Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers

Abstract

Background:

The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation.

Materials and methods:

We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research.

Results:

We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers’ concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention.

Conclusions:

We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Introduction

The United States is amidst an opioid epidemic. More than 115 people die from opioid overdose every day,¹ and in 2017, over 11 million people used prescription opioids for nonmedical purposes.² Prescription opioids may lead to physical dependence and make a critical contribution to the opioid epidemic by causing fatal and nonfatal overdoses. Previous studies have demonstrated that within the surgical field, overprescribing results in excess pills available for nonmedical use.^3–5 To address overprescribing while simultaneously assuring patients receive adequate pain control around the time of surgery, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) multicomponent intervention to reduce reliance on opioids for surgical pain management.

The intervention as originally envisioned consists of five core components: (1) Preoperative patient education, delivered in print and as interactive online modules, to address pain management expectation setting, multimodal methods of analgesia, and opioid safety. (2) Clinician education which emphasizes the reduction of surgical providers’ reliance on opioids for postsurgical pain management. Physicians, residents, physician assistants, nurse practitioners, and pharmacists receive interactive mixed-content educational material consisting of videos, questions, and exercises pertaining to safe opioid prescribing. (3) Monthly comparative prescribing reports generated for prescribers detailing the total number of opioid prescriptions, number of pills/prescription, and mean per patient morphine milligram equivalents normalized to 100 patients. (4) Surgeon training to utilize Screening, Brief Intervention, and Referral to Treatment (SBIRT) in the preoperative clinic to assess patients’ risk for addictive behavior. (5) EHR-based computerized decision support tools made available for prescribers to reduce opioid prescribing. These include postoperative and discharge order sets, nonopioid alternatives, procedure-specific opioid quantity recommendations, and automated pain service consultation for daily opioid dose surpassing 60 morphine milligram equivalents. The intervention will be implemented across an Illinois-based health system comprising six diverse hospitals.

Implementation science literature demonstrates that to effectively facilitate change within systems and enhance the likelihood that interventions will be successful, it is critical to understand barriers and facilitators to implementation.^6,7 Existing studies on barriers to implementing opioid reduction initiatives focus on settings including emergency medicine and primary care.^8,9 The perspectives of key stakeholders regarding feasibility of implementing opioid reduction interventions in surgical prescribing contexts, however, are under explored in the literature.

In this study, we conducted a formative evaluation of the development and implementation of our surgical opioid reduction intervention to identify perceived implementation barriers prior to implementation. Formative evaluation enables researchers to identify barriers and facilitators and gain an enhanced understanding of implementation setting, stakeholder perceptions of intervention utility, and other factors related to adoption.¹⁰ The Consolidated Framework for Implementation Research (CFIR)¹¹ provided a framework to comprehensively explore contextual barriers that need to be overcome for successful implementation.

Materials and methods

Data collection

Before implementation of the intervention, we conducted semistructured interviews to identify potential barriers and facilitators in the six participating hospitals. We used purposive sampling, followed by snowball sampling, to select a sample of health system employees—attending surgeons, nurse practitioners, nurses, pharmacists, and administrators—within all six hospitals. The components of the intervention were introduced to each interviewee, verbally, as part of the interview process. The interview protocol was designed to specifically inquire about the interviewee’s perceived utility of each component, as well as barriers to change and solutions for implementation (Box 1) In addition, we asked about hospital-specific culture and work environment. The interview protocol is included in the Appendix. Interviews were audio recorded and transcribed verbatim for analysis.

Box 1. Overview of Interview Protocol.

1. Role of provider interviewees.

2. Prior and current opioid reduction initiatives.

3. Introduction of intervention components.

4. Identification of implementation barriers and facilitators.

5. Hospital administrator, clinician, and patient receptivity to intervention.

Coding and data analysis

Transcripts were analyzed thematically using a constant comparative approach. Themes were identified both deductively, by applying the CFIR,¹¹ and inductively, based on interview content. The team chose CFIR as a model for organizing the codes because the CFIR domains address the contextual factors affecting implementation.¹¹ For example, the framework covers intervention characteristics including adaptability and the implementation climate of the inner setting in which the intervention will be implemented. As such, the CFIR framework covers the need- for adaptations of the intervention to achieve robust and sustainable implementation within each hospital.

