Identifying barriers and facilitators for nurse practitioners' opioid management of chronic pain : Journal of the American Association of Nurse Practitioners

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Systematic Review

Identifying barriers and facilitators for nurse practitioners' opioid management of chronic pain

Kim, Hyunsoo DNP, FNP-BC (Post-doctoral Fellow)1; Korzynski, Alexandra BSN, RN (DNP Student)1; Hershberger, Patricia E. PhD, APRN, FNP-BC, FAAN (Rhetaugh G. Dumas Endowed Professor and Chair)2; Durham, Marianne L. DNP, RN, CPPS, CPHQ (Clinical Associate Professor)1

Author Information
Journal of the American Association of Nurse Practitioners 35(1):p 12-20, January 2023. | DOI: 10.1097/JXX.0000000000000805

Abstract

Nearly 100,306 Americans died from a drug overdose during the 12-month period from 2020 ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before. Among these, overdose death from opioids is estimated at 75,673 for 12-month period ending in April 2021 (Centers for Disease Control and Prevention [CDC], 2021). Opioid overdoses killed nearly 50,000 Americans in 2019, with nearly 73% of those deaths involving synthetic opioids such as fentanyl (Mattson et al., 2021). In addition, the opioid epidemic has taken a sharp turn for the worse since the COVID-19 pandemic. According to the American Medical Association (2022), more than 40 states have recorded increases in opioid-related deaths since the pandemic began. These increases have been attributed to factors ranging from lockdown-induced loss of community and social support to the closing of schools. For example, one emergency department in San Francisco saw approximately 2.5 patients per day exhibiting opioid overdose from March 16 to April 18, 2020, when a shelter-in-place order was in effect, compared with 1.4 such patients per day between January 1 and March 15, 2020.

When pain was recognized as an important vital sign requiring measurement in the 1990s, health care providers were challenged to treat pain more aggressively, resulting in increased prescription of opioids. In 1992, McCaffery pointed out that pain should not be underestimated by health care professionals, and nurses were told that short-term prescription of opioids for patient pain would not lead to addiction (McCaffery and Ferrell, 1992). Since that time, however, nurses' knowledge of pain assessment, opioid dosing, and the likelihood of addiction has increased. Long-term use of opioids may put a patient with chronic pain at risk of developing opioid use disorder, and in fact, opioid abuse in the United States has increased steadily since 1999 (Denis, 2019). As a result, the number of opioid overdose deaths in 2008 was four times higher than in 1999. The pharmaceutical industry is widely blamed for generating the opioid crisis, and it certainly played an important role (Florence et al., 2016). For example, industry marketing of opioid products to physicians was associated with increased prescription of opioids (Hadland et al., 2019). Additionally, loosening of government regulations for prescription narcotics followed, and the number of prescriptions again rose (Ostling et al., 2018).

Despite the growing crisis over the years, health care providers wrote 259 million opioid prescriptions in 2012, primarily for patients' chronic pain (Brady et al., 2016). In the study by Lozada et al. (2020), among 222,689 primary care providers sampled in 2015, 3.8% of Doctor of Medicine (MD), 6.3% of nurse practitioners (NPs), and 8.8% of physician assistants (PAs) overprescribed opioids; also, 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed opioids for at least 50% of their patients. In that study, overprescription was defined as meeting at least one of the following criteria: prescribing any opioid for over 50% of patients, prescribing more than 100 Morphine Milligram Equivalents/day for more than 10% of patients, and prescribing an opioid for more than 90 days for more than 20% of patients (Lozada et al., 2020).

Chronic pain is one of the most prominent causes of disability worldwide (Vos et al., 2012). Affecting at least 116 million U.S. adults, the annualized prevalence of chronic pain in this population was 20.5% in 2021 (Yong et al., 2021). Considering the public health impacts posed by chronic pain prevalence and the opioid epidemic, NPs and other health care providers are called on to assess patients not only for chronic pain and its management but also for potential opioid dependence before and during therapy.

