A qualitative evidence synthesis to explore healthcare professionals’ experience of prescribing opioids to adults with chronic non-malignant pain

Abstract

BackgroundDespite recent guidelines suggesting that patients with chronic non-malignant pain might not benefit, there has been a significant rise in opioid prescription for chronic non-malignant pain. This topic is important because an increasing number of HCPs are prescribing opioids despite very limited evidence for long-term opioid therapy for chronic non-malignant pain outside of end-of-life care. To better understand the challenges of providing effective treatment, we conducted the first qualitative evidence synthesis to explore healthcare professionals’ experience of treating people with chronic non-malignant pain. We report findings that explore healthcare professionals’ experience of prescribing opioids to this group of patients.MethodsWe searched five electronic bibliographic databases (Medline, Embase, CINAHL, PsychINFO, AMED) from inception to November 2015 and screened titles, abstracts and full texts of potential studies. We included studies in English that explored healthcare professionals’ experience of treating adults with chronic non-malignant pain. Two reviewers quality appraised each paper. We used the methods of meta-ethnography developed and refined for large reviews, and the GRADE-CERQual framework to rate confidence in review findings.ResultsWe screened 954 abstracts and 184 full texts, and included 77 studies in the full review. 17 of these 77 studies included concepts that explored the experience of prescribing opioids. We abstracted these concepts into 6 overarching themes: (1) Should I, shouldn’t I? (2) Pain is Pain; (3) Walking a fine line; (4) Social guardianship; (5) Moral boundary work; (6) Regulations and guidelines. We used the GRADE-CERQual framework to evaluate confidence in findings. A new overarching concept of ‘ambiguity’ explains the balancing required around the factors taken into account when prescribing opioids. Managing this ambiguity is challenging and these findings can inform healthcare professionals dealing with these decisions.ConclusionsThis conceptual model demonstrates the complexity of making a decision to prescribe opioids to someone with chronic non-malignant pain. Although opioid prescription is underpinned by the therapeutic aim of alleviating pain, this aim may be misplaced. This has implications for education in light of the new regulations for opioid prescription. Findings also demonstrate that the decision is influenced by intra- and interpersonal factors and broader external concerns.

A meta-ethnography to understand the experience of living with urinary incontinence: ‘is it just part and parcel of life?’

“…One option might be to start your search with a single data base and expand as analysis proceeds [17]. Our previous QES indicate that Medline retrieves the majority of studies [7,13,14,35]. We therefore limited our initial search to one bibliographic database (Medline) from inception to January 2017 and subsequently updated the search to include studies to February 2019.…”

“…Toye and colleagues suggest that it would be 'useful to find ways in which we can be more discerning about what to include' in QES [35]. QES reviewers spend a lot of time searching for studies and this time might be more valuable spent on analysis.…”

“…Toye and colleagues suggest that it is important for reviewers (and funders) to consider whether or not an exhaustive search of the literature is necessary for QES [8]. We limited our search to Medline for several reasons: firstly, previous QES have shown that Medline retrieves a large proportion of the studies included in a QES [7,13,14,35]; secondly, our scoping review indicated that we were likely to find a large number of studies; thirdly, although Campbell and colleague suggest that 38 studies is sufficient for meta-ethnography [33], there is limited agreement about the optimum amount of studies required to have confidence in QES findings. Intuitively, a certain weight and spread of data appears more convincing.…”

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

“…Primary care providers such as FPs are the main access point for the management of CNCP, 5,6 but medical training leaves many FPs feeling unprepared in this domain. 7,8 New guidelines and public health initiatives have emerged to target opioid prescribing in an attempt to support FPs in their management of CNCP, 9,10 yet the problem persists. Such initiatives are more likely to be successful if they address the context in which prescribing takes place and target the real-world circumstances of opioid prescribing in daily practice.…”

“…11 Numerous qualitative studies have explored health care providers' experience of prescribing opioids, describing overarching themes of uncertainty, the need to balance the benefits and risks of opioid use, the primary aim of addressing pain, and fear of judgment, among others. 8 These studies were conducted primarily in the United States, with only 3 such studies addressing opioid prescribing in Canada. Two were focused on long-term care and captured a multidisciplinary perspective with mini-mal physician input, 12,13 and the other explored the perspectives of pain specialists.…”