Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
Penn State College of Medicine, Hershey, Pennsylvania.
Pain Med. 2020 Nov 1;21(11):3187-3198. doi: 10.1093/pm/pnaa045.
Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy.
We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology.
We identified three approaches to assuming a new patient's opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians "dumping" patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses.
Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.
鉴于阿片类药物在政治和社会环境方面的变化，我们研究了门诊环境中的临床医生如何为已经接受长期阿片类药物治疗的新患者管理阿片类药物处方。
我们对南加州的 32 名在门诊环境中为慢性疼痛开具阿片类药物的临床医生进行了深入访谈。这项定性研究的研究设计、访谈指南和编码均由建构主义扎根理论方法指导。
我们确定了三种方法来承担新患者的阿片类药物处方。坚决反对者（大多是接受过疼痛医学专业培训的临床医生）反对为新患者继续开阿片类药物处方，并且经常筛选出寻求阿片类药物的门诊患者。谨慎和矛盾的开处方者对开阿片类药物处方持谨慎态度，但如果他们认为患者值得信赖且药物在他们的舒适范围内，则愿意续方。前两组的临床医生对其他临床医生将“倾倒”给他们的患者的阿片类药物处方感到不满。建立融洽关系者（大多是初级保健医生）最愿意承担阿片类药物处方的责任，并且在将患者过渡到更安全剂量的方法上具有策略性。
在疼痛管理方面接受过最多培训的临床医生最不愿意为已经接受长期阿片类药物治疗的患者承担阿片类药物处方的责任。相比之下，初级保健临床医生最愿意承担这一责任。然而，初级保健临床医生在为患有复杂疼痛状况的患者提供高质量护理方面面临障碍，例如就诊时间短和专门培训较少。
