‘If you can’t see a dilemma in this situation you should probably regard it as a warning’: a metasynthesis and theoretical modelling of general practitioners’ opioid prescription experiences in primary care

Abstract

Introduction: The prescribing of opioids has increased internationally in developed countries in recent decades within primary and secondary care. The majority of patients with chronic non-malignant pain (CNMP) are managed by their general practitioner (GP). Recent qualitative studies have examined the issue of opioid prescribing for CNMP from a GP viewpoint. The aim of this study is to identify and synthesise the qualitative literature describing the factors influencing the nature and extent of opioid prescribing by GPs for patients with CNMP in primary care. Methods: MEDLINE, Embase, PsycINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986 to February 2018. The full text of included articles was reviewed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. The papers were coded by two researchers and themes organised using Thematic Network Analysis. Themes were constructed in a hierarchical manner, basic themes informed organising themes which informed global themes. A theoretical model was derived using global themes to explain the interplay between factors influencing opioid prescribing decisions. Results: From 7020 records, 21 full text papers were assessed, and 13 studies included in the synthesis; 9 were from the United States, 3 from the United Kingdom and 1 from Canada. Four global themes emerged: suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision-making processes underlying opioid prescribing whereby the physician both consciously and unconsciously quantifies the risk–benefit relationship associated with initiating or continuing an opioid prescription. Conclusion: Recognising the inherent complexity of opioid prescribing and the limitations of healthcare systems is crucial to developing opioid stewardship strategies to combat the rise in opioid prescription morbidity and mortality.

Collaboration between adult patients and practitioners when making decisions about prescribing opioid medicines for chronic non-cancer pain in primary care: a scoping review

“…Discussions about opioids were directed by pressure from guidance, 25,27 greater patient pain catastrophisation 23 or where practitioners were orientated towards psychosocial interventions. 23 Practitioner and patient disagreement 25,32,33,36 along with requests for an increase in opioid dose were associated with the significantly worse experience of consultations. 24 Negative interactions happen where decisions were taken unilaterally by the practitioner, 27,30,32 or where the stigma associated with prescribing opioids resulted in a reluctance to prescribe and interrogation of the patient.…”

“…One of the included studies is a meta-synthesis. 36 Some of the studies included in the meta-synthesis 17–20,22,33 are also included in this review. The rationale for including the meta-synthesis in this review is to incorporate the authors’ theorised perspective of the practitioner–patient relationship.…”

“…21,26,27 Practitioner perspectives/experience of opioid prescribing was the aim of three further studies 22,29,35 as well as the meta-synthesis. 36 Both patient and practitioner perspectives/experience of opioid prescribing was the aim in two studies. 17,18…”

“…A systematic meta-synthesis of practitioner perceptions theorised that opioid risk and practitioner suspicion shape opioid-prescribing decisions. 36…”

Opioids, opioids and more opioids

“…The second paper by Kennedy et al 4 demonstrates the complexity of the decision-making process when prescribing opioids. They report the findings of a systematic review and meta-synthesis of qualitative studies exploring perspectives on opioid prescribing for persistent pain in primary care.…”