Barriers and facilitators to implementing changes in opioid prescribing in rural primary care clinics

AbstractBackground:Opioids are more commonly prescribed for chronic pain in rural settings in the USA, yet little is known about how the rural context influences efforts to improve opioid medication management.Methods:The Six Building Blocks is an evidence-based program that guides primary care practices in making system-based improvements in managing patients using long-term opioid therapy. It was implemented at 6 rural and rural-serving organizations with 20 clinic locations over a 15-month period. To gain further insight about their experience with implementing the program, interviews and focus groups were conducted with staff and clinicians at the six organizations at the end of the 15 months and transcribed. Team members used a template analysis approach, a form of qualitative thematic analysis, to code these data for barriers, facilitators, and corresponding subcodes.Results:Facilitators to making systems-based changes in opioid management within a rural practice context included a desire to help patients and their community, external pressures to make changes in opioid management, a desire to reduce workplace stress, external support for the clinic, supportive clinic leadership, and receptivity of patients. Barriers to making changes included competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources in rural areas.Discussion:The barriers and facilitators identified here point to potentially unique determinants of practice that should be considered when addressing opioid prescribing for chronic pain in the rural setting.

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

Journal of Opioid Management ◽

10.5055/jom.2021.0684 ◽

2021 ◽

Vol 17 (6) ◽

pp. 499-509

Author(s):

Elizabeth C. Danielson, PhD ◽

Christopher A. Harle, PhD ◽

Sarah M. Downs, MPH ◽

Laura Militello, MA ◽

Olena Mazurenko, MD, PhD

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Treatment Decisions ◽

Healthcare Organizations ◽

Chronic Noncancer Pain ◽

Opioid Prescribing ◽

Prevention Guideline ◽

Multistep Process ◽

Primary Care Clinicians ◽

Noncancer Pain

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.

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Barriers and facilitators to utilisation of rehabilitation services amongst persons with lower-limb amputations in a rural community in South Africa

Prosthetics and Orthotics International ◽

10.1177/0309364618789457 ◽

2018 ◽

Vol 43 (1) ◽

pp. 95-103 ◽

Cited By ~ 2

Author(s):

Ugendrie Naidoo ◽

Liezel Ennion

Keyword(s):

South Africa ◽

Lower Limb ◽

Rural Areas ◽

Lower Limb Amputation ◽

Barriers And Facilitators ◽

Rural Setting ◽

Limb Amputation ◽

Rehabilitation Services ◽

Personal Factors ◽

Persons With Disabilities

Background: Persons with disabilities who reside in rural areas experience challenges accessing and utilising health services and rehabilitation. Due to the high prevalence of diabetes mellitus in rural regions, the risk of having a lower-limb amputation is increasing. Comprehensive rehabilitation is vital to mitigate the negative impact that a lower-limb amputation has on a person. Objective: To explore the barriers and facilitators to accessing rehabilitation experienced by persons with lower-limb amputations in a rural setting. Study Design: A qualitative descriptive approach was used to collect and analyse data. Methods: Data were collected from 11 conveniently sampled participants from three sub-district hospitals in the rural iLembe district, Kwa-Zulu Natal, South Africa. Data were collected using semi-structured interviews to explore the barriers and facilitators perceived by persons with lower-limb amputations in a rural region. Results: The three main barriers identified in this study were environmental factors, financial constraints and impairments. These barriers negatively impacted the participant’s utilisation of rehabilitation. The two main facilitators identified were environmental facilitators and personal factors which aided participant’s utilisation of rehabilitation. Conclusion: Access to rehabilitation was mainly hindered by the challenges utilising transport to the hospital, while self-motivation to improve was the strongest facilitator to utilising rehabilitation. Clinical relevance Rehabilitation is essential in preparation for prosthetic fitting. If a person cannot access rehabilitation services, they will remain dependent on caregivers. Highlighting the challenges to utilisation of rehabilitation in rural areas can assist to reduce these barriers and improve the functional status of persons with lower-limb amputations.

