicine, Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, University of Minnesota Medical School, Minneapolis VAMC (152), One Veterans Dr, Minneapolis, MN 55417.
    Affiliations
    Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota

    Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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  • Alicia A. Bergman
    Affiliations
    Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), VA Greater Los Angeles System, Los Angeles, California
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  • Jessica M. Coffing
    Affiliations
    Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
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  • Steffanie R. Campbell
    Affiliations
    Department of Medicine, Baylor College of Medicine, Houston, Texas
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  • Richard M. Frankel
    Affiliations
    Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana

    Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana

    Regenstrief Institute, Inc, Indianapolis, Indiana
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  • Marianne S. Matthias
    Affiliations
    Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana

    Regenstrief Institute, Inc, Indianapolis, Indiana

    Department of Communication Studies, Indiana University–Purdue University, Indianapolis, Indiana
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Published:August 29, 2014DOI:https://doi.org/10.1016/j.jpain.2014.08.006

      Highlights

      • Barriers to opioid guideline implementation include physician beliefs and attitudes.
      • Time pressure may lead to underuse of recommended opioid management practices.
      • Patients describe prevention of opioid-related harm as a physician responsibility.

      Abstract

      Prior studies have demonstrated poor physician adherence to opioid management guidelines in primary care. The objectives of this qualitative study were to understand physicians' and patients' perspectives on recommended opioid management practices and to identify potential barriers to and facilitators of guideline-concordant opioid management in primary care. Individual semistructured interviews were conducted with 14 primary care physicians and 26 of their patients receiving long-term opioid therapy. Data were analyzed using a qualitative immersion/crystallization approach. We identified 3 major barriers to and 1 facilitator of use of recommended opioid management practices. Major barriers were inadequate time and resources available; relying on general impressions of risk for opioid misuse; and viewing opioid monitoring as a “law enforcement” activity. The third barrier was most apparent for physicians in the context of drug testing and for patients in the context of opioid agreements. Beliefs about the need to protect patients from opioid-related harm emerged as a major facilitator, especially among patients. We hypothesize that future interventions to improve opioid management in primary care will be more effective if they address identified barriers and use a patient-centered framework, in which prevention of opioid-related harm to patients is emphasized as the primary goal.

      Perspective

      This article describes primary care perspectives on guideline-recommended opioid management practices. Barriers identified in this study may contribute to underuse of recommended opioid management practices. Consideration of barriers and facilitators to guideline-concordant care could improve effectiveness of future interventions aimed at improving opioid management in primary care.

      Key words

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