Exploring Opioid Management Challenges in Chronic Non-Tumor Pain: Findings from a Mixed-Methods Study among General Practitioners

Abstract

Background: Germany has seen a significant increase in opioid prescriptions, particularly for high-potency opioids, despite limited evidence of their long-term efficacy for chronic non-tumor pain. 87% of these prescriptions are written by general practitioners. The high classified S3-LONTS guideline provides comprehensive recommendations for responsible opioid management. However, there is little insight into the implementation of these recommendations in primary care. This study explores the extent to which these recommendations are considered in general practice. Methods: A mixed-methods study comprising an online survey and telephone interviews with general practitioners was conducted to assess the implementation of four key recommendations: 1) Setting realistic treatment goals, 2) Using long-acting opioids, 3) Adhering to fixed intake schedules, and 4) Considering opioid reduction or discontinuation in responsive patients. Questionnaire data were analyzed descriptively and through correlation analysis, while interviews were analyzed using an inductive-deductive method based on Kuckartz. Results: A total of n=131 completed questionnaires and n=21 interviews were analyzed. The survey identified several gaps in implementing recommendations: nearly 50% of general practitioners did not set individualized, realistic treatment goals, half preferred combining long-acting opioids with fixed intervals and short-acting opioids on demand, about 16% used short-acting opioid monotherapy on demand, considered a treatment error. Over half did not discuss reducing or discontinuing opioids after six months of effective pain relief. Qualitative analysis revealed barriers such as general practitioners being inadequately informed, prioritizing personal experience over guidelines, lacking a structured approach to opioid management, and being reluctant to deprescribe opioids due to concerns about compromising treatment success. Conclusion: Barriers to implementing evidence-based opioid management for chronic non-tumor pain in primary care may contribute to opioid overuse and misuse. Structured treatment programs, peer exchanges about guidelines in quality circles, and a stronger emphasis on guideline importance in (continuing) medical training could enhance the integration of evidence-based recommendations into routine care and reduce concerns about therapy success.