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Primary care physician opinion survey on FDA Opioid Risk Evaluation and Mitigation Strategies

Journal of Opioid Management ◽

10.5055/jom.2011.0053 ◽

2018 ◽

Vol 7 (2) ◽

pp. 109-115 ◽

Cited By ~ 21

Author(s):

Kieran A. Slevin, MD ◽

Michael A. Ashburn, MD, MPH

Keyword(s):

Primary Care ◽

Patient Education ◽

Risk Evaluation ◽

Care Physician ◽

Mitigation Strategies ◽

Rural Practice ◽

Prescription Opioid ◽

Opioid Prescribing ◽

Mandatory Education ◽

Family Practice Physicians

Introduction: In response to disturbing rises in prescription opioid abuse, the Food and Drug Administration (FDA) has proposed the implementation of aggressive Risk Evaluation and Mitigation Strategies (REMS) that will require prescribers to obtain mandatory education, provide mandatory patient education, register patients into registries, and so forth before prescribing certain opioids. The first opioid to be subject to the new REMS was the recently approved fentanyl buccal soluble film (Onsolis™). The FDA plans to extend mandatory REMS to other opioids, including all rapid-onset formulations and eventually all long-acting opioids, whether or not they already have FDA approval. To assess the likely impact of REMS on opioid prescribing, the authors conducted a survey of how REMS implementation might affect opioid prescribing.Methods: After obtaining Institutional Review Board’s approval, a survey regarding opioid prescribing was sent via e-mail to 2,800 physician members of the Pennsylvania Academy of Family Physicians. Practicing family practice physicians were asked to respond to questions regarding their current opioid prescribing, and how various components of REMS might alter their future opioid prescribing.Results: A total of 259 surveys were completed. Of the 259 physicians who responded, 87 percent reported themselves as being primary care practitioners; others identified themselves as specialists. Of all respondents, 96 percent currently prescribe opioids for acute pain, 77 percent for cancer pain, and 83 percent for chronic nonmalignant pain. The respondents were split from 52 percent to 48 percent in terms of being in an urban versus a rural practice setting. Forty-eight percent of all respondents reported their willingness to complete no more than 2 hours of training if it were available locally to be able to continue prescribing opioids. A similar percentage (50 percent) also said that they would encourage patient compliance with education and register their patients on a 6-month basis. However, the following percent of respondents reported that they would discontinue prescribing an opioid product if required to comply with the following REMS requirement: obtain 4-8 hours of training, followed by 2 hours of pain-related continuing medical education every 2 years (13.4 percent); complete mandatory patient education (12.2 percent); document ongoing monitoring of therapy including efficacy, safety, and monitoring for aberrant drug-related behavior (10.4 percent); or register each patient in a patient registry, and have the patient re-registered every 6 months (18.3 percent).Conclusions: The results suggest that 50 percent of the responding physicians would be willing to comply with the mandatory education component of REMS, including the requirement to provide education to patients. For some REMS components, willingness to continue to prescribe despite the restriction was higher (up to 90 percent). However, this leaves a substantial proportion of physicians who would not be willing to prescribe opioids controlled by the new REMS, which could have the unintended effect of decreasing access to these medications for legitimate medical purposes.

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An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy

MDM Policy & Practice ◽

10.1177/2381468319892572 ◽

2019 ◽

Vol 4 (2) ◽

pp. 238146831989257

Author(s):

Elizabeth C. Danielson ◽

Olena Mazurenko ◽

Barbara T. Andraka-Christou ◽

Julie DiIulio ◽

Sarah M. Downs ◽

...

Keyword(s):

United States ◽

Primary Care ◽

Chronic Pain ◽

The United States ◽

Opioid Therapy ◽

Opioid Overdose ◽

Chronic Noncancer Pain ◽

Opioid Prescribing ◽

Limited Effectiveness ◽

Pain Care

Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis ( n = 10), spondylosis ( n = 6), and low back pain ( n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.

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Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program

Pain Medicine ◽

10.1093/pm/pnaa033 ◽

2020 ◽

Vol 21 (10) ◽

pp. 2154-2162

Author(s):

Ameer Ghodke ◽

Timothy J Ives ◽

Anna E Austin ◽

William C Bennett ◽

Naishal Y Patel ◽

...

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Substance Misuse ◽

Clinical Epidemiology ◽

A Priori ◽

General Medicine ◽

Patient Characteristics ◽

Event Analysis ◽

Controlled Substances ◽

Opioid Prescribing

Abstract Background Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. Methods A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. Results Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001). Conclusions PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.

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Opioid Use Among Rural Medicare Beneficiaries

Innovation in Aging ◽

10.1093/geroni/igab046.1293 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. 335-335

Author(s):

Yvonne Jonk ◽

Heidi O'Connor ◽

Karen Pearson ◽

Zachariah Croll ◽

John Gale

Keyword(s):

