Rural Clinicians Efforts to Maintain Relationship-Centered Care Amidst Conflicting Tensions with Inherited Opioid Prescribing Practices.

backgroundRural primary care clinicians face numerous challenges when caring for patients using prescription opioid medication for chronic pain. Research has elucidated the magnitude of the opioid use problem and novel management approaches. Rural primary care clinicians' experiences caring for patients on prescription opioids amidst deprescribing pressures are less well studied.

objectiveTo explore rural primary care clinicians' experiences caring for patients they inherited from other clinicians who were also currently requiring high doses of opioids.

designExploratory qualitative interview study using a constructivist grounded theory approach within an interpretivist paradigm.

participantsTwelve rural primary care clinicians (physicians, physician associates, nurse practitioners). APPROACH: A network of 29 rural public hospitals in Washington State supported voluntary participant recruitment. Semi-structured interviews elicited participants' examples regarding inherited prescribing, yielding descriptively rich cases. Deidentified transcripts were inductively analyzed through code application, thematic development, and constant comparison. Iterative discussions challenged the relationship of the data to the evolving conceptual model. KEY

resultsResearchers identified four tension-filled themes. Within the context of the origins of patients' opioid use, historical prescribing patterns, and clinicians' practice philosophies, clinicians experienced tensions (1) in relationships with patients, (2) in collaboration with colleagues, (3) with inadequate community resources, and (4) with regulatory environments, all of which influenced their opioid deprescribing efforts in ways that aligned with their relationship-centered philosophies. Participants defined health care broadly to include social determinants of health.

conclusionsMultiple conflicting tensions in relationships and with regulations in resource-poor environments make opioid deprescribing difficult. Opioid deprescribing occurs as a relationship-centered activity and conflicts with opioid control policies that target populations for harm reduction. Findings from this research explicate this contradiction in rural settings. Understanding rural health systems in this context and studying effective strategies for including rural clinicians' voices in policy decisions are areas ripe for future research.