The study team independently read and coded one interview transcript and then met as a group to reconcile any differences in coding.¹² This process was repeated with a second transcript to finalize the codebook. In addition, the study team coded each identified contextual factor as a “barrier” or “facilitator”. The final codebook consisted of codes pertaining to 12 of the 39 CFIR contextual factors and three interventional factors related to role (role of residents; role of pharmacists; and role of pain specialist) organized across the five intervention components (patient education, provider education, prescribing data feedback, risk screening, and EHR optimization), as well as the general intervention (Table 1). All remaining transcripts were distributed to three study team members for coding, with a fourth researcher coding all transcripts to ensure consistency. The study team met to reconcile any differences, with the team member who did not code a given transcript acting as the tie-breaker to reconcile coding discrepancies. Once coding was completed, we identified the themes that were most prominent in the data.¹³ All study procedures were approved by the Northwestern University Institutional Review Board office (IRB Project ID STU00205053).

Table 1 –

Codebook.

Domain	Code	Description
Relevant domains from the Consolidated Framework for Implementation Research
Innovation characteristics	Evidence strength and quality	Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the innovation will have desired outcomes.
	Relative advantage	Stakeholders’ perception of the advantage of implementing the innovation versus an alternative solution.
	Adaptability	The degree to which an innovation can be adapted, tailored, refined, or reinvented to meet local needs.
	Complexity	Perceived difficulty of the innovation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.
	Design quality and packaging	Perceived excellence in how the innovation is bundled, presented, and assembled.
Outer setting	Needs and resources of those served by the organization	The extent to which the needs of those served by the organization (e.g., patients), as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization.
	External policy and incentives	A broad construct that includes external strategies to spread innovations including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting.
Inner setting	Culture	Norms, values, and basic assumptions of a given organization.
	Implementation climate tension for change	The degree to which stakeholders perceive the current situation as intolerable or needing change.
	Implementation climate relative priority	Individuals’ shared perception of the importance of the implementation within the organization.
Characteristics of individuals	Knowledge and beliefs about the innovation	Individuals’ attitudes toward and value placed on the innovation, as well as familiarity with facts, truths, and principles related to the innovation.
Process	Engaging	Attracting and involving appropriate individuals in the implementation and use of the innovation through a combined strategy of social marketing, education, role modeling, training, and other similar activities.
Intervention domains and themes
Intervention component	Patient education	Preoperative patient education will address pain management expectation setting, multimodal methods of analgesia, and opioid safety and will be delivered in print and as interactive online modules.
	Provider education	Clinicians will complete education, which emphasizes the reduction of surgical providers’ reliance on opioids for postsurgical pain management.
	Prescribing data feedback	Monthly comparative prescribing reports will be generated for prescribers.
	Risk screening	Surgeons will undergo training to utilize screening, brief intervention, and referral to treatment (SBIRT) in the preoperative clinic to assess patients’ risk for addictive behavior.
	EHR optimization	EHR-based computerized decision support tools will be made available for prescribers to reduce opioid prescribing.
	General intervention	Implementation of the intervention in general.
Role	Role of residents	Any involvement in, influence on, or responsibilities pertaining to the intervention components of MOPiS.
	Role of pharmacists	Any involvement in, influence on, or responsibilities pertaining to the intervention components of MOPiS.
	Role of pain specialists	Any involvement in, influence on, or responsibilities pertaining to the intervention components of MOPiS.

Results

We conducted 22 semistructured interviews with key stakeholders, including clinical nurse reviewers who lead surgical quality improvement project implementation at their hospitals (n = 6), attending surgeons (n = 4), pharmacists (n = 7), various administrators (n = 4), and a nurse practitioner (n = 1). Six interviewees were employed at a large academic hospital, six were employed at one of two large community hospitals, and 10 were employed at one of three small community hospitals. The 12 CFIR contextual factors and three interventional factors were organized by five intervention domains, as well as the intervention in general, as shown in Table 2, with illustrative verbatim quotes supporting each identified barrier and facilitator.

Table 2 –

Barrier and facilitator illustrative quotes for common themes.

