Nurse Practitioner Opioid Prescribing and Safety Measure Utilization Patterns in Ontario: An Explanatory Sequential Mixed Methods Study

Background. There has been a rise in opioid-related hospitalizations, emergency department visits, and mortality due to opioid poisoning across Canada. There is a gap in research related to Nurse practitioner (NP) opioid prescribing and safety measure utilization patterns and sparse literature related to physician opioid prescribing (Pittman et al., 2020). Purpose. A mixed methods approach, specifically an explanatory sequential three-phase study, was undertaken to explore this topic. The initial phase was development of the quantitative survey, followed by collection and analysis of the quantitative data. A final qualitative phase added insight into the quantitative results. There were four objectives for this study to 1) identify opioid medications prescribed by NPs in Ontario for acute conditions, chronic non-cancer pain conditions, cancer pain, and palliative symptom, 2) examine NPs safety measure utilization when prescribing opioids in Ontario, 3) explore which provider factors (years in practice, practice location, and setting) are associated with NP utilization of The 2017 Canadian Guideline for Opioids for Chronic NonCancer Pain and 4) survey NP confidence levels when prescribing opioids. Results. Quantitative results from an online survey completed by NPs in Ontario (n = 158) indicated that the top three opioid medications prescribed for both acute and chronic pain were hydromorphone followed by acetaminophen with codeine and oxycocet. The top three acute conditions treated by NPs with opioids were 1) fracture, 2) postoperative/surgical pain, and 3) joint or muscle strain/sprain. The top three chronic conditions were 1) cancer/palliative care pain, 2) chronic low back pain, and 3) osteoarthritis. NPs in inpatient settings reported utilizing safety measures less often than v their community counterparts. Qualitative follow-up was conducted via one-on-one semistructured interviews with NPs (n = 14) from various geographic locations in Ontario. Results from these interviews revealed that hydromorphone was the preferred opioid due to its appealing side effect profile and the ability to prescribe smaller doses, especially in the elderly. Nurse practitioners practicing in inpatient setting did not use safety measures as often as the community NPs given that institutional policies and safeguards are in place related to opioid prescribing and dispensing. However, regardless of setting, most NPs (n = 11) felt that limiting medication supply or controlled dispensing was the most effective safety measure when prescribing opioids. The impact of the COVID-19 pandemic was explored as a potential contributing factor to the results but was not influential. NPs expressed feeling more confident prescribing opioids when the patient has an established diagnosis and are less confident with patients who have a history of addiction to alcohol or other substances, when the patient diagnoses are not clear, and with chronic pain patients taking high dosages of opioids. Conclusion. Nurse practitioners in Ontario are highly under-researched. Findings from this study can inform curricula changes to incorporate education related to opioid prescribing in the populations in which NPs expressed less confidence and education related to opioid tapering for patients on high doses of opioids. Recommendations from this study include the development of specific opioid prescribing guidelines for NPs practicing in inpatient settings. This study did not collect data from NPs working specifically in emergency departments, which would be a topic for future researc