Table 1.

Representative Quotes for Theme 1: Factors Affecting Prescriber Communication with and Care of Patients

Subtheme(s)	Representative Quote(s)
Patient data and behavior	… I’ll also look at the medical history for recent or uh, surgeries and, and when I look I’ll say … ‘[Y]ou’re taking Percocet® couple times a day, okay you’re on benzos to sleep right now, okay. Or you’re taking Xanax® and you take two a day right now.’ I’m looking for the benzos, I’m looking for the opiates. I’m looking to see their medical history … then I’m a bit skeptical if the next thing out of their mouth is now uhh, ‘When you do this crown prep here you gonna give me a prescription for drugs?’
	… [W]e track those patients [on chronic pain management], we’ve got a log, we track them, it’s part of our QI process. We keep a close eye on them and we bring them in for randomized pill counts, randomized drug screens … we’ve got a very straight protocol that we follow… .
	… [P]ain is a subjective data point. And you know our best efforts for the pain scales and everything else I mean it’s not uncommon at all that I’ll work in the ER and be talkin’ to someone who says they have 10 out of 10 pain, texting on their cell phone not paying attention to me with a perfectly flat face while I’m doing it. Like you know so even when we try to apply the objective points to it, it’s not well received and you know and there’s no, no way to measure it quantitatively and so patients will tell us what they want to tell us you know.
	… [P]ain medication or other drugs that are more stigmatized than tobacco people tend to be more defensive, they don’t want to talk about it. Tobacco anybody will answer what they do, other drugs most people try to not answer exactly—and will get more defensive.
	… [We’ve] all been burned by someone that was either using or diverting and um so you uh there’s always you know a voice in the back of your head when you’re prescribing you know okay this looks legit but I’ve been you know burned before. Um. It’s just there’s a level of uh, of um uneasiness in a relationship I think at times.
Prescriber education and experiences	… [W]e were never really taught how to treat pain…. it has been kind of on the fly.
	Conducting a risk assessment or drug abuse screen. Yeah, I mean, that is the thing where I feel I’m not as qualified … as I should be … I don’t feel that I’ve had enough education in that regard… . ideally you would do that um but the reality is … I don’t feel very confident in exactly how to do that.
	… I self-reported … had the struggles that most addicts have with this, trying to gain, you lose control … that’s when I went to rehab in [city] and that’s … when I first got any kind of information on the pathophysiology and biology of addiction. Wasn’t taught that in medical school, and I was fascinated … I said, you know, there are not accidents and there are no coincidences, there is a purpose in this and that helped fueled me wanting to do addiction medicine.
Prescriber competing demands and tension	I tell [patients] it’s often because then the entire focus of all their issues is about your pain medicine you know. You’ve got diabetes, hypertension, high cholesterol, and COPD and all you wanna talk about is your Lortab® … I’ve got other things I need to focus on you know. And not, not that I’m trying to be negative toward your pain but of all these things, this will kill you, this won’t. You know I’ve got to focus on these first and all you wanna talk about is your pain medicine and so we’ve got to get away from that and I’ve got to talk about your other issues first… . It’s difficult.
	… [W]hen I get somebody … what they expect is a narcotic. They, they expect that and you know I’m in a business and if I don’t give it to ‘em, I know I’m gonna lose ‘em as … a client… . that is a point for a lot of people, uh so a lot of people just write you know they think uh you know tramadol’s not that bad or 5 milligrams hydrocodone just to appease the patient because they know that’s what they want.
	… [I]n our location it’s a challenge [with prescription drug monitoring programs] because we’ve got three other states… . and you know we can do Virginia on the same website you know which is helpful as the Tennessee but you have to have a separate log in for North Carolina and I just not even bother with it anymore. It’s just you, you have less and less time to do more and more administrative work … and less patient care.
	… [T]hose are always the difficult decisions um because you know my compassion doesn’t allow me to just say well ‘I can’t ever give [pain medication] to you.’ But then on the other hand it’s very um, very, very difficult to do that in a way that doesn’t put them right back into uh an addiction.
Prescriber-patient relationship	… [Y]ou can have a totally different approach and level of giving, uh, with certain patients versus other patients. Like you might just cut yourself off ‘okay, I’ve given you two tries, I’m moving on to the third, forget it, I’m out of here.’ Whereas, a patient that’s very important to you, you have a great relationship, you know, I’m going to try number four, to number five and then pushes to number six. ‘I know, you have to be hearing me. I know you are.’ You know, sometimes you just really go that far with a patient that you have such a relationship with.
	… I’ve seen providers feel like they’re powerless over the patient… . And they feel like that the patient is more in charge than they are. And that they have no control [in a situation involving drug seeking behavior] … And it’s like well no, you do have control… . And you don’t have to [prescribe]. You can say to the patient, ‘No, I’m not comfortable with this.’
	As far as prescription pain meds … when I first moved here especially, the most frequent visit I would get would be back pain. People who wanted umm treatment for back pain, which has slowed down now a little bit. I think just because I have been here a little bit longer. I think at first people try new providers to see if they get pain medications from them.
Prescriber-patient relationship	… I’ve got patients that have been to those pain clinics … and the pain clinics want to put ‘em, escalate their [pain medication] and the patients don’t want to escalate it and then they get fired from the pain clinic and then they come back to me sayin’ you know ‘I’m perfectly fine takin’ 5 milligrams 3 times a day but I didn’t want to get put on morphine or whatever and they fired me.’ You know then it puts the burden back on me.
Prescriber and patient resources	We have care managers here, people who are experienced, know who to look for, know the resources in the community, have context of those, I think those people are helpful to connect people who are here and want help [for prescription drug abuse] to help, um yeah.
	… [W]hat I have envisioned would be great is if we had um, a psychologist on board with us who could help us, um, first of all make sure um that we pick the right people for chronic narcotics uh, you know have a profile, know whether this person is um, has an addictive personality, or um, and then also help with pain management um just uh you know techniques.
	… [Our] patients that are ummm uninsured, limited access… . specialists won’t see them because they are uninsured. And they won’t, they won’t see our patients like this. The, even the pain clinics will tell them they want two hundred and fifty dollars, up front, and they don’t have that kind of resources and that kind of money.
	I say, ‘I know you got a toothache right here and I know it’s hurting right now and I’m gonna take it out.’ And I’ve even taken them out for free because generally most addicts are usually, they’re like lower income, they don’t have any money and I said, ‘I’m going to take it out at no charge to you.’
Environmental pressures and policies on controlled prescription drugs	Oh, I think Joint Commission, the sixth uh vital sign … all of that just pushed [to treat pain] … I can’t tell you how many people we had, once that notice was up front from Joint Commission that you had to post saying … ‘We’ll treat your pain.’ You know, just out of the wood work. Come in say, ‘Oh yeah, doc I come because I have so much pain.’ And it’s like, okay. I’ve been doing this and for how long and I don’t remember that every patient, or every other patient I see, is ‘Oh doc, I’m here because I’m having pain.’ … And all of a sudden you were having this.
	Prescriber: Well a lot of [patients] come to us, especially nowadays saying ‘My doctor won’t write pain meds for me anymore.’ Pretty much every patient is saying that nowadays. Researcher: So why won’t their doctor write them pain medicine anymore? Prescriber: Because they know about the pain medicine abuse epidemic in this region. And they think that the feds are gonna be knockin’ on their doors any moment. And they are just in quote getting out of the pain medicine business.
	So we don’t refill narcotics now without a visit you know as a policy… . If you need a narcotic you have to come in. There may be individual doctors that on certain occasions will write one and leave it up front or something else, but you know as a policy we say we don’t.