General practitioners' decision-making process to prescribe pain medicines for low back pain: a qualitative study

Giovanni E Ferreira; Joshua Zadro; Caitlin Jones; Julie Ayre; Christine Lin; Bethan Richards; Christopher Needs; Christina Abdel Shaheed; Andrew McLachlan; Richard O Day; Christopher Maher

doi:10.1136/bmjopen-2023-074380

General practitioners' decision-making process to prescribe pain medicines for low back pain: a qualitative study

BMJ Open. 2023 Oct 29;13(10):e074380. doi: 10.1136/bmjopen-2023-074380.

Authors

Giovanni E Ferreira^{1

2}, Joshua Zadro^{3

2}, Caitlin Jones^{3

2}, Julie Ayre⁴, Christine Lin^{3

2}, Bethan Richards^{3

5}, Christopher Needs⁵, Christina Abdel Shaheed^{3

2}, Andrew McLachlan⁶, Richard O Day⁷, Christopher Maher^{3

2}

Affiliations

¹ Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia giovanni.ferreira@sydney.edu.au.
² Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
³ Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.
⁴ Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
⁶ Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
⁷ St Vincent's Clinical School, Department of Clinical Pharmacology & Toxicology, University of New South Wales, Sydney, New South Wales, Australia.

Abstract

Background: Pain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines.

Objectives: The aim of this study was to investigate what influences GPs' decision to prescribe pain medicines for LBP.

Design: Qualitative study with in-depth interviews.

Setting: Australian primary care.

Participants: We interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes.

Data analysis: We summarised GP's choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP's decision-making.

Results: GPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient's pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process.

Conclusions: We identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.

Keywords: decision-making; low back pain; opioids; sciatica.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Analgesics, Opioid / therapeutic use
Antidepressive Agents
Australia
Female
General Practitioners*
Humans
Low Back Pain* / diagnosis
Low Back Pain* / drug therapy
Male
Middle Aged

Substances

Analgesics, Opioid
Antidepressive Agents