Intervention component	CFIR domain and theme	Barrier	CFIR domain and theme	Facilitator
Patient education	Design quality and packaging	“We have a lot of older adults, and so some of them, almost 50/50, some are very computer savvy, and some don’t have email, or they’re not good with the computer…I’d hate to miss a group because they don’t have access to a computer or they don’t feel comfortable working on a computer.”—Administrator	Adaptability	“They’ll all be great because of ERAS…Setting expectations and doing the education ahead of time has been so phenomenal and has taken off just wonderfully…The patients love it and we find that it has really, really helped.”…Nurse Practitioner
	Needs and resources of those served by the organization; role of pharmacists	“If [pharmacists] have the resources and the time available, they could play a large part in the education of patients…It would be challenging to fit that into the current workflow.” - Pharmacist	Design quality and packaging	“An important piece of it is making sure that it’s presented multiple times, maybe even in multiple ways so that people can hear it the way that they want to hear it.”—Pharmacist
	Needs and resources of those served by the organization	[On lack of education on safe opioid disposal:] “Well at this point, I don’t have a good thing to tell them, as far as where they can dispose of it…But if I had something easily available, I would tell them.”—Surgeon	Design quality and packaging	“…If it’s either the doctor’s office or the preop clinic or both, the messages should be aligned…It needs to be a consistent message that goes across and there needs to be an easy-to-understand explanation for patients about what the other things are that you can do besides just taking opioids. What are the nonopioid options?”—Clinical Nurse Reviewer
	Knowledge and beliefs	“You have to go through a lot of marketing that people put in pain free this, pain free that on TV and on everything else that you hear. Which is not true. So they come in with expectations…So try to break that.”—Surgeon
Provider education (provider education continued)	Design quality and packaging	“I have concerns about the education for the surgeons. Not always are they great at reading their email. So I think we’d have to have a multipronged approach… I don’t think it can just be emails. ‘Cause I’m afraid that it will get lost.”—Clinical Nurse Reviewer	Evidence strength and quality	“The providers are all pretty in-tune with what’s been in the media. I mean, there are publications about opioid prescribing practices frequently now. It’s in the news, it’s in what they’re reading, in their journal articles. That’s where they’re getting their information.”—Administrator
	Needs and resources of those served by the organization	“Time is an issue for them, so something that’s going to take a lot of time isn’t going to work well. It’s all about what is the…quickest form of communication for them.”—Administrator	Relative advantage	“You’ve got to make it what’s relevant to me? Why do I need to know this? And that’s like my attention grabber. Wow, the number of deaths has increased phenomenally over the last four years…then they want to know how does this impact me? And then you can translate it into, well, reflect on your opioid prescribing practices and habits.”—Pharmacist
	Knowledge and beliefs; role of residents	[On residents as frequent prescribers:] “Really they’re the ones that are prescribing most of the time in the end…They’ll do what’s either easiest for them, or will make for less phone calls, or what they think I want, or what they think I think I want.”—Surgeon	Design quality and packaging	“They’re going to give this some time, but not a lot of time…They’re going to appreciate the information being delivered in succinct ways…Short and sweet.”—Administrator
			Role of pharmacists	“I think pharmacists… have a very big role in the opioid epidemic…So if we’re able to identify that and provide education to not only prescribers and caregivers, but also to patients themselves, then I think that can help address some of the gaps in education. And I think we’re really well equipped to provide that.”—Pharmacist
			Role of residents	[On providing education to the residents:] “They’re the real focus. I think for the residents, standardization would be the other thing that would help, because they’re trying to read our minds a lot of times.”—Surgeon
Prescribing data feedback			Evidence strength and quality	“In many cases…by showing data, usually physicians are open minded, they want to know how am I doing? How am I doing compared to my peers? And the top line is, they want to make sure that their patients are receiving the highest quality of care.”—Pharmacist
Risk screening	Relative advantage	“Risk screening. Yeah, that’s a tough one. What exactly would be the value in risk screening? If you had somebody that had a higher potential for substance abuse, would we go to greater lengths to prevent them from receiving opioids?”—Pharmacist	Engaging	“We have really some great physicians and leaders of the hospital who…are just clamoring for things to identify opioid use disorder, to identify methods to be able to get the patients diagnosed and to get them into treatment.”—Nurse Practitioner
