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CDA 07-215 – HSR&D Study

 
CDA 07-215
Improving the Quality and Safety of Opiate Prescribing in Primary Care
Erin E. Krebs MD MPH
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: February 2009 - January 2014

BACKGROUND/RATIONALE:
Prescribing of opioid medications for chronic non-cancer pain has increased dramatically over the last two decades. Although many questions remain about the risks and benefits of long-term opioid use in chronic pain, the greater availability of opioids has been associated with a rise in prescription-opioid related deaths and serious adverse effects, as well as increased abuse of prescription opioids in the community. To mitigate these potential harms, national organizations, including the American Pain Society, the US Departments of Veterans Affairs (VA) and Defense, and the Canadian Federation of Medical Regulatory Authorities, recommend structured monitoring of opioid pain management, using strategies such as validated pain assessment measures, urine drug tests, and opioid treatment agreements. Considerable variability in practice exists despite these clinical practice guidelines. Surveys and chart reviews have found that primary care providers are concerned about misuse of prescribed opioids, but infrequently employ recommended opioid prescribing and monitoring practices. Reasons for this gap are unclear.

OBJECTIVE(S):
To understand primary care providers' and patients' experiences with opioid monitoring and their perspectives on the value of specific opioid monitoring strategies; to identify barriers and facilitators of opioid monitoring in primary care.

METHODS:
This is a qualitative study using an individual semi-structured interview approach to data collection. We used maximum variation snowball sampling to capture a broad range of perspectives. Interview questions were designed and refined after pilot testing to elicit experiences with opioid monitoring, perceptions about interpersonal consequences of monitoring, and barriers/facilitators to monitoring. Members of the analysis team initially reviewed transcripts separately to establish provisional codes, then met as a group to review data together, reach consensus on coding categories, and identify emerging themes.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Barriers to guideline-concordant opioid management are complex, involving provider beliefs and negative attitudes about opioid monitoring, as well as logistical and practice barriers. Patients perspectives were largely supportive of opioid monitoring in general and of specific practices such as urine drug testing. Interventions to improve opioid management need to address complex factors involved in underuse of recommended practices. Guideline implementation strategies may be more effective when they use a patient-centered framework for opioid management, in which prevention of opioid-related harm to patients is emphasized as a primary goal. Future research should evaluate strategies to improve implementation of recommended opioid management practices, as well as effectiveness of these practices to improve patient outcomes in primary care.


External Links for this Project

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PUBLICATIONS:

Journal Articles

  1. Matthias MS, Krebs EE, Collins LA, Bergman AA, Coffing J, Bair MJ. "I'm not abusing or anything": patient-physician communication about opioid treatment in chronic pain. Patient education and counseling. 2013 Nov 1; 93(2):197-202. [view]
  2. Bair MJ, Poleshuck EL, Wu J, Krebs EK, Damush TM, Tu W, Kroenke K. Anxiety but not social stressors predict 12-month depression and pain severity. The Clinical Journal of Pain. 2013 Feb 1; 29(2):95-101. [view]
  3. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012 Mar 7; 307(9):940-7. [view]
  4. Krebs EE, Bergman AA, Coffing JM, Campbell SR, Frankel RM, Matthias MS. Barriers to guideline-concordant opioid management in primary care--a qualitative study. The journal of pain : official journal of the American Pain Society. 2014 Nov 1; 15(11):1148-55. [view]
  5. Outcalt SD, Kroenke K, Krebs EE, Chumbler NR, Wu J, Yu Z, Bair MJ. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. Journal of behavioral medicine. 2015 Jun 1; 38(3):535-43. [view]
  6. Matthias MS, Krebs EE, Bergman AA, Coffing JM, Bair MJ. Communicating about opioids for chronic pain: a qualitative study of patient attributions and the influence of the patient-physician relationship. European journal of pain (London, England). 2014 Jul 1; 18(6):835-43. [view]
  7. Thaler KJ, Morgan LC, Van Noord M, Gaynes BN, Hansen RA, Lux LJ, Krebs EE, Lohr KN, Gartlehner G. Comparative effectiveness of second-generation antidepressants for accompanying anxiety, insomnia, and pain in depressed patients: a systematic review. Depression and anxiety. 2012 Jun 1; 29(6):495-505. [view]
  8. Krebs EE, Becker WC, Zerzan J, Bair MJ, McCoy K, Hui S. Comparative mortality among Department of Veterans Affairs patients prescribed methadone or long-acting morphine for chronic pain. Pain. 2011 Aug 1; 152(8):1789-95. [view]
  9. Kroenke K, Theobald D, Wu J, Tu W, Krebs EE. Comparative responsiveness of pain measures in cancer patients. The journal of pain : official journal of the American Pain Society. 2012 Aug 1; 13(8):764-72. [view]
  10. Krebs EE, Bair MJ, Damush TM, Tu W, Wu J, Kroenke K. Comparative responsiveness of pain outcome measures among primary care patients with musculoskeletal pain. Medical care. 2010 Nov 1; 48(11):1007-14. [view]
  11. Bergman AA, Matthias MS, Coffing JM, Krebs EE. Contrasting tensions between patients and PCPs in chronic pain management: a qualitative study. Pain medicine (Malden, Mass.). 2013 Nov 1; 14(11):1689-97. [view]
  12. Krebs EE, Lorenz KA, Bair MJ, Damush TM, Wu J, Sutherland JM, Asch SM, Kroenke K. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of general internal medicine. 2009 Jun 1; 24(6):733-8. [view]
  13. Krebs EE, Bair MJ, Carey TS, Weinberger M. Documentation of pain care processes does not accurately reflect pain management delivered in primary care. Journal of general internal medicine. 2010 Mar 1; 25(3):194-9. [view]
  14. Lorenz KA, Krebs EE, Bentley TG, Sherbourne CD, Goebel JR, Zubkoff L, Lanto AB, Asch SM. Exploring alternative approaches to routine outpatient pain screening. Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1291-9. [view]
  15. Kroenke K, Wu J, Bair MJ, Damush TM, Krebs EE, Tu W. Impact of depression on 12-month outcomes in primary care patients with chronic musculoskeletal pain. Journal of musculoskeletal pain. 2012 Jan 1; 20(1):8-17. [view]
  16. Johns SA, Kroenke K, Krebs EE, Theobald DE, Wu J, Tu W. Longitudinal comparison of three depression measures in adult cancer patients. Journal of pain and symptom management. 2013 Jan 1; 45(1):71-82. [view]
  17. Bergman AB, Coffing J, Matthias MS, Krebs EE. Managing chronic pain with opioid medications: Patients voices. Journal of general internal medicine. 2012 Mar 1; 27(S2):S243. [view]
  18. Poleshuck EL, Bair MJ, Kroenke K, Damush TM, Krebs EE, Giles DE. Musculoskeletal pain and measures of depression: response to comment on the article by Poleshuck et al. General hospital psychiatry. 2010 Jan 1; 32(1):114-5. [view]
  19. Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. General hospital psychiatry. 2009 May 1; 31(3):206-19. [view]
  20. Krebs EE, Lurie JD, Fanciullo G, Tosteson TD, Blood EA, Carey TS, Weinstein JN. Predictors of long-term opioid use among patients with painful lumbar spine conditions. The journal of pain : official journal of the American Pain Society. 2010 Jan 1; 11(1):44-52. [view]
  21. Mattocks KM, Skanderson M, Goulet JL, Brandt C, Womack J, Krebs E, Desai R, Justice A, Yano E, Haskell S. Pregnancy and mental health among women veterans returning from Iraq and Afghanistan. Journal of women's health (2002). 2010 Dec 1; 19(12):2159-66. [view]
  22. Haskell SG, Ning Y, Krebs E, Goulet J, Mattocks K, Kerns R, Brandt C. Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. The Clinical Journal of Pain. 2012 Feb 1; 28(2):163-7. [view]
  23. Krebs EE, Ramsey DC, Miloshoff JM, Bair MJ. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain medicine (Malden, Mass.). 2011 May 1; 12(5):740-6. [view]
  24. Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. The journal of pain : official journal of the American Pain Society. 2011 Sep 1; 12(9):964-73. [view]
  25. Stubbs D, Krebs E, Bair M, Damush T, Wu J, Sutherland J, Kroenke K. Sex Differences in Pain and Pain-Related Disability among Primary Care Patients with Chronic Musculoskeletal Pain. Pain medicine (Malden, Mass.). 2010 Feb 1; 11(2):232-9. [view]
  26. Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. JAMA. 2014 Jul 16; 312(3):240-8. [view]
  27. Haskell SG, Mattocks K, Goulet JL, Krebs EE, Skanderson M, Leslie D, Justice AC, Yano EM, Brandt C. The burden of illness in the first year home: do male and female VA users differ in health conditions and healthcare utilization. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jan 1; 21(1):92-7. [view]
  28. Frank JW, Bair MJ, Becker WC, Krebs EE, Liebschutz JM, Alford DP. Update in pain medicine for primary care providers: a narrative review, 2010-2012. Pain medicine (Malden, Mass.). 2014 Mar 1; 15(3):425-31. [view]
  29. Alford DP, Krebs EE, Chen IA, Nicolaidis C, Bair MJ, Liebschutz J. Update in pain medicine. Journal of general internal medicine. 2010 Nov 1; 25(11):1222-6. [view]
  30. Bair MJ, Krebs EE. Why is urine drug testing not used more often in practice? Pain practice : the official journal of World Institute of Pain. 2010 Nov 1; 10(6):493-6. [view]
  31. Mattocks KM, Haskell SG, Krebs EE, Justice AC, Yano EM, Brandt C. Women at war: understanding how women veterans cope with combat and military sexual trauma. Social science & medicine (1982). 2012 Feb 1; 74(4):537-45. [view]
Journal Other

