Prescribers Behavior
This section of the research will seek to review the literature from different studies that have been performed on the prescriber’s behavior. In order to make this review, it will be necessary to formulate a PICOT question based on the three hypotheses that need to be tested. The hypotheses that were formulated for this researcher are:
HO1: A prescriber is influenced by patient satisfaction score.
HO2: The number of all prescribers who access the states data base is less than 48 percent.
HO3: The prescriber influenced by the satisfaction survey score of the patient during the prescription of opiates.
These three hypotheses formed the basis from which the themes and subthemes of the study were built. For the purpose of this research, a total of 25 journal articles includin empirical and non-empirical studies were reviewed to examine the reasons for the prescribers not following the evidence-based guidelines and medication.
PICOT Question
Are the prescribers (P) who do not follow evidence-based medicine and guidelines (I) influenced by the patient satisfaction score when describing opiates (O) as compared with those who do not have access to the state prescribing data base (PDMP) (C) before the subscription of opiates (T)?
Major Themes
Factors influencing Prescriber Behavior in the Prescription of Opiates
In a study conducted by Sinnenberg et al. (2017), the authors examined the factors that affect the decisions of prescribers in prescribing opioids in emergency departments. The authors argued that the participants presented a variety of factors that influenced their patterns of the drug prescription. Such prescriptions as indicated by Von Korff et al. (2011) were based on the patient-based considerations, practice environment, and the provider assessment of the characteristics of pain. In this context, Sinnenberg et al. (2017) further presented the pain characteristics as the characteristics of a range of chronic and acute syndromes such as the empathy of the prescribers because of the experience they have ever had with pain. On the other hand, the factors of the practice environment involve hospital regulation or legislature, guidelines, and policy (Barnett, Olenski, & Jena, 2017). The study has described the patient characteristics as ethnicity, race, and trustworthiness as well as the interest in the risk of misuse. It was concluded that incentives are associated with the satisfaction scores of the patients and also the policy which cannot permit the decisions which are individualized and patient-centered on others.
There has been increasing literature that explicitly explains the way prescribers view the usage of opioids based on prescription decisions. Barnett, Olenski, and Jena (2017) utilized the approach of survey to offer a description of the attitude of the physician towards the use of opioid. In this context, the authors point out the trends that the opioid analgesis (OA) have had on the rates of prescribing. Levy et al. (2012) has presented the results of such trends in the U.S where they posit that the data depicted the trends that are diverging in opioid prescribing among the U.S medical specialties between 2007 and 2012. This survey concludes that it is vital to engaging the medical specialties at an individual level for the continuous improvement in the treatment of pain that is effective and safe. Sinnenberg et al. (2017) postulate that prescribers showed greater interest in the prescription drug monitoring program (PDMP) guidance, which has put immense competing pressure on the prescription of the drug.
Prescribers’ Access to the State Prescribing Database (PDMP)
There has been an increasing literature as to whether prescribers have access to the state prescription drug monitoring programs (PDMP) in their daily practices. One study has indicated that PDMC has been a useful tool for surveillance (Baehren et al., 2009). The study by Baehren et al. (2009) studied PDMP use in an ED where the review of the data of the ED clinician contributed to their change of their clinical management in the cases which accounted for 41 percent. The data also depicted that 61 percent of such cases got fewer or no opioids as compared to the clinician who had initially come up with the plan to prescribe before the review of the PDMP data (Baehren et al., 2009). The remaining 39 percent comprised those who received additional medication as opposed to the one that was planned previously since the clinician could not confirm the absence of the patient’s history of opioid use (Baehren et al., 2009). This argument indicates that prescribers have been able to access the state PDMP data so as to make their prescriptions.
Barriers to the Prescribing Tools
Several studies have performed to examine the barriers that have impeded the use and effectiveness of the prescribing tools in clinical practice. Morgan and Kennedy (2010) have presented financial constrain as the key factor that affects the physicians since they consider some drugs prescribed being expensive to the users. According to them, there has have been some cases of the rates of non-compliance to prescribed treatments which are related to cost, which has added more evidence of inequity in accessing prescribed drugs in the United States (Onishi et al., 2017). They add that Americans tend to skip the prescribed drugs as a result of high costs and thus resulting to higher rates of financial barriers. It has been argued that some people skip the prescribed doses based on affordability issues. For instance, in America, the low-income earners have proved to be at high risk of non-adherence that is cost-related (Onishi et al., 2017).
On other hand, Hahn (2012) postulates that the financial effect on the payers from prescribing opioid use has been a barrier to the physician use of the prescribing tools. It has been reported that the costs of healthcare for the abusers of opioid has been high, eight times greater as compared to that of non-abusers. According to Hahn (2012), the key contributors to this high costs include the hospital inpatient visits, treatment of comorbidities, and insurance fraud by prescription. Additionally, Wightman et al. (2012) point out another barrier as the increasing rates of addiction and economic. Addiction to the prescribed opioids means that users abuse opioids, thus, increasing the cost of the prescription.
