The dilemma of repeat weak opioid prescriptions – experiences from swedish GPs

Elsa Ekelin,Anders Hansson

doi:10.1080/02813432.2018.1459241

Elsa Ekelin, Anders Hansson

Open Access

https://doi.org/10.1080/02813432.2018.1459241

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Abstract

Objective: To explore general practitioners’ (GP) experiences of dealing with requests for the renewal of weak opioid prescriptions for chronic non-cancer pain conditions.Design: Qualitative focus group interviews. Systematic text condensation analysis.Setting and subjects: 15 GPs, 4 GP residents and 2 interns at two rural and two urban health centres in central Sweden.Main outcome measures: Strategies for handling the dilemma of prescribing weak opioids without seeing the patient.Results: After analysing four focus group interviews we found that requests for prescription renewals for weak opioids provoked adverse feelings in the GP regarding the patient, colleagues or the GP’s inner self and were experienced as a dilemma. To deal with this, the GP could use passive as well as active strategies. Active strategies, like discussing the dilemma with colleagues and creating common routines regarding the renewal of weak opioids, may improve prescription habits and support physicians who want to do what is medically correct.Conclusion: Many GPs feel umcomfortable when prescribing weak opioids without seeing the patient. This qualitative study has identified strategic approaches to deal with that issue.Key points Opioid prescription for chronic non-cancer pain is known to cause discomfort, feelings of guilt and conflicts for the prescribing doctor. From focus group interviews with GPs we found that to deal with this: • Doctors can use active strategies, such as confronting the patient or creating common routines together with their colleagues, or… • They can use passive coping strategies such as accepting the situation, handing over the responsibility to the patient or choosing not to see that there is a problem. • Opportunities for doctors to discuss prescription routines may be the best way to influence prescription habits.

Highlights

A recurring theme throughout the interviews was a sense that, no matter how you acted as a doctor, some professional ethical rule or inner conviction could be violated
Confronting the patient Referring patients back to their previous prescriber Creating and using common routines from severe pain, which is against the doctor’s ethical code. To this should be added the risk of losing the patient’s confidence, or of being at loggerheads with your colleagues or the management of the health centre, as there are no resources to compensate for the extra time it would take to motivate patients to quit their addiction
The renewal of weak opioid prescriptions without a consultation is experienced as an ethical dilemma for the general practitioner (GP) and leads to various adverse emotions

Summary

Introduction

Since the year 2000, drug-related mortality in Sweden has increased, and more than half of these deaths are related to opioids [1]. Legal prescription of opioids can cause other side effects, besides death, such as sleep disorders, constipation, nausea, risk of falls, increased pain, addiction and abuse [2,3]. Awareness of these side effects creates a dilemma for the general practitioner (GP) when prescribing opioids for chronic non-cancer pain [4]. While weak opioids are less potent, side effects and the risk for developing addiction are more or less the same [5]. According to Swedish national guidelines introduced in 2002, there are indications for both weak and strong opioids for the treatment of chronic non-cancer pain as a complement when first-hand

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