title: How do physicians adopt and apply opioid prescription guidelines in the emergency department? A qualitative study.
abstract: OBJECTIVE
  An increase in prescriptions for opioid pain medications has coincided with increasing opioid overdose deaths. Guidelines designed to optimize opioid prescriptions written in the emergency department have been implemented, with substantial controversy. Little is known about how physicians perceive and apply these guidelines. We seek to identify key themes about emergency physicians' definition, awareness, use, and opinions of opioid-prescribing guidelines.
  
  
  METHODS
  We conducted semistructured qualitative interviews with a convenience sample of 61 emergency physicians attending the American College of Emergency Physicians Scientific Assembly (October 2012, Denver, CO). Participants varied with respect to age, sex, geographic region, practice setting, and years of practice experience. We analyzed the interview content with modified grounded theory, an iterative coding process to identify patterns of responses and derive key themes. The study team examined discrepancies in the coding process to ensure reliability and establish consensus.
  
  
  RESULTS
  When aware of opioid-prescribing guidelines, emergency physicians often defined them as policies developed by individual hospitals that sometimes reflected guidelines at the state or national level. Guidelines were primarily used by physicians to communicate decisions to limit prescriptions to patients on discharge rather than as tools for decisionmaking. Attitudes toward guidelines varied with regard to general attitudes toward opioid medications, as well as the perceived effects of guidelines on physician autonomy, public health, liability, and patient diversion.
  
  
  CONCLUSIONS
  These exploratory findings suggest that hospital-based opioid guidelines complement and occasionally supersede state and national guidelines and that emergency physicians apply guidelines primarily as communication tools. The perspectives of providers should inform future policy actions that seek to address the problem of opioid abuse and overdose through practice guidelines.
authors.affiliation: Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Austin S
authors.initials: AS
authors.lastname: Kilaru
authors.affiliation: Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Gadsden
authors.affiliation: Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Jeanmarie
authors.initials: J
authors.lastname: Perrone
authors.affiliation: Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Breah
authors.initials: B
authors.lastname: Paciotti
authors.affiliation: Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Frances K
authors.initials: FK
authors.lastname: Barg
authors.affiliation: Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Electronic address: zfm@upenn.edu.
authors.forename: Zachary F
authors.initials: ZF
authors.lastname: Meisel
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D036301:Qualitative Research; D014481:United States / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid
references.citation: Int J Qual Health Care. 2006 Jun;18(3):167-76
references.pmid: 16766601
references.citation: JAMA. 2013 Mar 6;309(9):879-80
references.pmid: 23462783
references.citation: Ann Emerg Med. 2004 Apr;43(4):483-93
references.pmid: 15039692
references.citation: J Gen Intern Med. 2013 Dec;28(12):1604-10
references.pmid: 23797920
references.citation: JAMA. 2008 Jan 2;299(1):70-8
references.pmid: 18167408
references.citation: Ann Emerg Med. 2013 Apr;61(4):394-403
references.pmid: 23312670
references.citation: Acad Emerg Med. 2006 Feb;13(2):140-6
references.pmid: 16436793
references.citation: N Engl J Med. 2003 Jun 26;348(26):2635-45
references.pmid: 12826639
references.citation: J Opioid Manag. 2006 Nov-Dec;2(6):335-40
references.pmid: 17326595
references.citation: Clin J Pain. 2010 Jul-Aug;26(6):512-7
references.pmid: 20551726
references.citation: JAMA. 2012 Apr 4;307(13):1377-8
references.pmid: 22474199
references.citation: BMJ Qual Saf. 2011 Mar;20(3):228-36
references.pmid: 21209134
references.citation: Ann Emerg Med. 2012 Oct;60(4):499-525
references.pmid: 23010181
references.citation: Ann Intern Med. 2013 Jun 4;158(11):841-2
references.pmid: 23567824
references.citation: Ann Emerg Med. 2013 Sep;62(3):237-40
references.pmid: 23374416
references.citation: MMWR Morb Mortal Wkly Rep. 2013 Jul 5;62(26):537-42
references.pmid: 23820967
references.citation: Ann Intern Med. 2013 Jun 4;158(11):843-4
references.pmid: 23567867
references.citation: J Med Toxicol. 2012 Dec;8(4):353-9
references.pmid: 23055125
references.citation: JAMA. 2000 Jul 26;284(4):478-82
references.pmid: 10904512
references.citation: Ann Emerg Med. 2013 Oct;62(4):293-302.e10
references.pmid: 23561465
references.citation: BMC Geriatr. 2011 Jul 14;11:35
references.pmid: 21752299
references.citation: MMWR Morb Mortal Wkly Rep. 2011 Nov 4;60(43):1487-92
references.pmid: 22048730
references.citation: JAMA Intern Med. 2013 Sep 23;173(17):1573-81
references.pmid: 23896698
references.citation: J Opioid Manag. 2011 Jul-Aug;7(4):267-76
references.pmid: 21957826
references.citation: JAMA. 1999 Oct 20;282(15):1458-65
references.pmid: 10535437
references.citation: BMJ. 2000 Jan 1;320(7226):50-2
references.pmid: 10617534
references.citation: J Pain. 2013 Jun;14(6):613-27
references.pmid: 23541067
references.citation: Int J Qual Health Care. 2007 Dec;19(6):349-57
references.pmid: 17872937
references.citation: JAMA. 2000 Jul 19;284(3):357-62
references.pmid: 10891968
references.citation: Ann Emerg Med. 2013 Sep;62(3):241-3
references.pmid: 23541629
references.citation: J Opioid Manag. 2011 Nov-Dec;7(6):427-33
references.pmid: 22320024
references.citation: JAMA. 2011 Apr 6;305(13):1299-301
references.pmid: 21467282