Opioid reduction for patients with chronic pain in primary care: systematic review

Background: Long-term opioid treatment in patients with chronic pain is often ineffective and possibly harmful. These patients are often managed by general practitioners, who are calling for a clear overview of effective opioid reduction strategies for primary care. Aim: Evaluate effectiveness of opioid reduction strategies applicable in primary care for patients with chronic pain on long-term opioid treatment. Design: Systematic review of controlled trials and cohort studies. Method Literature search conducted in Embase, Medline, Web of Science, Cochrane CENTRAL register of trials, CINAHL, Google Scholar and PsychInfo. Studies evaluating opioid reduction interventions applicable in primary care among adults with long-term opioid treatment for chronic non-cancer pain were included. Risk of bias was assessed using Cochrane risk of bias (RoB) 2.0 tool or Risk-of-Bias in Non-randomized studies of Interventions (ROBINS-I) tool. Narrative synthesis was performed due to clinical heterogeneity in study designs and types of interventions. Results: Five RCTs and five cohort studies were included (total n= 1717, range 35-985) exploring various opioid reduction strategies. Six studies had high RoB, three moderate RoB, and one low RoB. Three cohort studies investigating a GP supervised opioid taper (critical ROBINS-I), an integrative pain treatment (moderate ROBINS-I) and group medical visits (critical ROBINS-I) demonstrated significant between-group opioid reduction. Conclusion: Results carefully point in the direction of a GP supervised tapering and multidisciplinary group therapeutic sessions to reduce long term opioid treatment. However, due to high risk of bias and small sample sizes, no firm conclusions can be made demonstrating need for more high-quality research.

A qualitative study of resident and early-career family physicians’ focused practice choices in Canada

Background: Although focused practice within family medicine may be increasing globally, there is limited research on the factors contributing to decisions to focus practice. Aim: We aimed to examine the factors influencing resident and early-career family physician choices of focused practice across three Canadian provinces. Design and Setting: We analyzed a subset of qualitative interview data from a study across British Columbia, Ontario, and Nova Scotia. Method: A total of 22 resident family physicians and 38 early-career family physicians in their first 10 years of practice who intend to or currently practice in a focused area were included in our analysis. We compared participant types, provinces, and the degree of focused practice while identifying themes related to factors influencing the pursuit of focused practice. Results: We identified three key themes of factors contributing to choices of focused practice: self-preservation within the current health care system, support from colleagues, and experiences in medical school and/or residency. Minor themes included alignment of practice with skills, personal values, or ability to derive professional satisfaction; personal lived experiences; and having many attractive opportunities for focused practice. Conclusion: Both groups of participants unanimously viewed focused practice as a way to circumvent the burnout or exhaustion they associated with comprehensive practice in the current structure of the health care system. This finding, in addition to other influential factors, was consistent across the three provinces. More research is needed to understand the implications of resident and early-career family physician choices of focused practice within the physician workforce.