title: Barriers to guideline-concordant opioid management in primary care--a qualitative study.
abstract: Prior studies have demonstrated poor physician adherence to opioid management guidelines in primary care. The objectives of this qualitative study were to understand physicians' and patients' perspectives on recommended opioid management practices and to identify potential barriers to and facilitators of guideline-concordant opioid management in primary care. Individual semistructured interviews were conducted with 14 primary care physicians and 26 of their patients receiving long-term opioid therapy. Data were analyzed using a qualitative immersion/crystallization approach. We identified 3 major barriers to and 1 facilitator of use of recommended opioid management practices. Major barriers were inadequate time and resources available; relying on general impressions of risk for opioid misuse; and viewing opioid monitoring as a "law enforcement" activity. The third barrier was most apparent for physicians in the context of drug testing and for patients in the context of opioid agreements. Beliefs about the need to protect patients from opioid-related harm emerged as a major facilitator, especially among patients. We hypothesize that future interventions to improve opioid management in primary care will be more effective if they address identified barriers and use a patient-centered framework, in which prevention of opioid-related harm to patients is emphasized as the primary goal.
  
  
  CONCLUSIONS
  This article describes primary care perspectives on guideline-recommended opioid management practices. Barriers identified in this study may contribute to underuse of recommended opioid management practices. Consideration of barriers and facilitators to guideline-concordant care could improve effectiveness of future interventions aimed at improving opioid management in primary care.
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota. Electronic address: erin.krebs@va.gov.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Krebs
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), VA Greater Los Angeles System, Los Angeles, California.
authors.forename: Alicia A
authors.initials: AA
authors.lastname: Bergman
authors.affiliation: Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Coffing
authors.affiliation: Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Steffanie R
authors.initials: SR
authors.lastname: Campbell
authors.affiliation: Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Frankel
authors.affiliation: Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana; Department of Communication Studies, Indiana University-Purdue University, Indianapolis, Indiana.
authors.forename: Marianne S
authors.initials: MS
authors.lastname: Matthias
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use*; D059350:Chronic Pain / Q000188:drug therapy*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D036301:Qualitative Research
chemical_list: D000701:Analgesics, Opioid
keywords: Chronic pain; guidelines; opioid analgesics; primary care; qualitative research