Subthemes
The Evidence-Based Guidelines and Medicine to be followed by Prescribers of Opiate
There are few studies that have focused on the evidence-based guidelines and medicine which need to be followed in the prescription of opioid by prescribers. Nonetheless, the literature from most of the studies has concentrated on the various health concerns in different parts of the world which need medical intervention as well as guidelines. Dowell et al. (2016) investigated the Center for Disease and Control (CDC) guideline for the prescription of opioid for chronic pain. In this study, the authors suggested the guidelines for the selection of opioid, duration, dosage, follow-up, and then discontinuation. Dowell et al. (2016) also argued that there is a need for contextual evidence to offer the information concerning the dangers and benefits of non-pharmacologic and non-opioid pharmacologic therapy as well as the epidemiology of medication overdose of opioid pain. Cochran et al. (2016) point out that the prescription opioid misuse has become a critical public health concern in the US.
There are few studies that have been performed to support the concept of the reasons for the prescribers not following the evidence-based medicine and guidelines (Cho & Kim, 2015). On the other hand, Jamison et al. (2014) acknowledge the fact that is an increased health concern concerning the misuse and non-adherence among patients having chronic pain and need prescribed opioids for pain. Hahn (2011) has pointed out the medical errors result for the prescribers not adhering to medical guidelines and thus suggests an electronic prescribing to reduce such errors. Furthermore, Levy et al. (2015) postulate that most of the prescriptions of opioid analgesic are the factors in the overdose of drugs, though there is little evidence concerning the pattern of among the medical experts.
Are Prescribers Treating the Patient’s Requests or Objective Findings?
The literature performed on this subject has depicted varied views among the researchers. Most of the studies have provided evidence that prescribing the drugs based on the patient’s requests may be misleading and thus the prescription entirely depends on the objective of the prescribing drug given to the patients or users. Wilson et al. (2013) has pointed out that long-term efficacy as well as the severe impacts of opioids, together with increases in opioid prescribing, have constituted the many political, regulatory, and clinical responses forming the objective for the prescription of the drugs. In this case, the prescribes looks at the past history of the user to determine which drugs that needs to be prescribed rather than making prescriptions based on what the patient wants. Dowell et al. (2016) argue that patients need to receive appropriate treatment of pain on the basis of a careful consideration of the advantages and risks of the alternatives of treatment. This argument emanates from the fact that patients may experience pain that persist and not well controlled, thereby leading the patient to patient to make a request to reduce such pain.
In contrast, Pasternak (2014) provides different view which tends to support the prescription based on the request of the cancer patients. His argument stems from the idea that the management of pain among the patients suffering from cancer requires individualization of the therapy due to the response vulnerability among such patients to diverse pain treatments and medications. For instance, a single patient may get a relief with one analgesic which is excellent, while another patient may obtain desirable results with another treatment (Cantrill, 2016). He adds that is necessary to consider the requests of the patients based on his or her description of the case and then give a specific dose for that particular problem whose aim it to manage pain, which seems to differ remarkably among the patients.
How the Patient’s Satisfaction Score Influences Prescribers Work
Nwokeji et al. (2007) suggest that there is conflicting information concerning the proper use of long-acting analgesics for chronic nonmalignant pain (CNMP). This situation is tempting since it can make the physicians to be reluctant to prescribe such drugs even when there is medical appropriateness. The authors present further evidence that two thirds of physicians indicated their somewhat willingness in the prescription of long-acting opioids to their patients having CNMR. Additionally, it has been indicated that the attitude of the physicians slightly favorable towards the higher scores of the satisfaction of the patients (Nwokeji et al., 2007). Savage (2008) also sought to examine the challenges that are experienced in the use of opioid in the treatment of pain in patients with substance use disorders. In this study, Savage (2008) found out that the level of pain that the patient experiences determine the prescriber’s behavior towards the treatment to give. Chronic pain is different from acute pain since it does not serve survival or any other beneficial purpose any longer, where it has beyond the limits that are normally associated with the healing of the tissue (Fields & Margolis, 2015). Thus, Fields and Margolis (2015) argue that effective treatment of chronic pain has to respond to the context in which the pain appears, the feedback cycles that may seek to sustain it, and the multidimensional effect of the pain. Additionally, The American Society for Pain Management Nursing (ASPMN) believes in the fact that the practice of prescribing opioid analgesics doses based on the pain intensity of a patient need to be prohibited (Pasero et al., 2016). The implication of this argument is that such a practice does not consider the relevance of other elements of assessment that are important and may result in untoward outcomes of the patient.
The Framework of Care for Opiates Medication Misuse in Community Pharmacy
Some frameworks of the care for the opioid medication misuse in the community pharmaceutical practices have been developed in several studies. Cochran et al. (2015) have examined the execution of the ADAPT-ITT model or rather a model for the modification of the evidence-based behavioral interventions to new populations as well as service settings. This framework has been developed to give guidance to the development of a behavioral health model for the medication misuse of opioid in the setting of community pharmacy. On the other hand, the current strategies have focused on the development that may bring about the reduction of the risk for misuse as well as abuse of opiates medications (Hahn, 2011). In consequence, such frameworks lead to the improvement of patient outcomes and as well lower costs to the patients and health insurers. Wilson et al. (2013) designed a framework that sought to assess the current as well as the evolving beliefs concerning opiates and their use in patients diagnosed with chronic pain. In this study, researchers presented the beliefs and behaviors of physicians among medical specialties as well as geographic regions using a nationally representative sample by use of this model.
