Abstract
Purpose: The few studies about primary care based controlled substance safety committees (CSSC) to date have been primarily quantitative, focused on patient outcomes and lacked contextual data around their implementation. The purpose of this study is to qualitatively identify barriers and facilitators to the use of CDCs guidelines around opioid prescribing and the implementation of controlled substance safety committee in a primary care practice.
Methods: Ten semistructured interviews were conducted with primary care clinicians in an academic medical practice. Potential barriers and facilitators to the uptake and use of the CDC opioid guidelines and the practice’s CSSC were coded and analyzed against the Capability, Opportunity, and Motivation framework for Behavior change framework (COM-B).
Results: Six key themes were identified around uptake of the CDC guidelines. In general, the CSSC addressed some of the capability barriers around the guidelines but had limited impact on increasing motivation to follow the guidelines. We found the same recommendation in the guidelines could have differing impact on prescribing behavior.
Conclusions: Simply promoting guidelines may be insufficient, especially for those viewing them as rules rather than recommendations. Our findings underscore the fact that guidelines are merely a starting point, not an endpoint of implementation.
- Centers for Disease Control and Prevention (U.S.)
- Controlled Substances
- Drug Control
- Family Medicine
- Implementation Science
- Motivation
- Opioids
- Pain Management
- Physician's Practice Patterns
- Safety
Millions of Americans receive prescription opioids for chronic pain, risking misuse and overdose.1–4 The Centers for Disease Control (CDC) issued guidelines in 2016 to ensure safer, effective pain management, updated in 2022 to emphasize tapering high-dose opioids, exploring alternatives, and shared decision making.5,6 Implementing these guidelines presents challenges, as clinicians require the capability and motivation to follow guidelines, while patients must have opportunities to receive prescriptions. Requirements such as behavioral health consultations further complicate this process.7–9
To address these issues, primary care practices have adopted controlled substance safety committees (CSSCs) that review policies and develop clinician education.10–12 Despite their existence, few studies have assessed CSSC effectiveness, often focusing on patient outcomes without contextual data on implementation.10–14 This study utilizes the Capability, Opportunity, Motivation, and Behavior (COM-B) framework to explore barriers and facilitators to CDC guideline use and CSSC implementation in a primary care practice, highlighting the importance of capability, opportunity, and motivation to follow guidelines among clinicians.
Methods
Design
We conducted semistructured interviews (SSI) with clinicians (NP, MD/DO) from a primary care practice in an academic medical center.
CSSC
In 2017, the primary care practice developed a CSSC to support clinicians in following the CDC guidelines for prescribing opioids for long-term noncancer pain. The standing CSSC included physician attendings and residents, nurse practitioners, behavioral health clinicians, a care coordinator, data analyst, and a pharmacist. They met monthly to review opioid-managed chronic pain cases and provided feedback to clinicians with patients who had potentially unsafe opioid prescriptions (eg, ≥90 Morphine Milligram Equivalents (MMEs) for ≥90 days).11 Along with reviewing cases, they also developed a set of best practices for prescribing opioids that clinicians could use with patients.
Study Population
At the time of the study, approximately 66 clinicians (NPs, MDs/DOs) were in practice. Participation in the study was not compensated. Eligibility included willingness to audio record the SSI and to have worked at the practice since the CSSC's inception. All participants had some experience with patients that were prescribed opioids for chronic pain. We recruited clinicians during a monthly practice meeting by presenting an overview of the study and inviting participation. Ten clinicians expressed interest and were interviewed. The study sample included family medicine physicians, residents, and nurse practitioners and reflected a range of key traits of the practices’ clinicians (rank, scope of practice, gender). Our target sample size was 8 to 10, based on available resources and reports of knowledge saturation.15
Data Collection
We developed the SSI guide based on the principles of the COM-B framework, a review of the literature on CSSCs and CDC guidelines. No one of the research team was a member of the standing CSSC. During the SSI we (1) asked participants about their knowledge and use of the CDC guidelines followed by (2) questions that explored their COM to use the practice’s CSSC. Our SSI guide is included in the Appendix.
We conducted 15 to 20-minute SSIs via Zoom. Research assistants obtained verbal consent, briefed participants on the protocol, and requested recording approval before each interview. To ensure anonymity, participants turned off video cameras and removed names from the Zoom grid. We deidentified and transcribed SSIs verbatim, then analyzed data using MAXQDA 2022 (VERBI Software, 2021).
The University of Rochester’s Institutional Review Board approved the study.
Analysis
Our coding was deductive, a priori aligned with the COM-B framework. We inductively added more codes as the need arose. We (MS, HR, AR) coded for themes, barriers and facilitators to implementation. We determined coding saturation after we no longer needed new codes within individual transcripts. We identified themes if a topic was noted more than once and present in at least 2 transcripts.16 Our coding processes considered our formative experiences with opioid stewardship, background knowledge on opioid prescribing, and available contextual information.
We approved the final coding structure after 3 iterations. At least 2 team members coded each transcript. We met to review any coding discrepancies and resolved them by group consensus. Codes were entered into the MAXQDA database for analyses.
Results
Our adapted COM-B components and the definitions are presented in the Appendix. Table 1 illustrates the distribution of coded COM-B domains and exemplary themes and quotes. Most of the codes were Motivation/Reflective (39.51%), Capability/Psychological (30.24%) and Opportunity/Social (17.86%).
COM-B Components and Definitions
Themes around Guideline Implementation
We identified 6 Key themes: (1) Multifactorial (2) Building trust, (3) Navigating mistrust, (4) Clinical (Un) Certainty, (5) Honoring previous decisions and (6) Risk Tolerance.
