What are the qualities of dilemmas experienced when prescribing opioids in general practice?

Abstract

The decision process preceding prescribing analgesics is complex and the physician is often struggling to balance several disparate considerations in order to work out what is rational. Several factors--medical, intellectual, emotional and logistic--influence the decision whether or not to prescribe, and the decision itself influences how the physicians feel about themselves. In this study the 'critical incident technique' was used for exploring the qualities of dilemmas among general physicians prior to prescribing analgesics to patients in primary health care. The study displayed two main types of problems in connection with prescription of opioids. The first main problem was a concern about abuse and addiction with no proper indication for the drug. The second main type of problem was related to the appropriateness of the drug, although the indication as such might be correct, i.e. acute or chronic pain. An important consequence of the dilemmas experienced influenced the physicians' self-esteem negatively, including failures in the patient-physician relationship. This results in emotional strain and is often experienced as a personal defeat. Only a few physicians denied prescription despite the experience of a dilemma, which might indicate an ambivalence or lack of knowledge among physicians with regard to proper indications for opioid prescription. However, it may also suggest that physicians need more training in saying no, or skills in deciding proper indications for opioids, which needs to be addressed during educational programmes.

Providers’ Experiences Treating Chronic Pain Among Opioid-Dependent Drug Users

“…Most providers we interviewed experienced difficulty coping with the ambiguity of making decisions about chronic opioid pain management. Our findings support those of Bendtsen et al, who reported that the quandary of prescribing opioids led to dissatisfaction with decisions, low self-esteem, and discontent with colleagues 9 .…”

“…To successfully manage chronic pain with opioids, providers must balance analgesia and restoration of function with the risks of diversion, dependence, and addiction. Variability in opioid prescribing practices may be explained in part by the inherent uncertainty of the opioid risk-benefit equation [6][7][8][9][10] .…”

Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses

“…Indeed, in many states, a disability diagnosis constitutes a key criterion for eligibility for the program (32). The substantial amount of documentation required to establish this diagnosis may also attenuate any providers' concerns that their patients' complaints of chronic pain may be spurious (33). Second, to the extent that the time physicians are able to spend with Medicaid patients is constrained, they may lack the time to consult their state's prescription monitoring program concerning their patients' history of prescriptions for controlled substances.…”

Chronic Opioid Therapy and Preventive Services in Rural Primary Care: An Oregon Rural Practice-based Research Network Study

“…cal dependence, tolerance and addiction [21][22][23][24][25] ; concern about possible diversion of opioid medication for other purposes 12,15,23,24,[26][27][28][29] ; and concern about possible sanctions by state and federal regulatory agencies. 21,27,28,[30][31][32][33] These concerns may complicate clinical decision making regarding the prescription of opioids 34,35 and may result in extra time demands, failures in the patient-physician relationship, and less time on other activities.…”