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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3015 — Perceptions of Opioid Monitoring in VA Primary Care: “We Just Hope They Don’t Call Back.”

Krebs EE, and Matthias MS, Roudebush VAMC; Indiana University; Regenstrief Institute; Bergman A, and Coffing J, Roudebush VAMC; Campbell S, Indiana University; Frankel R, Roudebush VAMC; Indiana University; Regenstrief Institute;

Opioid prescribing for chronic pain has increased substantially and has been associated with rising opioid overdose and abuse rates. VA guidelines recommend structured monitoring of opioid pain management to maximize effectiveness and prevent harm, but tools such as urine drug screening are under-used in primary care. Our objectives were to understand primary care perspectives on opioid monitoring and identify barriers to opioid monitoring in VA primary care.

We conducted semi-structured qualitative interviews with primary care physicians and their patients, using maximum variation snowball sampling. Interviews with 14 physicians were conducted by two trained interviewers using an interview guide. Analysis was guided by grounded theory, using constant comparative methods. Investigators reviewed transcripts independently, then met weekly to review data together, reach consensus on coding categories, and identify emerging themes. Patient interviews (2-3 per participating physician) are ongoing.

Physicians were familiar with opioid monitoring tools and described a broad range of opioid monitoring practice, but few reported regular use of opioid monitoring for all patients. Many described an individualized approach to monitoring, basing decisions about prescribing and monitoring on clinical intuition (“I use more my gestalt with the patient than anything...”) and presence of observed problematic behavior. Barriers to opioid monitoring included both beliefs and systems issues. Some physicians felt opioid monitoring interfered with patient-doctor relationships and was more like policing than doctoring; as one put it, “the worst thing about [drug testing] is you do not see the patient as a patient.” Others felt these concerns were readily addressed through patient education (“I tell them this is standard protocol. I’m not singling you out...I’m not treating you like an addict.”) Structural barriers included infrequent appointments and the pharmacy mail system. As one physician said, “we just hope they don’t call back and be happy with what they got. You know it’s not a good system...”

Complex factors are involved in primary care underuse of recommended opioid management practices.

Simple interventions, such as education or clinical reminders, are unlikely to substantially improve VA primary care opioid prescribing practice. Future interventions will need to address complex factors involved in underuse of guideline-recommended practices.

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