Pasero et al. (2016) suggest the foundation of an individualized pain management that is effective and safe, comprehensive pain assessment. This medical model includes, though not limited to, the determination of the intensity of pain if the patient has the ability to report it. Pasero et al. (2016) argued that an unpredicted consequence of the extensive utilization of pain intensity rating scales can refer to the practice of specific doses prescription of opioid analgesics on the basis of specific pain intensity. Pasero et al. have also asserted that there are numerous factors besides the intensity of pain which impact the requirements of opiates (Pasero et al., 2016). Nonetheless, no research has indicated that a specific dose of opioid can relieve specific pain intensity in all patients suffering from chronic pain. Jeihooni et al. (2016) also sought to examine another model known as the health belief model (HBM) along with the social cognitive theory (SCT) for the preventive nutrition behavior of osteoporosis among women. Their findings indicated the HBM effectiveness as well as the constructs of social support and self-regulation on the increased bone density for the prevention of osteoporosis and the adoption of nutrition behaviors, which were similar to findings by Hooten and Bruce (2011).
Strategies to Prevent Opiates Misuse and Abuse
Several studies attempted to examine the current strategies used by the prescribers in the reduction of the risk for misusing and abusing medications of opioids. Hahn (2011) postulates that the implementation of the strategies that allow the use of safe practices in the management of pain by the prescribers is vital as it cuts down the risk of misuse and abuse of the medications of chronic pain. One of the strategies included developing the prescription monitoring programs (PDMP) for the detection pharmacy or physician shopping. The second approach that was suggested was the detection of inappropriate prescribing as well as the medical errors. Hahn further indicates points out the strategy of extensive physician and patient education concerning pain medications as well as their associated risks for abuse and misuse (Hahn, 2011). Added to these approaches is the use of physician–patient contracts regarding the treatment of opiates and also screening provisions of urine drug toxicology to ensure safe disposal of opiates that have not been used (Adams et al., 2004). Furthermore, Pasternak (2014) suggested the approaches such as the referrals to pain as well as addiction specialists and also potential encouragement of opiates formulations use whose aim is to reduce misuse and abuse. Additionally, Hahn suggests the need for the presentation of photo identification upon picking an opioid prescription at the pharmacy (Hahn, 2011). This argument stems from the findings that there have rising cases of abuse which as associated with the identity theft.
Limitations in the Existing Literature
The existing literature seems to have several limitations that need to be addressed in the further stud in the offing. For instance, the studies where interviews were conducted took place at a big national conference where the emergency medicine physicians who had interests in the subject were involved (Furtak et al., 2012). In most studies, most of the interview participants have been male, accurately reflecting the breakdown of gender of active physicians of emergency medicine in the nations like the United States. There has also been a limitation of race and ethnic disparities since some data of race and ethnicity of participants was not gathered. In effect, such a scenario has limited the ability for the investigators in the incorporation of such these data into the analysis of the reflections of the participants on ethnic and racial issues. In some studies, there is evidence that no practice setting of participants were collected, though the respondents could discuss the way their practice setting serves a contextual function in such medical decisions (Barnett, Olenski, & Jena, 2017). Notably, it cannot be possible to generalize the findings to the whole population of emergency physicians, and also to the actual practices of prescribing.
Additionally, the limitations related the study by Jeihooni et al. (2016) comprises the sampling method it uses. It has to be noted that convenience sampling relates to the selection of the participants of research based on the accessibility and convenience to the researcher. The limitation of this kind has resulted in the cognitive psychologists warning that the memory of human beings is fallible, making the reliability of self-reported data to be tenuous on various aspects. Therefore, there is a necessity for future research with the consideration of many physicians for effective and efficient quantitative testing of the distribution of themes that have been formulated in this research (Aguinis & Lawal, 2012; White & Sabarwal, 2014). In other words, there are high chances that the participants may be subjected to susceptibility of biases of social desirability.
Conclusion
The research seeks to focus on the identification of reason for the subscribers not to adhere to the evidence-based guidelines as well as medicine. It has been essential to examine the three main themes in this study. One of the themes that were formed from the hypotheses is identifying factors that influencing prescriber behavior in opiates prescribing. Secondly, the paper has investigated the accessibility of prescribers to the State prescription drug monitoring program (PDMP). Thirdly, it was necessary to examine the barriers to the prescribing tools. On the other hand, the subthemes under the main themes were discusses by reviewing the previous studied that have been performed on the topic of research. Finally, the limitation such as race and ethnic disparities and the sampling methods have been identified and further work recommended addressing them.
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