Title Primary care providers ' perspective on prescribing opioids to older adults with chronic non-cancer pain : A qualitative study Permalink

Background: The use of opioid medications as treatment for chronic non-cancer pain remains controversial. Little information is currently available regarding healthcare providers’ attitudes and beliefs about this practice among older adults. This study aimed to describe primary care providers’ experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults. Methods: Six focus groups were conducted with a total of 23 physicians and three nurse practitioners from two academically affiliated primary care practices and three community health centers located in New York City. Focus groups were audiotape recorded and transcribed. The data were analyzed using directed content analysis; NVivo software was used to assist in the quantification of identified themes. Results: Most participants (96%) employed opioids as therapy for some of their older patients with chronic pain, although not as first-line therapy. Providers cited multiple barriers, including fear of causing harm, the subjectivity of pain, lack of education, problems converting between opioids, and stigma. New barriers included patient/family member reluctance to try an opioid and concerns about opioid abuse by family members/caregivers. Studies confirming treatment benefit, validated tools for assessing risk and/or dosing for comorbidities, improved conversion methods, patient education, and peer support could facilitate opioid prescribing. Participants voiced greater comfort using opioids in the setting of delivering palliative or hospice care versus care of patients with chronic pain, and expressed substantial frustration managing chronic pain. Conclusions: Providers perceive multiple barriers to prescribing opioids to older adults with chronic pain, and use these medications cautiously. Establishing the long-term safety and efficacy of these medications, generating improved prescribing methods, and implementing provider and patient educational interventions could help to improve the management of chronic pain in later life. Background The use of opioid medications to treat chronic non-cancer pain (hereafter referred to as chronic pain) in older patients remains controversial [1-3]. Two recently published guidelines for managing chronic pain [1,2] recommend that clinicians consider opioid therapy for older patients who continue to report moderate-to-severe pain or experience pain-related functional impairment despite non-opioid therapy. However, a recently published comparative safety study with 12,840 participants (mean age = 80 years) suggested that opioids (vs. nonselective and selective nonsteroidal anti-inflammatory medications) confer substantial risks when used to treat older adults with non-cancer pain disorders [3]. Little information is available regarding healthcare providers’ attitudes and practices regarding the use of opioids as a treatment for chronic pain in older adults. Provider concerns have been identified in prior studies that did not focus on older adults [4-10]. Concerns identified in these studies included the potential for patient addiction, tolerance and physical dependence [4-10]; abuse, misuse or diversion of opioid medications [4,5,9-12]; inadequate provider training [5,9,12-14]; patient harm from adverse effects [4,6,7,12]; and regulatory sanctions [5-7,9,10]. * Correspondence: mcr2004@med.cornell. edu Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY, USA Full list of author information is available at the end of the article Spitz et al. BMC Geriatrics 2011, 11:35 http://www.biomedcentral. com/1471-2318/11/35 © 2011 Spitz et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Age-related changes in cognition, pharmacodynamics and pharmacokinetics, as well as higher rates of comorbidity, polypharmacy, and frailty [15,16] complicate the management of pain in later life, and likely increase providers’ concerns about using this class of medications in older patients. Lin et al. [5] surveyed practicing geriatricians and internists to assess for possible provider differences in attitudes regarding the use of opioids as a treatment for patients with chronic pain. Geriatricians voiced far less concern for addiction and more concern for the possibility that patients’ pain was being under-treated relative to internists [5]. Provider concerns about causing harm from pharmacologic interventions such as opioid use may contribute to the under-treatment of pain, which is a recognized problem and is associated with advancing age [17]. The Declaration of Montreal, a document developed at the 1st International Pain Summit in 2010, states that “access to pain management by adequately trained health care professionals is a fundamental human right” [18]. Health care providers therefore have an ethical responsibility to relieve pain-related suffering by providing informed and unbiased access to pain medications. Identifying primary care providers’ barriers to the use of opioids as a treatment for chronic pain among older adults could identify possible targets for intervention, and ultimately improve pain management in this expanding patient population. Accordingly, we sought to elucidate primary care providers’ perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults. We also sought to characterize providers’ experiences and attitudes towards using this class of medications in older patients.