Sources of distress in primary care opioid management and the role of a controlled substance review group: A qualitative study

Objective. The objective of the study was to explore provider perspectives surrounding opioid prescribing in the context of the early implementation of a multidisciplinary group, called the Controlled Substance Review Group, that provided structured opioid case discussion and consultation to primary care providers. Setting. A Veterans Health Administration primary care clinic in Portland, Oregon. Participants: 12 members of primary care clinic staff representing multiple disciplines with recent participation in the Controlled Substance Review Group. Methods. Six semistructured interviews with primary care providers, one focus group discussion with six Nurse Care Managers, and 28 structured observations of CSRG meetings were conducted. In an iterative process using applied thematic analysis, a trained qualitative researcher reviewed textual data for themes. Results. Four broad domains with associated themes emerged from the analysis: 1) challenges of pain management'objective pain measures, changing guidelines, lack of coordinated approach; 2) patient attachment to opioids'threats, entitlement, abandonment; 3) provider frustration'confrontation in clinic visits, lack of mental health engagement, complex social situation; and 4) role of the Controlled Substance Review Group'communication techniques, supporting mental health engagement, structured backing. Conclusions. Primary care providers experience stress associated with opioid prescribing, including the provision of appropriate pain management using opioid analgesics and difficult patient-provider communication. The Controlled Substance Review Group functions to support providers through assistance with decision-making and shared responsibility for decision outcomes.