Multifactorial
There was variation in how clinicians interpreted and applied the guidelines, Figure 1 Some used the guidelines as general principles while others used them as hard and fast rules. Their clinical reasoning and motivation to follow the guidelines were related to Capability and Motivation factors.
Exemplary quotes of how the guidelines crosscut the Capability, Opportunity, Motivation, and Behavior (COM-B) to impact clinical care.
Building Trust with Patients
Another key theme was building trust. A resident expressed concern about limited time with patients (Opportunity/Social; Opportunity/Physical).
“When you have 20 minutes and you're a resident, you have three years to build a rapport … you probably see them maybe five, six times. …And let's be honest, … you're not going to trust that physician to reduce your opioid unless you build the rapport.”
Clinician 5
Navigating Mistrust of the Guidelines
There were concerns about mistrust of the guidelines and their lack of attention to the risks of deprescribing.
“… not nearly as much written about patients with legitimate need for opioid medications who have ended up being caught in a deprescribing kind of philosophy from their physicians.”
Clinician 4
Clinical (Un) Certainty
Many of the clinicians indicated the severity of some conditions, such as terminal cancer or acute traumatic injuries, facilitated risk tolerance and clinical certainty around when to prescribe. (Motivation/Reflective)
“…the guy's got an acute tibial fracture or a gunshot wound and they're like Tylenol, ibuprofen. And you're like, yeah, no, this is what they make narcotics for.”
Clinician 6
Contrary to this, uncertain diagnoses or undefined opioid use duration lowered risk tolerance (Motivation/Reflective). Clinicians prioritized alternative treatments but faced barriers like lengthy referrals or lack of insurance coverage for options such as physical therapy or acupuncture.
Honoring Previous Decisions
One of the most prominent themes was the challenge of keeping with a previous treatment decision of a colleague.
“I think it's most challenging when I have inherited a patient who's been on a large dose … and so they have negotiated the dose with someone else and then, I inherit them. … I think about how do I start reducing them on that medication … it can be challenging.”
Clinician 3
Risk Tolerance
Clinicians with more experience expressed greater risk tolerance compared with newer clinicians.
“…some of my colleagues, who've been practicing medicine for 20, 30 years, …got trained in an era that was different than ours. So, I think I do try to follow these guidelines a little bit more strictly.”
Clinician 5
“I see that all the time as the younger generation of physicians has been told that opioids are terrible medicines …”
Clinician 6
Implementing the CSSC
The most frequently used code for the CSSC was Capability/Physical. Most clinicians reported difficulty physically attending meetings but found them beneficial when present. The CSSC monthly feedback report on patients that were on potentially unsafe doses was most useful. Some found informal consultations with colleagues helpful.
Table 2 lists clinicians’ suggestions for CSSC adaptations at the patient, clinician, and practice levels, including an asynchronous meeting option.
Suggested Controlled Substance Safety Committees (CSSC) Adaptations
Discussion
We identified 6 key themes around uptake of the CDC guidelines that mapped to the COM-B framework. The guidelines were seen as both barriers and facilitators for prescribing. The recommended safe dosing threshold resonated with some clinicians as rule rather than a guideline. The clinicians appreciated the CSSC as an opportunity to get peer support with challenging cases.
Our findings further suggest the CSSC’s efforts to provide structured resources and support for clinicians had its challenges. Most clinicians suggested a more informal process or a centralized person or group where they could send questions asynchronously as opposed to waiting for a meeting time. The tools (eg, feedback reports and curbside consults) were highly rated.
The ongoing epidemic of deaths from opioid overdose combined with increased rates of patients struggling with chronic pain syndromes represents an ongoing challenge for our health care system.17–19 Educating busy clinicians on the complexities of patient-centered pain management while minimizing opioid prescribing risks is difficult. Although the CDC guidelines aim to promote safe opioid prescribing, difficulties in addressing patients already on high doses, along with fears of professional or legal repercussions, hinder consistent understanding and application of these guidelines.20
Limitations
Our study is limited to one academic family medicine practice. In addition, we were focused on residency training clinical practice and so there may be differences among private practice and clinicians practicing in other types of offices. Our sample of convenience may not represent the views of all clinicians in the practice.
Strengths
This is the first study we are aware of looking at these efforts from a qualitative perspective using the COM-B framework. We believe the qualitative data can help practices tailor future opioid stewardship efforts more efficiently and effectively toward the goal of improving safety rather than simply decreasing MMEs.
Conclusion
Simply promoting guidelines may be insufficient, especially for those viewing them as rules rather than recommendations. Neglecting nuanced training may produce clinicians ill-equipped for safe opioid prescribing. This can have downstream effects for “legacy” pain patients and worsen existing disparities in pain treatment for historically undertreated marginalized populations.11,21,22 Our findings underscore the fact that guidelines are merely a starting point, not an endpoint of implementation. In addition, given the time constraints, CSSCs may benefit from asynchronous options for busy clinicians.
Appendix
CODING MANUAL FOR CLINICIANS
Notes
This article was externally peer reviewed.
Funding: Funding for this project was provided by the McDaniel-Farley-Fogarty Family Medicine Faculty Scholarship Fund awarded to Drs Mechelle Sanders and Mathew Devine in 2021.
Conflict of interest: None.
To see this article online, please go to: http://jabfm.org/content/38/3/577.full.
- Received for publication June 5, 2024.
- Revision received August 7, 2024.
- Revision received October 25, 2024.
- Revision received January 14, 2025.
- Accepted for publication January 29, 2025.