Primary Care ◽

Rural Areas ◽

Urban Areas ◽

Primary Care Providers ◽

Community Dwelling ◽

Prescribing Patterns ◽

Medicare Beneficiaries ◽

Care Providers ◽

Opioid Prescription ◽

Opioid Prescribing

Abstract This study examines differences in opioid prescribing rates among a nationally representative sample of Medicare beneficiaries across rural and urban areas, as well as among beneficiaries with chronic overlapping pain conditions (COPCs). We assess whether prescribing patterns exceed the Centers for Disease Control and Prevention guidelines for dose and duration, and identify socioeconomic and health risk factors associated with opioid prescribing using logistic regression analyses. Data were from the 2010-2017 Medicare Current Beneficiary Survey files. Rural-Urban Commuting Area codes were used to identify patients’ residential location. The Area Health Resource Files were used to identify market characteristics such as primary care and mental health shortage areas. With the exception of 2010, over years 2011-2017, higher percentages of community-dwelling rural beneficiaries received opioid prescriptions (21.8-25.4%) compared to their urban counterparts (19.1-23.7%). During the same time period, facility-dwelling rural beneficiaries were more likely to receive opioid prescriptions (39.8-47.2%) compared to their urban counterparts (28.8-35.0%). Higher percentages (18.8%) of the community dwelling population in rural had COPCs compared to urban (15.2%), and a higher percentage of rural beneficiaries with COPCs (31.4%) received an opioid prescription than their urban counterparts (22.2%). Previous research points to other factors contributing to a lack of alternatives to opioids for pain management in rural areas, including greater reliance on primary care providers, lack of access to chronic pain specialists and alternative therapies, and travel barriers. Improving the capacity of rural primary care to deal with COPCs and expanding access to specialists via telehealth warrants further attention from policymakers.

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Barriers Faced by Rural and Non-Rural Primary Care Physicians During the Process of Seeking Health Information from their Practice Settings

Pakistan Journal of Information Management and Libraries ◽

10.47657/201617895 ◽

2016 ◽

Vol 17 ◽

pp. 69-85

Author(s):

Salman Bin Naeem ◽

Rubina Bhatti

Keyword(s):

Primary Care ◽

Health Information ◽

Information Content ◽

Primary Care Physicians ◽

Rural Practice ◽

Rural Setting ◽

Practice Setting ◽

Chi Square ◽

The Difference ◽

Content Availability

To compare the barriers (e.g., relating to health information content, efficiency, availability, etc.) that obstruct the health information behavior of primary care physicians (PCPs) in a rural versus non-rural practice setting. A survey was conducted in the Public health facilities of the District of Multan, Pakistan. Primary care physicians (PCPs) were classified into rural and non-rural according to their practice setting. The term non-rural was used to avoid the confusion with other terms such as urban and metropolitan. Convenience sampling was used to gather the data for this study. Post-hoc Chi-square test was applied to assess any difference between the demographic information of the rural and non-rural PCPs. Mann-Whitney U statistics were applied to assess the differences among the barriers (e.g., relating to health information content, efficiency, availability, etc.) faced by PCPs in rural and non-rural practice settings. The difference in gender of the PCPs was much higher in rural than non-rural practice settings. Almost half the respondents were in the 31-40 year age range, and that- of this group most were working in non-rural settings. The barriers faced by PCPs (relating to health information content, availability, cost, efficiency and skills) in rural and non-rural practice settings were significantly different. Age as well as working experience was statistically significant factors which were perceived by PCPs as the barriers lying in their way of seeking health information. The findings of this study showed that PCPs in a non-rural setting faced significantly greater barriers relating to information content, efficiency, skills, availability, and cost) than the ones faced by PCPs in a rural setting.

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Putting the (R) Ural in Preceptorship

Nursing Research and Practice ◽

10.1155/2012/528580 ◽

2012 ◽

Vol 2012 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Deirdre Jackman ◽

Florence Myrick ◽

Olive Yonge

Keyword(s):

Nursing Students ◽

Rural Areas ◽

Nursing Student ◽

Role Model ◽

Rural Practice ◽

Rural Setting ◽

Rural Nursing ◽

Important Approach ◽

Research Gap ◽

The One

Rural nursing is recognized as a unique health care domain. Within that context, the preceptorship experience is purported to be an important approach to preparing safe and competent rural practitioners. Preceptorship is the one-to-one pairing of a nursing student with a professional nurse who assumes the mandate of teacher and role model in a designated clinical/contextual setting, in this case the rural setting. A research gap exists in the literature in which rural preceptorship is specifically explored. The purpose of this paper is to review preceptorship in relation to preparing nursing students specifically for the rural setting. Understanding how preceptorship as an educational model can prepare nursing students to transition to rural practice is an important endeavor. An authentic rural preceptorship may serve to influence the recruitment and retention needs for registered nurses in rural areas. A greater understanding of rural preceptorship serves to illustrate the appropriate support, socialization and contextual competence required to prepare nursing students for rural nursing practice. This paper's review may serve to highlight the research that currently exists related to rural preceptorship and where additional research can contribute to further understanding and development for authentic rural nursing preparation.

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