	Needs and resources of those served by the organization	“There’s just not time…On the list of priorities, it’s going to fall way down, right, because I need to talk about their cancer, and the cancer treatment first, and that takes me 45 min a lot of times, so. It, I think, is hard to do. To prioritize. I’m not totally sure, honestly, that I see the importance of it.”—Surgeon	Design quality and packaging	“If there’s some way you can incorporate it in the usual preop screening they do, asking about alcohol, cigarettes, and other drug use.”—Clinical Nurse Reviewer
EHR optimization	Adaptability	“I think this is true in all physician realms, is everything seems to be making it more difficult for us, you know? It’s more clicks. It’s more modifications. It’s more…you know the electronic medical record has not made our lives easier. It has made our lives harder.”—Surgeon	Design quality and packaging	“Find a way to give them a template. If you have a Lap Chole, you should only need this many versus if you have total hip replacement you’re going to need this. Kind of spell it out and make it a template that would be in e-scribe, if there’s a way, to pick something and it’s already mapped out and they don’t have to figure it out on their own. Otherwise, they’re just gonna default to what they’ve always done.”—Clinical Nurse Reviewer
			Role of pharmacists	“I think pharmacists can play a very integral role in a few different ways, with the electronic health records…Utilizing [the EHR] to make power plans that drive towards alternative agents first…Once the recommendations are rolled out, [pharmacists] could be instrumental in working with prescribers to make sure that those guidelines and recommendations were followed.”—Pharmacist
General intervention	Relative advantage Relative advantage	[On prescribers’ reluctance to reduce prescription quantity:] “I think it’s just a habit that’s hard to break, or they just don’t want that phone call in the middle of the night.”—Clinical Nurse Reviewer [On surgeons who are resistant to changing their practice:] “There’s going to be certain people that are going to give the narcotics whether we want them to or not, and they’re going to give the amount they’ve been giving for years because…they know that it works for patients. I think those are the people, late-adopters or resisters that you’ll have to overcome. They need to know that there’s a different way that works, but it’s got to be compelling enough for them to change their practice for years, right, and be convinced that it’s better for their patients.”—Surgeon	Culture	“I’ve definitely seen a shift. For a long time with prescribing practices, it was give the patient whatever they want. Obviously there were problems with that, which I’m sure you’re all aware of. But there has been another shift away from that practice.”—Administrator
	Complexity	“If you were to implement something like this, it would really need to be something very streamlined for them in the office to be able to do it, because, you know, turnaround of patients is kind of a key thing. If you have 20 questions or something that takes ten, fifteen additional minutes, you know, that compounds to a lot of time.—Pharmacist	Implementation climate—tension for change	“I think you’re at a good point in time because it has been on the media so much and it is such a nationwide problem. You’re really, I think, at a very good point in time for doing it because it’s pretty much all over the news. It is a reality. There’s quite a bit of information and statistics to back it up. It’s such an important initiative.”—Clinical Nurse Reviewer
	Needs and resources of those served by the organization; role of pharmacists	“We have a lot of pharmacists that would be very passionate to be involved in this, but it’s a matter of balancing existing responsibilities and having enough resources to provide that education… so it’s boiling it down to resources.” - Pharmacist	Implementation climate—relative priority	“I would say that like globally speaking, people are very receptive to it and want to do something to address the opioid epidemic. Everyone recognizes that as a system, we’re in a position where we could potentially influence this or make a positive change, and so there is a desire to address it in some way.”—Pharmacist
	External policy and incentives	“The physicians don’t want to practice to a survey, but at the same time, if that’s going to impact how they’re perceived and these scores, they get posted, and that can result in possibly a negative impression of them in the community. I think it plays a role.”—Administrator	Engaging	“My senior leaders, they’re very in touch about the patients and what can we do to put our patients first and provide the safest possible care. That’s the message I’ve received, loud and clear.”—Administrator
	Role of pharmacists	“In our setting here [pharmacists] do nothing with discharge. I think that’s where a big part of the issue is. We know people are getting discharge prescriptions for way too much for far too long. Because we don’t have a role in that, there’s not much we can do.”—Pharmacist
	Needs and resources of those served by the organization; role of pain specialist	“There were a number of patients we had to send out of our system because we didn’t have any pain specialists or any primary care even that took their insurance.”—Nurse Practitioner

