Summary
In order to identify important targets for interventions, it is necessary to understand the challenges that providers experience when considering the use of opioids in the management of patients with pain.
An existing AD intervention targeted to PCPs was leveraged to identify barriers related to safe prescribing of opioids. The coding of field notes obtained through open-ended feedback from 186 AD visits with PCPs resulted in the identification of six themes related to barriers impacting safe opioid prescribing in primary care. Gaps in knowledge and lack of PMP utilisation were most commonly identified. Additional, albeit less commonly identified, issues raised by providers included pressure from patients to prescribe opioids, limited patient access to other pain treatments/specialists due to insurance coverage, provider beliefs, and health system pain management practices.
Overall, the findings from this study underscore issues relevant to safe opioid prescribing and pain-management practices to improve patient outcomes.
Strengths and limitations
To the authors’ knowledge, the current study is the largest qualitative study focused on the identification of barriers to safe opioid prescribing in primary care and the first to describe barriers among PCPs practising outside of the VHA. This study also demonstrated that field notes associated with an AD visit can be used as a novel approach to identify and facilitate barriers to safe opioid prescribing among PCPs within a health system on a large scale.
The themes identified in this study must be interpreted in consideration of several limitations. Themes were generated from open-ended questions and feedback as PCPs were not interviewed or asked directly about barriers they perceived to opioid prescribing through standardised questions. Because field notes documented from the perspective of the detailer were solely used to identify opioid prescribing barriers, this may have limited the depth and breadth of the barriers identified relative to other qualitative approaches (for example, interviews, focus groups). Detailers were asked to provide information on all aspects of the visit; however, there was much variation in the length and detail of the field notes for each documented visit.
The AD intervention was delivered to providers regardless of their prior opioid prescribing patterns, which may have impacted the barriers identified. Providers specialising in paediatrics and obstetrics/gynaecology were not included among the PCP participants, which may have impacted the barriers identified. Participating providers specialised in primary care and practised within a single health system in the Chicagoland region, potentially limiting the generalisability of the findings. However, this subgroup of providers prescribes the largest proportion of opioids, and, therefore, the findings remain relevant.
Comparison with existing literature
Direct educational outreach through AD is an increasingly used strategy to supplement providers’ knowledge with the most current, evidence-based information related to pain management and safe opioid prescribing.12–19 The results from this study were largely consistent with those reported among PCPs within the VHA, including knowledge gaps, provider attitudes and beliefs, patient–provider interactions, and health system pain-management practices.23–25
The identified barriers related to PMP use were consistent with previous studies, which included online registration and access difficulties, lack of time to access PMPs, and lack of PMP usability.30,31 Novel findings from this research highlighted the impact of insurance policies on opioid prescribing due to limited reimbursement for alternative pain management and the PMP as barriers to safe opioid prescribing in primary care.
Implications for research and practice
Gaps in knowledge were the most commonly identified barriers to safe opioid prescribing. This finding is not surprising given the limited number of courses incorporating pain management in US health professional schools.7 Due to the evolving pain-management landscape, there is a clear need for increased pain-management education.32 AD programmes can be developed and tailored to include relevant resources and materials to facilitate safe opioid prescribing (Supplementary Table S1) that are applicable to the targeted setting (for example, primary care). However, implementation on a large scale in the targeted setting may be challenging due to factors that may impact provider engagement such as time constraints and uncertainty about the value of AD. Thus, incorporating useful incentives into the AD programme may overcome challenges to provider engagement and large-scale AD programme implementation within a health system. A potential incentive may be to provide continuing medical education (CME) on safe opioid prescribing through an accredited AD programme. Expanding opportunities for providers to gain opioid-related CME credit are especially relevant due to growing the state legislative requirements for licensed controlled-substance prescribers in order to maintain their licensure.33
Barriers to PMP utilisation were the second-most frequently reported theme. PMPs are state-wide electronic databases that collect timely information from retail pharmacies on dispensing of schedule II through V controlled-substance prescriptions (for example, drug name, payment type, and prescriber information).34 Thus, PMPs can be used to identify problematic controlled-substance utilisation behaviours and support clinical decision making to reduce prescription opioid misuse, abuse, and diversion.35 Effectiveness of PMPs relies on prescribers to access and review the database prior to prescribing controlled substances, but prescribers have reported a lack of routine use even though many are aware of the PMP and its utility.36,37 Based on the identified barriers to PMP use, potential strategies to overcome these barriers include mandatory PMP use to facilitate increased utilisation,38,39 and integration of PMPs with electronic medical records to improve direct PMP access.40 Additionally, consent for authorised delegates to access the PMP on the provider’s behalf may be a useful strategy to reduce time constraints on providers.40 Implementation of these strategies has been associated with modest reductions in unsafe opioid prescribing and prescription opioid overdose deaths, which suggest PMPs can be helpful, although insufficient on their own.41–43 However, the PMP is the main tool that providers have at their disposal to assess a patient’s controlled-substance history. Therefore, the development of user-centred online training programmes by state PMPs can help to improve the utilisation and navigation of the PMP database.44 Aligning such training programmes with evidence-based guidelines may facilitate more effective use of the PMP and enhance clinical decision making.
Less frequently reported, although critically important, were insurance-related barriers that impacted access to, and affordability of, pain treatments and specialists. Providers reported that patients’ insurance often lacked coverage for non-opioid treatments. This left providers with few options outside of prescription opioids, which were more often covered. Although non-opioid treatments are recommended as initial pain management options by evidence-based guidelines for chronic pain,26,45 coverage policies are inconsistent and were noted as factors impeding access to, and affordability of, non-opioid treatments relative to prescription opioids.46,47
Based on the identified insurance-related barriers, adoption of coverage policies aligned with evidence-based guidelines, such as step therapy requirements with non-opioid treatments prior to opioid initiation, would incentivise PCPs to use non-opioid treatments initially when managing patients with chronic pain. Implementation of such policies could broaden the selection of non-opioid treatments to make guidelines easier to follow, which may help to reduce prescription opioid misuse, abuse, and overdose death.46,48 Moreover, providers expressed a desire to refer patients for specialised pain management, but those efforts were hindered by utilisation management policies. The affordability of visits to pain specialists may be increasingly challenging for patients when insurance coverage is limited. By revising current coverage and reimbursement policies to reflect evidence-based guidelines that support increased access to non-opioid treatments and pain management services,49 insurers can play a pivotal role in facilitating safe opioid prescribing practices in primary care.
Although AD has typically aimed to modify prescribing behaviour at the provider level, collecting information from providers during the AD visit and sharing it with health system leadership may provide an opportunity for systemwide improvements. With challenges to implementing the CDC guideline in practice becoming more prominent,49 this study’s findings demonstrate that AD can be used as an opportunity to clarify evidence-based recommendations with providers to ensure their appropriate application. However, solutions to address insurance-related barriers require action at the health plan/insurer level, which influences guideline-concordant opioid prescribing practices.
In conclusion, six themes were identified related to barriers impacting safe opioid prescribing among a large group of PCPs through AD. These findings can be used to inform targeted efforts to facilitate improved clinical decision making related to opioid prescribing and pain management. Gaps in knowledge and lack of PMP utilisation were most frequently identified. These findings support the need for enhanced pain-management education and continued efforts to maximise PMP utilisation to facilitate safe opioid prescribing in primary care. Additionally, this study’s findings suggest a need for adoption of evidence-based coverage and utilisation management policies by insurers that increase access to, and affordability of, non-opioid treatments and pain management services. This study also highlights the use of AD as an approach to identify barriers to safe opioid prescribing and facilitate solutions to the identified barriers.
