Joniak-Grant Elizabeth, Blackburn Natalie A, Dasgupta Nabarun, Nocera Maryalice, Dorris Samantha Wooten, Chelminski Paul R, Carey Timothy S, Ranapurwala Shabbar I
University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA.
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7440, USA.
SSM Qual Res Health. 2023 Jun;3. doi: 10.1016/j.ssmqr.2023.100273.
Opioid dependence and overdose are serious public health concerns. States have responded by enacting legislation regulating opioid-prescribing practices. Through in-depth interviews with clinicians, state officials, and organizational stakeholders, this paper examines opioid prescribing limits legislation (PLL) in North Carolina and how it impacts clinical practice. Since the advent of PLL, clinicians report being more mindful when prescribing opioids and as expected, writing for shorter durations for both acute and postoperative pain. But clinicians also report prescribing opioids less frequently for acute pain, refusing to write second opioid prescriptions, foisting responsibility for patient pain care onto other clinicians, and no longer writing opioid prescriptions for chronic pain patients. They directly credit PLL for these changes, including institutional policies enacted in response to PLL, and, to a lesser degree, notions of "do no harm." However, we argue that misapplication of and ambiguities in PLL along with defensive medicine practices whereby clinicians and their institutions center their legal interests over patient care, amplify these restrictive changes in clinical practice. Clinicians' narratives reveal downstream consequences for patients including undertreated pain, being viewed as drug-seeking when questioning opioid-prescribing decisions, and having to overuse the medical system to achieve pain relief.
阿片类药物依赖和过量使用是严重的公共卫生问题。各州已通过颁布法规来规范阿片类药物的处方行为作为应对措施。通过对临床医生、州政府官员和组织利益相关者进行深入访谈，本文研究了北卡罗来纳州的阿片类药物处方限制立法（PLL）及其对临床实践的影响。自PLL出台以来，临床医生报告称在开具阿片类药物处方时更加谨慎，正如预期的那样，对于急性疼痛和术后疼痛的处方时长缩短。但临床医生也报告称，开具阿片类药物治疗急性疼痛的频率降低，拒绝开具第二张阿片类药物处方，将患者疼痛护理的责任推给其他临床医生，并且不再为慢性疼痛患者开具阿片类药物处方。他们将这些变化直接归因于PLL，包括为响应PLL而制定的机构政策，以及在较小程度上归因于“不造成伤害”的观念。然而，我们认为PLL的误用和模糊性，以及临床医生及其机构将法律利益置于患者护理之上的防御性医疗行为，加剧了临床实践中的这些限制性变化。临床医生的叙述揭示了对患者的下游影响，包括疼痛治疗不足、在质疑阿片类药物处方决定时被视为寻求药物，以及不得不过度利用医疗系统来缓解疼痛。