Patient education

Interviewees expressed concern about the ability to provide patient educational material in the patients’ preferred medium, whether that be computer-based or written material. In addition, the substantial amount of information patients receive during their visit may inhibit the processing of additional education regarding pain management; thus, the format and timing in which education is provided to patients is crucial (innovation characteristics: design quality and packaging). Many interviewees agreed that repetitive patient education, available as interactive online modules, as well as in print, would provide the most successful education (innovation characteristics: design quality and packaging).

Several pharmacist interviewees stated that although pharmacists would be willing to provide patients with education throughout their postoperative hospital stay and on discharge, at some sites they simply do not have the time or resources to be able to do so (role: pharmacists). Multiple interviewees stated that they do not have the resources to provide patients with education on safe disposal of unused opioid medication (outer setting: needs and resources). Finally, many patients present to preoperative clinic with preconceived notions about pain control based on inaccurate information gathered from television and internet advertisements (characteristics of individuals: knowledge and beliefs).

Anecdotally, interviewees agreed that they have witnessed surgeons and clinic staff successfully incorporating multimodal pain management education and expectation setting into the preoperative visit and have seen significant reductions in the use of postoperative opioid medication (innovation characteristics: adaptability) as part of the hospital system’s Enhanced Recovery After Surgery (ERAS) initiative. All members of the health care team should have a consistent, aligned message that is reiterated throughout all perioperative phases of care.

Provider education

Time is the major barrier to provider education (outer setting: needs and resources). In addition, if educational material is conveyed only via e-mail, providers may miss important information that is lost amongst several e-mails received throughout each busy work day (innovation characteristics: design quality and packaging). One attending surgeon highlighted the fact that in academic hospitals, the residents are typically the most frequent prescribers and their prescribing patterns often lack evidence-based data (characteristics of individuals: knowledge and beliefs; role: residents).

Interviewees suggested that to facilitate physician and resident education, providers must be presented with the current published guidelines on safe opioid prescribing practices (innovation characteristics: evidence strength and quality). In addition, providers must be made aware of the relevance of safe prescribing in their current practice to facilitate physician buy-in (innovation characteristics: relative advantage). Material should be presented in an easy to use and succinct online format that providers can access “on the go” (innovation characteristics: design quality and packaging). Pharmacists can be utilized to provide education regarding opioid alternatives and also monitor adherence to prescribing guidelines (role: pharmacists). Because resident physicians are high frequency prescribers, targeting evidence-based safe prescribing education at the residents may have a substantial impact on the facilitation of the intervention (role: residents).

Prescribing data feedback

Interviewees stated that physicians would be quite receptive to reviewing their personal prescribing data feedback, which compares them to current prescribing guidelines, as well as to their peers. Interviewees believed that by showing providers where they fall on this quality measure, they will be more invested in adjusting their prescribing practices, to provide the highest quality of care to patients (innovation characteristics: evidence strength and quality).

Risk screening

Surgeons and pharmacists did not see the relative advantage of screening all surgical patients preoperatively. They felt that screening was likely low yield because the vast majority of patients would be categorized as “low-risk.” Interviewees were also concerned that patients may misinterpret risk screening as being labeled as an opioid abuser. In addition, pharmacist interviewees were unsure of the utility of screening without a designated plan to utilize the information gathered from it (innovation characteristics: relative advantage). Surgeon interviewees stated that they did not have time to screen patients during busy preoperative clinic visits and were unable to identify a clinic staff member who could potentially fill this role (outer setting: needs and resources).

One interviewee stated that screening patients for opioid abuse risk is very important and that several providers, including pain specialists, are finding new ways to engage in that process (process: engaging). Another interviewee suggested that instead of taking time to complete an entire screening questionnaire during busy preoperative clinic visits, prior opioid use should be included in the general social history taking which is already conducted for each patient (innovation characteristics: design quality and packaging).

Electronic health record optimization

One surgeon interviewee stated that additional initiatives, even those which have been streamlined into the EHR, increase the workload per patient for providers as they attempt to comply with tremendous documentation regulations (innovation characteristics: adaptability).

Conversely, interviewees stated that the EHR can facilitate the intervention in two major ways: (1) developing standardized procedure-specific postoperative and discharge order sets will make opioid alternatives visible and easily accessible to providers (innovation characteristics: design quality and packaging), and (2) pharmacists can play an integral role by closely monitoring the EHR for adherent prescribing practices (role: pharmacists).

General intervention

Interviewees expressed concern that some surgeons will continue to overprescribe out of habit, or they will resist prescribing a smaller quantity to avoid extra patient clinic visits and/or phone calls for refills (innovation characteristics: relative advantage) and to prevent poor patient satisfaction scores (outer setting: external policy and incentives). Interviewees stated that engaging many different providers across multiple health care settings to address such a complex aspect of patient care may act as a barrier (innovation characteristics: complexity).

