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Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework

  • Health Services Research and Global Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior.

Methods

Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing.

Results

Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines).

Conclusions

Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.

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Funding

Dr. Lee is a National Research Service Award postdoctoral fellow supported by the National Cancer Institute (5T32 CA009672-23), and Dr. Waljee receives funding from the Michigan Department of Health and Human Services, the National Institute on Drug Abuse (RO1 DA042859), and the Agency for Healthcare Research and Quality (1K08 HS023313-01). The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or the Michigan Department of Health and Human Services.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA

    Jay S. Lee MD, Vartika Parashar, Samantha M. Bremmer, Joceline V. Vu MD & Lesly A. Dossett MD, MPH

  2. Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA

    Jacquelyn B. Miller MA

  3. Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA

    Jennifer F. Waljee MD, MPH, MS

  4. Division of Surgical Oncology, University of Michigan Comprehensive Cancer Center, 3303 Cancer Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5932, USA

    Lesly A. Dossett MD, MPH

Authors
  1. Jay S. Lee MD
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  2. Vartika Parashar
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  3. Jacquelyn B. Miller MA
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  4. Samantha M. Bremmer
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  5. Joceline V. Vu MD
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  6. Jennifer F. Waljee MD, MPH, MS
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  7. Lesly A. Dossett MD, MPH
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Corresponding author

Correspondence to Lesly A. Dossett MD, MPH.

Appendices

Appendix 1

Semi-structured Interview Guide

Decision Making for the Initial Postoperative Opioid Prescription

  1. 1.

    We are going to discuss your practice for prescribing opioids to cancer patients. How do you decide what pain medication to use and how much to prescribe (dose, quantity of pills, refills)?

  2. 2.

    How did you come up with the above strategy?

  3. 3.

    How much do you prescribe relative to how much you think the patient will actually consume?

    • If applicable, why do you prescribe more than they need? What are the possible risks of this unused medication?

  4. 4.

    What do you think other surgeons do with regard to prescribing opioids?

  5. 5.

    What would consider ideal practice for prescribing opioids?

  6. 6.

    What are the barriers to prescribing less opioid medication?

Counseling Patients on Safe Opioid Use:

  1. 7.

    Now we are going to discuss counseling patients on opioid use. What key factors do you address when counseling patients on opioid use?

    • If applicable, why do you not discuss the following factors: risk of abuse, risk of diversion, safe disposal of medication.

  2. 8.

    Describe how counseling on opioid use is typically delivered to your patients (who provides it, who receives it, when is it given, written vs. oral)?

  3. 9.

    What do you think other physicians do for counseling patients?

  4. 10.

    What would you consider ideal practice?

  5. 11.

    What are the barriers to achieving this?

Management of Opioid Misuse:

  1. 12.

    After discharge, who most commonly answers questions from patients regarding opioid use and pain management?

  2. 13.

    How do you determine if a patient is inappropriately using opioids?

  3. 14.

    What do you do for these patients?

  4. 15.

    How do you think other physicians identify and manage inappropriate opioid use?

  5. 16.

    What would you consider to be ideal practice for identifying and managing inappropriate opioid use?

  6. 17.

    What are the barriers to achieving this?

How a Cancer Diagnosis Affects Opioid Prescribing:

  1. 18.

    How does a patient’s diagnosis of cancer affect your practice for prescribing opioids, counseling, and managing postoperative opioid use?

  2. 19.

    Anything else you would like to add?

Appendix 2

See Table 2.

Table 2 Additional sample quotes for theoretical domains and specific constructs for opioid prescribing
Full size table

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Lee, J.S., Parashar, V., Miller, J.B. et al. Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework. Ann Surg Oncol 25, 1843–1851 (2018). https://doi.org/10.1245/s10434-018-6466-x

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  • DOI: https://doi.org/10.1245/s10434-018-6466-x

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