Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework
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.
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.
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).
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.
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.
- 7.Mols F, Beijers T, Lemmens V, van den Hurk CJ, Vreugdenhil G, van de Poll-Franse LV. Chemotherapy-induced neuropathy and its association with quality of life among 2–11 year colorectal cancer survivors: results from the population-based PROFILES registry. J Clin Oncol. 2013;31(21):2699–707.CrossRefPubMedGoogle Scholar
- 14.Dreyer T, Rontal R, Gabriel K, Udow-Phillips M. Uncoordinated Prescription Opioid Use in Michigan. Ann Arbor, MI: Center for Healthcare Research and Transformation; Dec 2015. http://www.chrt.org/publication/uncoordinated-prescription-opioid-use-in-michigan/. Accessed 20 Feb 2017.
- 23.Patey AM, Islam R, Francis JJ, Bryson GL, Grimshaw JM. Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests. Implement Sci. 2012;7(1):52.CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Steinmo SH, Michie S, Fuller C, Stanley S, Stapleton C, Stone SP. Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement “Sepsis Six”. Implement Sci. 2016;11(1):14.CrossRefPubMedPubMedCentralGoogle Scholar
- 38.Hill MV, Stucke RS, McMahon ML, Beeman JL, Barth RJ Jr. An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. Ann Surg. 2017; 267(3):468.Google Scholar
- 39.Howard RA, Waljee JF, Brummett CM, Englesbe MJ, Lee JS. Reduction in opioid prescribing through implementation of evidence-based prescribing guidelines. JAMA Surg. 2017.Google Scholar