Almost unanimously, pharmacists stated that they are underutilized for a multitude of reasons. The inpatient role of pharmacists varies greatly across different sites, with pharmacists included on daily rounds with the surgical team in some hospitals, in some specific units. In addition, not all pharmacists participate in the patient discharge process. Time constraints and the burden of high patient volume would make it difficult to fit patient and provider education into the pharmacists’ current workflow (role: pharmacists).

Most of the interviewees identified the current culture surrounding opioid prescribing as a facilitator for implementing opioid interventions. Interviewees stated that shifts in the culture of opioid prescribing have dictated provider behavior. Previously, overprescribing was encouraged for patient and provider convenience; however, the media has highlighted the opioid epidemic and brought it to national attention (inner setting: culture). Patients and providers are now attuned to the risks of opioid prescriptions. The health care community has recognized its unique role and responsibility in the opioid crisis (inner setting: implementation climate—tension for change). As more information and data on the opioid crisis emerges, organizations are publishing guidelines and regulations. Thus, providers are becoming increasingly cognizant of their prescribing patterns and are making efforts to reduce opioid prescribing (inner setting: implementation climate—relative priority). Overall, this has led to significant engagement by senior hospital administrators who have made minimizing opioid prescribing a priority (process: engaging). Pain specialists, who have ample knowledge about pain management, would be instrumental in the implementation of the intervention. Although they contributed to the development of standardized pain management order sets, pain specialists could provide further assistance with patient and provider education, optimizing the implementation of multimodal analgesia, and planning discharge pain management regimens (role: pain specialist).

Discussion

In 2014, complications from opioid medications became the leading cause of injury-related death in the United States.¹⁴ Surgeons are responsible for approximately one in every 10 filled opioid prescriptions¹⁵; thus, surgeons play a pivotal role in the current opioid epidemic. This study identified implementation barriers to a multicomponent initiative, which aims to reduce opioid prescribing across a large healthcare system. Understanding barriers to quality improvement interventions such as this is imperative and may provide guidance to other health care systems planning to implement similar initiatives.

Major barriers surrounding patient and provider education were identified, the most prevalent being lack of time and resources and the formatting of educational material. Although the electronic health record has been instrumental in streamlining patient care, providers find themselves spending an increasing amount of time on documentation, often at the expense of providing direct patient care.^16,17 Facing increasing clinical time constraints, surgeons are burdened with the responsibilities of explaining diagnoses and surgical procedures, in addition to addressing any questions or concerns of the patient, all in a single clinic visit. The MOPiS intervention shares the responsibility of patient education among the entire health care team and delivers the education multiple times throughout the perioperative period. This not only lessens the burden on individual providers but also facilitates better retention of information by patients.

As emphasized by the interviewees, patient educational material should be presented in a variety of ways, so that patients can choose which is best tailored to their learning style and is easy to understand, utilize, and retain. In addition, the design and presentation quality is crucial if providers are expected to complete educational modules on top of balancing a busy surgical and clinical practice. By taking advantage of new technology, such as smartphones, streamlined provider education can be easily accessed “on the go.”

Providers’ concern of the impact of the intervention on patient satisfaction surveys was identified as a major barrier to the general implementation of the intervention. Patients frequently publicly post their ratings of providers online. In addition, the Centers for Medicare and Medicaid Services has implemented the value-based purchasing program, which weighs patient satisfaction at 25%.¹⁸ Because this has caught the attention of hospital leadership, patient satisfaction has begun to influence some providers’ practices regarding pain management.¹⁹ A study in 2016 which surveyed Emergency Medicine physicians demonstrated that 71% of physicians felt pressured to prescribe opioids to avoid administrative criticism and 98% stated that patient satisfaction scores were too highly emphasized for reimbursement.²⁰ Interviewees stated that out of concern for poor satisfaction scores, providers may intentionally overprescribe opioid medication. However, evidence shows that patient satisfaction ratings with pain management are not only based on the presence or absence of pain but also on provider empathy, patient and healthcare staff relationships, patient education on opioids, and provider communication on pain expectations.^21,22 In addition, a recent study showed that lowering the number of pills following surgery is not associated with a change in patient satisfaction ratings.²³ This new evidence could empower surgeons to promote the standard of care in pain management.

