This study represents an original contribution by producing a conceptual map of factors influencing NA utilization amongst injured workers, drawing specifically on the perspectives of physicians and pharmacists. Participants portrayed a complex and multifaceted phenomenon, depicting injured workers within their personal and social contexts, and identifying numerous factors operating at multiple levels. This is the first study to characterize the topic in a comprehensive manner, and to attempt to interrelate the contributing factors within a coherent framework.
Surprisingly, participants saw system-level factors as more amenable to intervention, despite their perceptions that patient-level factors are most influential to NA over
-utilization in this population. Numerous quantitative studies of NA usage have been conducted (some in the context of RTW), and the majority focus on identifying individual factors/characteristics that put patients at risk for abuse (e.g. age, psychiatric comorbities, history of substance abuse) [15
]. Russell and colleagues (2005) conducted a qualitative study of family practitioners related to managing RTW patients generally (not focused on NA) which revealed that physicians viewed 'external influences' (compensation boards, employers, etc.) with suspicion [8
]. In contrast, our participants indicated that they would welcome further guidance in managing workers from a variety of sources (including compensation boards). Interestingly, a large scale quantitative study by Shaw and colleagues (2005) looking at RTW reported that RTW and shorter duration of disability were predicted by employment factors rather than individual patient history and physical examination [34
Participants identified only one cluster of system-level factors ('Treatment Problems') as both strongly influencing NA overuse and highly amenable to intervention. This suggests that addressing the factors within this cluster is where interventions hold greatest promise of impacting NA utilization. This was surprising because to date, most interventional studies addressing NA overuse have focused on individual behaviour change (patient-level) [35
]. Our clinician participants instead indicated that there were changes at the system-delivery level that could be implemented to improve NA utilization amongst injured workers. This demonstrates the importance of employing both
rating maps to understand the problem and its potential solutions. If we relied solely on Figure (perceived drivers of over-utilization), we might erroneously conclude that interventions should be targeted primarily at the level of patient/worker behaviour change. Instead, participants identified practice- and system-level factors as more amenable to intervention. Participants rated one cluster ('Treatment problems') highly on both rating scales (important influencers on overutilization and
most amenable to change), suggesting that this might be the set of factors to which interventions should be targeted to improve outcomes. Tables and indicate that five factors specifically were ranked as particularly important to NA overutilization as well as being amenable to intervention. These were: 'lack of education/support for physicians in pain management' (52), 'unavailability of multidisciplinary team-based care'(44), 'inability to get non-pharmacologic treatments' (54), 'lack of continuity of care' (36), and 'lack of resources in assisting patients with NA addition/withdrawal'(21). This suggests that optimizing collaboration between physicians, pharmacists, clinical specialists, compensation experts, and injured workers may be most important to improving worker well-being and reducing the associated costs of time off work. That being said, the care of workers with chronic pain is complex and multifaceted approaches will be needed, with implementation of strategies targeting providers and treatment, coupled with an exploration of novel approaches to address patient-level factors. Intervention studies would have to be conducted to determine whether focusing on these factors translates into reductions in NA use.
Given that participants emphasized the lack of education/support for physicians in managing pain in injured workers, an intervention such as academic detailing might be an appropriate initial step to improving practice [42
]. Such approaches incorporate face-to-face interactions with trusted expert clinicians, and are thought to be more successful than traditional guideline dissemination approaches to changing practice [43
]. Participants suggested a number of avenues for improving interprofessional communication between physicians and pharmacists (e.g. through an electronic prescription monitoring system) [44
], and an enhanced role for compensation boards for communicating existing community-based resources for accessing specialty services and non-pharmacologic care.
