UCLA

This dissertation examines how clinicians are making decisions about prescribing opioids in the midst of a public health crisis. In the first paper, I used a qualitative study design to understand how, why, and when clinicians use risk mitigation strategies when prescribing opioids. For three risk mitigation strategies – the opioid agreement, urine drug testing, and risk screening checklists – I identified two groups of clinicians: Adopters, who found them useful and valuable and Non-adopters, who found them awkward and disruptive. In the second paper, I examined how clinicians made decisions about assuming new patients’ existing opioid prescriptions and identified three approaches: the Staunch Opposers, who were highly averse to continuing opioid prescriptions for new patients; the Cautious and Conflicted Clincians, who felt uneasy about prescribing opioids, but were willing to manage new patients’ prescriptions if the patient was perceived as trustworthy and if the dose and medication type fell within their comfort zone; and the Rapport Builders, who were the most willing to assume a new patient’s opioid prescription, even if the prescription was for a high dose. In the third study, I examined a sample of visits of patients seen by primary care clinicians for low back pain from 2013-2017 and analyzed whether receipt of an opioid prescription was associated with comorbidities that would indicate the prescription was potentially appropriate or inappropriate. I found that visits for which patients had selected NSAID contraindications, including kidney disease and concurrent or long-term use of anticoagulants or antiplatelet medications, had higher odds of the receipt of an opioid prescription, reflecting potentially appropriate prescribing. However, visits where patients had relative contraindications for opioids, such as concurrent benzodiazepine prescriptions or a history of substance use disorder, had significantly elevated odds of opioid receipt, reflecting potentially inappropriate prescribing. Findings from this dissertation expand and extend a conceptual model for decision-making around prescribing. I identified several new constructs that may influence prescribing, including (1) the nature of the patient-clinician relationship, (2) the management of risks to both the patient and clinician, (3) ethical considerations, and (4) the prescriber’s identity and role as a clinician.