The trouble with opioids: NSW General Practitioners and the diagnosis and management of prescription opioid dependence in patients prescribed opioids for chronic pain

Abstract Background Opioids are often prescribed by General Practitioners (GPs) to manage chronic pain (CP). GPs are concerned about the risk of opioid dependence in this group, a serious condition that, if diagnosed, can be effectively managed by methadone or buprenorphine within opioid dependence treatment (ODT) programs. GPs seem reluctant to prescribe ODT, an important factor in its limited availability. Given widespread GP opioid prescribing for CP, this PhD aimed to investigate New South Wales (NSW) GPs' experience diagnosing and managing opioid dependence in patients prescribed opioids for CP and elucidate the complexities, barriers and facilitators to providing treatment for opioid dependence due to prescribed opioids. Methods This PhD a) used the theory of planned behaviour to frame semi-structured interviews with NSW GPs in longitudinal, qualitative research between 2021 and 2023, and b) mixed methods research triangulating key informant interviews, document review and NSW ODT prescriber data to investigate the NSW ODT program and GP ODT prescribing from 1970 to 2022. Key findings Initiatives to increase NSW GP ODT prescribing have had some success: by 2022, 75% of ODT prescribers were GPs managing 50% of patients. This leaves a small group of other prescribers providing care for large numbers, creating a fragile system in which availability has never kept pace with increasing demand. Against the backdrop of Covid and exodus to specific interest, often non-Medicare, roles, 24 GP participants reported difficulty diagnosing and managing opioid dependence in their CP patients. Participants misunderstood diagnostic nuances. Knowledge, skill and attitudes were adversely affected by experiences of conflictual conversations with unwilling patients, fears of regulatory censure, and risk of ‘opening the floodgates’ to demand. Compounded by negative social norms and behavioural controls (lack of time, remuneration, and support), inertia and avoidance were common. Some participants’ attitudes and experiences improved over time, often driven by patients, who requested help after seeing concerns regarding addiction to prescribed opioids raised in the mainstream media. Positive social norms and collegiate support assisted GPs to diagnose and manage opioid dependence in their GP patients in the GP setting. Conclusions Activating patients, simplifying regulations, boosting funding and improving GP skills and support may assist GPs to diagnose and manage their CP patients with opioid dependence.