While there was considerable agreement between physicians and pharmacists regarding the cluster ratings, the minor differences identified on the pattern matches and go-zones are intriguing. These may be largely explained by the specific roles physicians and pharmacists play in the pain management of injured workers. In the pattern match, pharmacists ranked 'Addiction Risks' as more amenable to intervention than physicians. It may be that pharmacists are more aware than family physicians regarding strategies for managing addiction risks. Conversely, physicians ranked 'Systemic-Third Party Factors' as more amenable to intervention than pharmacists. This could be explained by the fact that physicians have more interaction with compensation boards (emphasized in the cluster 'Systemic-Third Party Factors') than do pharmacists, and so are likely more aware of opportunities for process redesign within that cluster. Interestingly, physicians ranked 'Pharmacy-related Factors' as more amenable to intervention than 'Physician-related Factors', while pharmacists were more optimistic that 'Physician-related Factors' could be improved than were physicians themselves.
While ours is the first study to address this topic using CM, others have used CM to explore opioid utilisation generally. Butler and colleagues conducted a series of CM studies (2004, 2006, 2007) as a preliminary step in developing patient self-report measures of prescription opioid abuse [24
]. None of these studies evaluated injured workers, and Butler focused exclusively on patient-level
drug-related behaviours. The purpose of using CM in our study was different, as we sought to catalogue a broad array of factors contributing to current NA utilization patterns (specifically in injured workers), and to organize them into a coherent framework. The study's results have confirmed that many factors beyond the injured worker are perceived to influence NA utilization. The participants in our study chose instead to emphasize the shortcomings of the healthcare system.
Two additional qualitative studies (neither employing CM nor focusing on work-related injury) have been conducted concerning NA prescription, one eliciting providers' perspectives, the other patients' [27
]. Dybward and colleagues (1997) focused on NA prescription behaviours amongst Norwegian family doctors [27
]. Like our participants, Norwegian practitioners depicted NA prescription as difficult work, but they emphasized patient-related factors (age, concomitant disease, autonomy) and a tendency to defer to the previous doctor to rationalize practice patterns [27
]. Blake (2007) studied patients' perspectives of NA prescription for chronic pain, describing how patients balanced pain relief against concerns regarding side effects (and fear of addiction) [45
]. The stigma of being perceived as addicted, the effects of pain on all aspects of their lives, and their ambivalence towards taking NA indicate that it is a complex process for patients as well [45
]. The qualitative literature on RTW indicates that patients characterize the RTW journey as very complex and multi-faceted [14
], far more so than is usually characterized by the clinicians interacting with them. The way RTW is characterized in the literature from practitioners' and epidemiologists' viewpoints is usually overly simplistic [18
], with assumptions that workers simply are trying to return to their premorbid status. But we know that for persons experiencing major illness or injury, the journey back to work is shaped by many factors (e.g. nature of illness/injury, the type of treatment received, family structure and social supports, gender, age and life stage, education and socioeconomic status, the type of work engaged in (job demands), personal perspectives and societal discourses regarding disability, being on compensation, being unemployed, and shifting notions of the meaning of work in their lives) [14
]. We also know that patients' and practitioners perspectives' often differ, whether concerning care received, health conditions treated, or expectations of recovery. For example, Kapoor and colleagues (2006) found that patient and physician expectations of RTW following occupational low back pain differed considerably [46
]. A quantitative study by Mäntyselkä et al. (2001) comparing patients' and family physicians' ratings of patients' pain found considerable discordance between the groups, with physicians consistently ranking intensity lower than patients. The discordance became more pronounced as the severity of patients' ratings increased [47
]. Future investigations using concept mapping methodology with injured workers is warranted.
This study has several limitations. First, we did not seek injured workers' perspectives, partly because of recent Canadian privacy regulations, and partly from concerns about not further stigmatizing this population. Instead, an exploratory study focusing on prescribers' and dispensers' views was seen as an appropriate first
step to understanding NA utilization patterns. Second, these findings are based on practitioner perceptions
. Nevertheless, perceptions inform behaviour and understanding, and as such offer valuable insights. Like all qualitative findings, ours are not meant to be generalisable at the population level. Rather we have produced a conceptual map highlighting linkages between factors from the perspectives of practitioners. While our participants practice in a particular jurisdiction (Ontario, Canada), the findings should be of interest to practitioners in other jurisdictions nationally and internationally. Concerns identified here - regarding interprofessional communication, coordination of care, availability of clinical practice guidelines, balancing pain relief against unwanted NA side effects - have been alluded to by international investigators [48