The role of resident physicians as frequent prescribers, the utilization of pharmacists, and the varying presence of a pain specialist in many health care settings emerged as significant themes, which could facilitate the intervention in different ways. Although attending physicians are ultimately responsible for promoting responsible prescribing for their surgical patients, in the academic setting, resident physicians write a significant proportion of inpatient and discharge opioid prescriptions. However, residents often do not receive training for safe opioid prescribing practices.^24,25 Prior studies which surveyed surgical specialty residents have identified attending preference as the most significant influence on prescribing choice.^25,26 Residents often knowingly prescribe more opioid medication than necessary to avoid being reprimanded.^24–26 In our study, surgeon interviewees agreed that residents do the majority of prescribing and often make decisions based on assumptions of attending preference. MOPiS will provide residents with safe opioid prescribing education as a mandatory component of their training and promote the utilization of standardized postoperative pain management order sets, which will substantially facilitate the implementation of the intervention.

Unanimously, pharmacist interviewees stated that their role varies across health care settings. In addition, pharmacists are not routinely incorporated into the treatment team, although they consistently express interest in educating patients and advising providers. Coupled with time and resource constraints from busy clinical duties, this has led to a significant underutilization of pharmacists during the postoperative and discharge periods. Pharmacists have specific knowledge on safe opioid prescribing and use among different types of patients and could be instrumental in providing face-to-face patient education before discharge, as well as provider education throughout the patient’s hospital stay.

The need for a dedicated pain specialist was emphasized, and in some hospitals, their absence was prominent. Depending on the healthcare setting, pain specialists are either not incorporated into the healthcare team, or they simply are not employed by the hospital. Vadivelu et al. discussed the essential role of the ambulatory pain specialist,²⁷ and much of what they recommended could be translated to the inpatient setting. Pain specialists are instrumental in developing standards of care for pain management, providing essential patient and provider education, optimizing the implementation of multimodal analgesia, and planning discharge pain management regimens. Multiple pharmacist and surgeon interviewees stated that they did not see the utility in screening patients for potential opioid abuse because they would not know what to do with that information. Pain specialists could be pivotal in managing pain control for patients with a history of substance abuse, as well as those patients at risk for potential opioid abuse. Thus, a dedicated pain specialist would be crucial for the implementation of an opioid reduction initiative.

Overall, the two main driving forces to overcoming implementation barriers are the current culture of pain management and the positive implementation climate. The culture of pain control has evolved over the last three decades. As greater emphasis was placed on the assessment and management of pain in the early 1990s, the era of “pain as the fifth vital sign” began with The Federation of State Medical Boards encouraging the use of opioid medications for pain control and reducing the oversight of physician prescribing,²⁸ to the Joint Commission mandating pain assessment and treatment.²⁹ As a result, health systems further promoted the liberalization of the use of opioids. Each year, mounting evidence is published on the increasing rates of opioid abuse and overdose, and the subsequent toll not only on the healthcare system but also on society as a whole.^{1–5,29–33} The increasing media coverage has generated increased awareness of hospital administrators, politicians, and providers, who have now made the opioid crisis a top priority. Thus, interviewees stated that the current environment surrounding opioid prescriptions has generated a strong tension for change and they anticipate that stakeholders also would perceive a high urgency for change.

Limitations

One limitation of the study is that front line clinical nurses were under-represented as interviewees. Nurses play a significant role in pain assessment and management, and their unique perspective would contribute important knowledge regarding implementation barriers. In addition, interviews were conducted within a single health care system. Future studies should include interviewees across a variety of health care systems to develop a comprehensive understanding of implementation barriers, which would better facilitate the adoption of opioid minimization interventions at other hospitals.

Conclusion

Implementation barriers have the potential to derail any improvement initiative, and successful implementation of an opioid reduction initiative will require specific strategies to overcome barriers. Although the interviewees in our study were generally positive about the MOPiS initiative and its implementation, they perceived implementation barriers related to a lack of prioritization of relevant resources and prescribers’ fear of a negative impact on patient satisfaction scores. This study is significant in its application of implementation science methods to understand barriers before the implementation of a multicomponent intervention across a large health system. Our findings will generate awareness of perceived barriers to implementing complex hospital-based opioid reduction interventions and will be valuable to researchers seeking to use formative evaluation methodology to explore implementation barriers across wide-ranging disciplines.

A benefit of conducting preimplementation interviews is that although residents, pharmacists, and pain specialists were not initially identified as key personnel for successful implementation, the importance of their respective roles emerged throughout the interviews. Thus, interventions will be designed to target these three provider roles to maximize the facilitation of the implementation. Furthermore, the process of conducting interviews created an opportunity to engage stakeholders and increase buy-in, thus easing the implementation process.