Nationwide efforts are in place to reduce opioid prescribing in response to dramatic increases in opioid-associated morbidity and mortality. There is a dearth of scientific research about the long-term consequences, positive or negative, of these reductions on patients, clinical care delivery, and community health. The proposed research study will qualitatively examine the consequences of reductions in opioid prescribing on chronic non-cancer pain patients with a history of substance use, their primary care clinicians and community stakeholders to inform clinical and policy recommendations.
We propose to use qualitative methods to examine the consequences of reductions in opioid prescribing for chronic non-cancer pain (CNCP) on patients, clinical care delivery, and community health. Over 80 million Americans report CNCP, defined as non-malignant pain that lasts longer than three months, not associated with end of life. Escalations in opioid prescribing for CNCP over the past two decades have been associated with dramatic increases in opioid-associated morbidity and mortality. In response, the Centers for Disease Control and Prevention, the American Pain Society, and the American Medical Association developed recommendations to limit reliance on opioids, by encouraging clinicians to (1) consult statewide prescription drug monitoring programs when prescribing opioids; (2) not initiate opioid therapy for CNCP; and (3) monitor, taper, and/or discontinue opioids in CNCP patients. These recommendations are being implemented nationwide and evidence suggests a concomitant decrease in the total number of opioid prescriptions. Yet, little data exist documenting the long term consequences, positive or negative, of reductions in opioid prescribing. The proposed study builds on our previous R01 (DA034625), Pain Management in the Clinic and Community (PMCC), that examined the management of CNCP in patients with a history of substance use who received pain care in safety net clinical settings. Medicaid insured patients with a CNCP diagnosis are more likely than their privately insured counterparts with CNCP to receive opioid prescriptions. Patients with a history of substance use are more likely to receive a diagnosis of CNCP, to be prescribed opioids, and to transition to chronic opioid therapy than patients without substance use histories. The proposed study will use the social-ecological model of health to address the following specific aims: (SA1) To examine the consequences of reductions in opioid prescribing on patients' experiences of CNCP; (SA2) To examine the consequences of reductions in opioid prescribing on patient-clinician relationships and clinical care delivery in primary care safety net settings; (SA3) To examine the consequences of reductions in opioid prescribing from the perspectives of community stakeholders. The proposed longitudinal study will take place in four safety-net clinics and patients' home/community environments in two diverse San Francisco Bay Area Counties. We will conduct qualitative enrollment and follow-up interviews with 30 primary care clinicians and 60 of their CNCP patients with a history of substance use, and clinical observations between clinicians and matched patients (SA1&2). We will theoretically sample 30 of the 60 CNCP patients and conduct ethnography in patients' home environments, and interview 40 community stakeholders (SA1&3). The multidisciplinary research team, consisting of a medical anthropologist, a physician investigator who studies opioid misuse and practices in the safety net, and a nurse/clinical pain policy expert will synthesize the data with the goal of improving our understanding of the consequences of opioid prescription reductions to make clinical and policy recommendations.