Family Physician Perceptions of Their Role in Managing the Opioid Crisis

Laura Desveaux; Marianne Saragosa; Natasha Kithulegoda; Noah Michael Ivers

doi:10.1370/afm.2413

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Table 1

Participant Demographics

ID	Sex	Age, y	Years in Practice	Area	Primary Funding Model
P001	F	32	2	Urban	Capitation
P002	M	37	5	Urban	Capitation
P003	M	33	4	Urban	Capitation
P004	F	46	17	Rural	Capitation
P005	F	31	4	Rural	Capitation
P006	M	32	4	Urban	Capitation
P007	M	38	8	Rural	Capitation
P008	F	37	9	Urban	Capitation
P009	F	36	9	Urban	Capitation
P010	M	31	2	Urban	Capitation
P011	F	43	14	Urban	Capitation
P012	F	38	9	Urban	Capitation
P013	F	53	27	Urban	Capitation
P014	F	54	27	Rural	Capitation
P015	M	47	13	Urban	Fee-for-service
P016	F	33	4	Urban	Capitation
P017	M	61	32	Urban	Capitation
P018	M	53	26	Urban	Capitation
P019	F	31	4	Urban	Capitation
P020	M	33	5	Urban	Capitation
P021	F	38	10	Urban	Fee-for-service
P022	M	58	25	Rural	Fee-for-service

F = female; M = male.

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Table 2

Supporting Qualitative Data for Primary Themes

Theme 1: What FPs were taught vs current expectations

“I came out of school in [the 1990s]. At that point, we were undertreating chronic pain, so we were told. So we were quite gung-ho about not under-treating pain, and using opioids because they were supposedly safer than anti-inflammatories. And now, the pendulum has swung … there’s new evidence that it might actually not be doing them any good.” P04

“I’m convinced we have to do things a lot safer, but if we go too far the other way, we’re protecting our own licenses perhaps, and maybe controlling the street supply of opioids, but I don’t know if it’s the very best thing for patient care.” P01

Theme 2: Navigating tensions between the FP’s role and patient and system expectations

“I think there’s [an expectation that] we need to be police officers at the same time as physicians, that’s always a conflict. As a physician, I can’t function if I don’t believe my patients. But there’s this overarching responsibility medically and legally for me to make sure I’m also suspicious of patients. So that’s a very big internal struggle.” P12

“It always goes back to the family doc. It’s very rare [for anyone] to say, well, now I’ll take this over, I’ll prescribe their opioids [or manage their pain]. It’s more often that they’re like, here’s some advice, go follow up with your family doctor.” P04

“[Patients] probably [have an opioid started] sometime during their hospitalization and then they just continued on opioids because of pain related issues. Unfortunately they probably have escalating doses of opioid and nobody actually addressed that, or no one actually attempts to wean them down or try other interventions.” P03

“I know that new recommendations have come out, I try but I’m not going to change my practice if I think that the patients are stable and well on them… . I think if I’m accurate and they are truthful and they are stable, I don’t think I’m going to make a huge effort to change it at this point in time.” P017

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Table 3

Supporting Qualitative Data for Variation in Perspectives That May Influence Physician Practice

Physicians with ≤5 years of practice experience

Challenges with clinical management; emotional component of patient interactions.

“There are obviously patients who probably leave me because they don’t like my rules and go to another doctor. But when you see how upset these patients are and how unstable they are, it’s hard to know how we should be doing, like instituting, all these new measures.” P001 (2 years in practice)

“I think the challenge, for me, is when you talk about decreasing, or trying to, patients kind of look at you and say ‘But I still have pain. What do I do?’ And often, there are not many other options. I don’t have anywhere else [to send them] … [so I] say yeah, I will do this for you. Sometimes you just don’t have it. And I think, for me, that’s the emotional part… . You’re caught between the college and trying to help this person, and the medical evidence and the lack of resources out there for people that should be there.” P016 (4 years in practice)

“I find it’s just challenging because I don’t know what else to offer. It’s more that you feel bad for these people because they are in pain and even though these medications aren’t good for pain really, I don’t know what else to do for them.” P019 (4 years in practice)

Physicians with ≥15 years of practice experience

Confident in the use of opioids in their practice; highlight the need for patient education.

“I feel like there should be some help for us in educating the public about keeping their use of opioids at the lowest possible level, it’s your safety. That they shouldn’t expect their pain to be zero because for chronic pain, it’s probably not going to be possible to reach zero. If they can go from an 8 to a 5, that’s already pretty amazing. I feel like there should be a bit more public awareness and education.” P013 (27 years of practice)

“Because I don’t have new patients, I have people I’ve known for 20, 25 years, I tend to have a lot of that background, to know, well, what’s their addiction potential, what are their issues? Then, whether or not I think they’re actually going to be more functional or less functional [on opioids], like, is this going to help you lay on the couch or is this going to help you go back to work?” P014 (27 years in practice)

“There isn’t any patient support material. I just have the guidelines and I’m supposed to relay the information to them. And I’m relaying the information to a client that’s very resistant to change. I have to be like a pharmaceutical rep. I have to detail the patient. I have to get them to buy into the risk of the high doses. I don’t have any support material for that. I don’t have any evidence or graphs or charts to present to the patient to say, ‘Hey, if you’re on a Benzo and a narcotic, you’re at a higher risk of dying.’” P018 (26 years of practice)

Physicians who were self-described strict prescribers

“It isn’t [a problem] any more. I got rid of those people. I stopped opioids on those people where it was a problem, or they left my practice and are probably getting it from another doctor. So, it’s hard to know if it’s successful… . I said, no, you broke the opioid contract I had you on and here’s a tapering dose and that’s it. And then sometimes I just don’t see them again.” P002 (5 years in practice)

“It’s almost impossible to get them off [opioids], because you can’t pry their pills from their fingers, from their cold, dead fingers. They just sort of latch onto them. And there are some people who try to minimize their dose, but there are other people who are constantly asking for more and more and more, because their pain is not controlled. And it’s not that they’re not getting enough, it’s that their pain is never going to be controlled by opioids.” P015 (13 years in practice)

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The Article in Brief

Family Physician Perceptions of Their Role in Managing the Opioid Crisis

Laura Desveaux , and colleagues

Background This study examines the perspectives of family physicians on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care as well as the differences in perspectives that may drive variations in practice.

What This Study Found Family physicians prescribe the greatest volume of opioids (22.9%) and number of prescriptions (31.2%) to individuals with chronic noncancer pain, making them targets for quality improvements in safer prescribing practices. Interviews with 22 family physicians in Ontario, Canada, from June to July 2017 identified key themes driving the overprescription of opioids in managing chronic pain: the contrast between doctors' training and current expectations; navigating patient and system expectations; and the duration and quality of therapeutic relationships. Physicians with 5 or fewer years' professional experience emphasized the need to create trusting relationships with their patients as well as the difficulties arising in conversations about chronic pain, including surveillance and urine screening. Physicians with longstanding, stable practices of around 15 years or more, described stronger, more trusting therapeutic relationships that lessened the need for strict enforcement measures. Both groups complained of a lack of resources to support effective pain management.

Implications

A combination of outside pressures and system expectations around the issue of opioid prescriptions places family physicians at the center of an emotionally-charged debate, and at a heightened risk of burnout.