Prescribers,Pharmacists, and the Opioid Dilemma-PA-13-015

The overarching goal of this project is to enhance our understanding of the opioid prescribing and dispensing decision-making processes of primary care providers (physicians, physician assistants, and nurse practitioners) and pharmacists. Since 1980, use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically. Increases in use of COT for CNCP have been paralleled by increased rates of prescription opioid use disorders (abuse and dependence) and opioid overdose deaths. Prescription opioid use disorders are the fastest growing form of drug abuse, and prescription opioids are the most common cause of accidental drug overdose in the United States (an “epidemic,” per the Centers for Disease Control and Prevention). The central dilemma facing clinicians who prescribe opioids for CNCP is how to best balance the benefits of pain relief with the risks of opioid misuse. Primary care providers and pharmacists who prescribe and dispense opioids with the objective of relieving pain play a central, albeit unintentional, role in this epidemic. Training, policies, and interventions are urgently needed to improve pain management and decrease opioid abuse, diversion, and deaths. To succeed, these programs need to be predicated on a thorough understanding of primary care providers’ and pharmacists’ decision-making processes when they prescribe and dispense opioids. Unfortunately these decision-making processes are poorly understood. To fill this knowledge gap, we propose to use face-to-face qualitative semistructured interviews to investigate primary care provider and pharmacist decision-making processes regarding COT for CNCP. Qualitative methods are ideal for this study because prior evidence is insufficient to construct conceptual models or hypotheses about how to improve clinical decision making about opioids. We have assembled a multidisciplinary team of physicians, health services researchers, a pharmacist, and qualitative methods experts with content expertise in chronic pain, addictions, and psychiatry, to analyze the detailed qualitative data about primary care provider and pharmacist decision making. Results will be used to construct a full conceptual model of primary care providers’ and pharmacists’ prescribing and dispensing behaviors regarding COT for CNCP. This model will enable diverse stakeholders to address this complex problem in an informed manner, generating testable hypotheses on specific approaches to addressing the prescription opioid epidemic via training, quality improvement infrastructure, clinical decisions support, and public and clinical policy.