title: Decision support for chronic pain care: how do primary care physicians decide when to prescribe opioids? a qualitative study.
abstract: BACKGROUND
  Primary care physicians struggle to treat chronic noncancer pain while limiting opioid misuse, abuse, and diversion. The objective of this study was to understand how primary care physicians perceive their decisions to prescribe opioids in the context of chronic noncancer pain management. This question is important because interventions, such as decision support tools, must be designed based on a detailed understanding of how clinicians use information to make care decisions.
  
  
  METHODS
  We conducted in-depth qualitative interviews with family medicine and general internal medicine physicians until reaching saturation in emergent themes. We used a funneling approach to ask a series of questions about physicians' general decision making challenges and use of information when considering chronic opioids. We then used an iterative, open-coding approach to identify and characterize themes in the data.
  
  
  RESULTS
  We interviewed fifteen physicians with diverse clinical experiences, demographics, and practice affiliations. Physicians said that general decision making challenges in providing pain management included weighing risks and benefits of opioid therapies and time and resource constraints. Also, some physicians described their active avoidance of chronic pain treatment due to concerns about opioid risks. In their decision making, physicians described the importance of objective and consistent information, the importance of identifying "red flags" related to risks of opioids, the importance of information about physical function as an outcome, and the importance of information that engenders trust in patients.
  
  
  CONCLUSIONS
  This study identified and described primary care physicians' struggles to deliver high quality care as they seek and make decisions based on an array of incomplete, conflicting, and often untrusted patient information. Decision support systems, education, and other interventions that address these challenges may alleviate primary care physicians' struggles and improve outcomes for patients with chronic pain and other challenging conditions.
authors.affiliation: Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA. charle@phhp.ufl.edu.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Harle
authors.affiliation: Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA. secbauer@ufl.edu.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Bauer
authors.affiliation: Mayo Clinic, Rochester, MN, USA. Hoang.Huong@mayo.edu.
authors.forename: Huong Q
authors.initials: HQ
authors.lastname: Hoang
authors.affiliation: Department of Epidemiology, University of Florida, Gainesville, FL, USA. cookrl@phhp.ufl.edu.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Cook
authors.affiliation: Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA. rhurley@mcw.edu.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hurley
authors.affiliation: Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA. rfillingim@dental.ufl.edu.
authors.forename: Roger B
authors.initials: RB
authors.lastname: Fillingim
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D058443:Catastrophization / Q000188:drug therapy; D059350:Chronic Pain / Q000188:drug therapy*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010817:Physician-Patient Relations; D058007:Physicians, Primary Care; D010818:Practice Patterns, Physicians'
chemical_list: D000701:Analgesics, Opioid