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

Abstract

Background: 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.

Factors That Affect Opioid Quality Improvement Initiatives in Primary Care: Insights from Ten Health Systems

“…Studies have examined provider challenges, 27 including competing time demands, 16 , 17 concerns about provider autonomy in prescribing opioids for pain, 16 and challenging conversations with patients about opioid tapering. 18 , 20 , 28 Systems-level challenges to implementing changes to opioid prescribing include challenges with existing data systems, 16 , 28 and a lack of nonpharmacological pain management resources. 19 , 29 We found similar challenges in our study.…”

“… 14 , 15 Previous studies have identified significant barriers to increasing guideline-concordant care, including inadequate time and resources, unavailability of quality data metrics, and provider and patient concerns. 16 – 20 …”

Characterizations of Opioid Prescribing in Community Health Centers in 2018

“…Many studies have demonstrated the barriers faced by rural providers to safely prescribe opioids. 32 - 36 These barriers include difficulty using the PDMP during patient visits, 32 competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources. 32 , 35 , 36 The COVID-19 pandemic disrupted all facets of primary care 37 and created the need for an unprecedented, rapid uptake of telemedicine.…”

“… 32 - 36 These barriers include difficulty using the PDMP during patient visits, 32 competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources. 32 , 35 , 36 The COVID-19 pandemic disrupted all facets of primary care 37 and created the need for an unprecedented, rapid uptake of telemedicine. 38 Uptake of telemedicine for medication treatment for managing patients with chronic pain may be one strategy for providers in rural areas to assist patients with getting the care they need 39 ; however, the effectiveness of telemedicine has not been proven, and barriers to its use in rural areas (eg, lack of broadband), may hamper this strategy.…”

Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review

“…Retention of patients on OAT can be complicated due to a wide range of intrinsic, extrinsic, and environmental factors, such as shortages of health care personnel, lack of technology for telehealth, failure of medication doses to meet the patient's needs, continued illicit drug use, and lack of social supports [8,[15][16][17][18][19]. Unfortunately, the premature cessation of OAT is associated with a variety of negative outcomes [20][21][22], including drug overdose, bloodborne infections, worsening substance use, and death [19,[23][24][25].…”