  1. Campbell SR, Matthias MS, Bergman AB, Krebs E. "I feel like I’m not a doctor”: Physicians’ perceptions of opioid management. [Editorial]. Journal of general internal medicine. 2011 Jul 1; 26(S-1):264-5. [view]
Book Chapters

  1. Bair MJ, Krebs E, Kroenke K. Treatment of chronic pain syndromes. In: Textbook of Psychopharmacology. 4th ed. Washington, DC: APA Publishing; 2009. [view]
VA Cyberseminars

  1. Krebs EE. Barriers to Opioid Monitoring in Primary Care. [Cyberseminar]. 2012 Apr 3. [view]
Conference Presentations

  1. Campbell SR, Matthias MS, Bergman AB, Krebs E. "I feel like I’m not a doctor”: Physicians’ perceptions of opioid management. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 10; Phoenix, AZ. [view]
  2. Matthias MS, Bergman AB, Bair MJ, Coffing JM, Collins LA, Krebs EE. "I'm not abusing or anything": Patient provider communication about opioid treatment. Paper presented at: International Conference on Communication in Healthcare; 2011 Oct 17; Chicago, IL. [view]
  3. Bair MJ, Krebs E, Damush TM, Kroenke K. Analysis of Depression Treatment Response after a Stepped-Care Intervention for Primary Care Patients with Comorbid Depression and Pain. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 1; Miami, FL. [view]
  4. Bergman AB, Matthias MS, Coffing JM, Krebs EE. Managing chronic pain with opioid medications: Patient voices. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 May 1; Orlando, FL. [view]
  5. Krebs EE, Matthias MS, Bergman AB, Coffing J, Campbell S, Frankel RM. Perceptions of opioid monitoring in VA primary care: "We just home they don't call back.". Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 14; National Harbor, MD. [view]
  6. Haskell SG, Ning Y, Goulet J, Mattocks K, Krebs E, Skanderson M, Kerns R, Brandt C. The prevalence of back pain in female and male Veterans returning from Iraq and Afghanistan. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]


DRA: Substance Use Disorders, Health Systems
DRE: Treatment - Observational, Prevention
Keywords: none
MeSH Terms: none

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