To help stem the epidemic of opioid analgesic misuse, addiction, and overdose, professional pain societies and regulatory agencies recommend that physicians implement opioid treatment agreements (OTAs) to define treatment and monitoring plans for patients prescribed long-term opioid analgesics for chronic pain. Though primary care physicians infrequently implement OTAs, little is known about their barriers to and facilitators of OTA implementation, or about interventions to improve OTA implementation in primary care settings.
The specific aims of this Mentored Patient-Oriented Research Career Development Award application are: (1) to identify barriers to and facilitators of OTA implementation among primary care physicians, (2) to develop a theory-guided intervention to promote OTA implementation in primary care, and (3) to determine whether a theory-guided intervention is associated with changes in OTA implementation in primary care. To achieve these aims, we will conduct semi-structured interviews with primary care physicians using the Theory of Reasoned Action / Theory of Planned Behavior as a theoretical framework, and an example OTA document as a prompt. Based on our findings, we will develop a theory-guided intervention to promote OTA implementation, and then refine it through pretesting and iterative feedback from primary care physicians. We expect that the intervention will include a tailored OTA document as well as components that support OTA implementation, including a two-part physician training, a reference guide, and quarterly case conferences. Finally, we will conduct a 12-month pilot study of the intervention in two large urban primary care practices. We will conduct pre-post analyses using electronic medical record data to determine whether the intervention is associated with changes in the use of OTA documents or urine drug testing, a key element of the monitoring strategy defined by OTAs. The knowledge gained from this proposal will inform future research and quality improvement initiatives to promote responsible opioid prescribing in primary care. The candidate, Joanna L. Starrels, MD, MS, is an Assistant Professor of Medicine at Albert Einstein College of Medicine. Her long-term goal is to become an independent investigator in defining and promoting evidence-based and responsible opioid prescribing strategies for primary care patients with chronic pain. Her short-term goals are to gain expertise in: opioid misuse in pain management, advanced qualitative research, interventions to change physician behavior, and analysis of longitudinal data. Dr. Starrels has assembled a mentoring team that includes national leaders in substance abuse, pain management, and health care delivery.

Public Health Relevance

The United States faces an epidemic of prescription pain killer abuse and overdose. Treatment agreements between physicians and their chronic pain patients who are prescribed such drugs may help to reduce abuse and overdose. This study will identify physicians'barriers to using treatment agreements and develop a model intervention to promote and study the use of treatment agreements in primary care settings.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Mentored Patient-Oriented Research Career Development Award (K23)
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Human Development Research Subcommittee (NIDA)
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Denisco, Richard A
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Albert Einstein College of Medicine
Internal Medicine/Medicine
Schools of Medicine
United States
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Starrels, Joanna L; Wu, Bryan; Peyser, Deena et al. (2014) It made my life a little easier: primary care providers' beliefs and attitudes about using opioid treatment agreements. J Opioid Manag 10:95-102
Merlin, Jessica S; Turan, Janet M; Herbey, Ivan et al. (2014) Aberrant drug-related behaviors: a qualitative analysis of medical record documentation in patients referred to an HIV/chronic pain clinic. Pain Med 15:1724-33
Fox, Aaron D; Shah, Pooja A; Sohler, Nancy L et al. (2014) I heard about it from a friend: assessing interest in buprenorphine treatment. Subst Abus 35:74-9
Starrels, Joanna L; Becker, William C; Weiner, Mark G et al. (2011) Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med 26:958-64
Becker, William C; Starrels, Joanna L; Heo, Moonseong et al. (2011) Racial differences in primary care opioid risk reduction strategies. Ann Fam Med 9:219-25