Narcotic analgesic utilization amongst injured workers: using concept mapping to understand current issues from the perspectives of physicians and pharmacists

BACKGROUND: Work-related injuries result in considerable morbidity, as well as social and economic costs. Pain associated with these injuries is a complex, contested topic, and narcotic analgesics (NA) remain important treatment options. Factors contributing to NA utilization patterns are poorly understood. This qualitative study sought to characterize the factors contributing to NA utilization amongst injured workers from the perspectives of physicians and pharmacists. METHODS: The study employed concept mapping methodology, a structured process yielding a conceptual framework of participants' views on a particular topic. A visual display of the ideas/concepts generated is produced. Eligible physicians and pharmacists (n = 22) serving injured workers in the province of Ontario (Canada) were recruited via purposive sampling, and participated in concept mapping activities (consisting of brainstorming, sorting, rating, and map exploration). Participants identified factors influencing NA utilization, and sorted these factors into categories (clusters). Next, they rated the factors on two scales: 'strength of influence on NA over-utilization' and 'amenability to intervention'. During follow-up focus groups, participants refined the maps and discussed the findings and their implications. RESULTS: 82 factors were sorted into 7 clusters: addiction risks, psychosocial issues, social/work environment factors, systemic-third party factors, pharmacy-related factors, treatment problems, and physician factors. These clusters were grouped into 2 overarching categories/regions on the map: patient-level factors, and healthcare/compensation system-level factors. Participants rated NA over-utilization as most influenced by patient-level factors, while system-level factors were rated as most amenable to intervention. One system-level cluster was rated highly on both scales (treatment problems - e.g. poor continuity of care, poor interprofessional communication, lack of education/support for physicians regarding pain management, unavailability of multidisciplinary team-based care, prolonged wait times to see specialists). CONCLUSIONS: Participants depicted factors driving NA utilization among injured workers as complex. Patient-level factors were perceived as most influential on over-utilization, while system-level factors were considered most amenable to intervention. This has implications for intervention design, suggesting that systemic/structural factors should be taken into account in order to address this important health issue.