Since the introduction of the Affordable Care Act in 2010, the capacity of physicians to serve a larger patient population has been strained, and more NPs have been called on to help meet the increased demand for health care services. In particular, NPs' role in medication prescription has expanded in primary health care (Doyle-Tadduni & Jackowski, 2016). Included in this role is the management of chronic pain in patients through prescription of opioids. In 2013, family physicians, internal medicine physicians, and NPs were the three largest groups of health care providers prescribing opioids, and NPs ranked third for opioid-related insurance claims for Medicare part D, which covers about 68% of the 50 million people on Medicare (Chen et al., 2015). More recently, according to Ellenbogen et al. (2020), NPs in primary care and hospital-based settings generated more insurance claims for opioid prescriptions under Medicare part D than physicians. Nurse practitioner–managed Medicare patients were also more likely to receive a high daily opioid dose compared with physician-managed patients (p = .048) (Muench et al., 2019). The factors contributing to these patterns of NPs' opioid management are little understood. Therefore, identifying the barriers and facilitators encountered by NPs in attempting to manage chronic pain by means of opioid prescription is critical to reducing opioid addiction and overdose.

In an attempt to address this knowledge gap, Nikpour and Broome conducted a scoping review in 2021 to identify barriers to NPs' ability to prescribe opioids for pain management and to treat opioid use disorder. The authors examined the impacts of state-level restrictions on patient access to effective pain management and concluded that legal limitations on NPs' scope of practice and prescriptive authority constituted a major barrier to managing chronic pain. Their findings suggested that NP scope of practice limitations had not achieved the joint goals of managing chronic pain while combatting the opioid epidemic (Nikpour & Broome, 2021). Although their review was useful in identifying legal restrictions that prevent NPs from treating chronic pain as well as opioid use disorder, the practical barriers, facilitators, and other factors influencing NPs' opioid management in the clinical setting were not comprehensively examined.

NPs are trained to provide holistic, patient-centered care and are well positioned to assume responsibility for opioid management when treating patients with chronic pain. To better understand factors affecting NPs' safe prescription of opioids, this integrative literature review was performed to examine published research regarding NPs' treatment of chronic pain with opioids. Data from the studies were synthesized to identify significant barriers, facilitators, and other influencing factors related to responsible opioid prescription among NPs. Based on the influencing factors identified, this integrative review offers recommendations for advancing NPs' role in opioid prescribing and chronic pain management to help mitigate the opioid epidemic.

Methods

Search and identification strategies

The integrative review was performed in accordance with PRISMA guidelines (Page et al., 2020) (Figure 1, which demonstrates the screening process of articles of a systematic review). A search for relevant studies was conducted using PubMed, CINAHL Plus with Full Text, PsycINFO, Embase, and Scopus. The initial search strategy included use of mapping medical subject heading terms that were consistent with the purpose of the review. The databases were searched using the following keywords for article titles and abstracts: (1) nurse practitioner OR advanced practice registered nurses (APRNs); (2) chronic pain OR persistent pain OR long-term pain; (3) opioid; (4) barriers OR obstacles OR challenges OR difficulties; and (5) prescribe OR prescriptions. A 60-minute consultation was held with a skilled health science research librarian to enhance retrieval efforts. The inclusion criteria for the review were that the studies (1) appeared in peer-reviewed journals, (2) were in English, (3) were available in full text, (4) were published between 2011 and 2021, (5) examined NP's chronic pain management by means of opioids, and (6) addressed barriers and/or facilitators for NPs' opioid management. The 2011 starting point for publications was selected because the Affordable Care Act went into effect beginning in 2010, after which more NPs were called on to help meet the increased demand for health care services. The exclusion criteria were that a study (1) did not include NPs, (2) had level Ⅳ or Ⅴ evidence based on the Johns Hopkins Nursing Evidence-based Practice Research Appraisal Tool, or (3) was conducted outside the United States. Excluding studies having level IV or V evidence increased the overall quality of our review findings. Studies conducted outside the United States were excluded due to the differing roles of NPs in other countries.

F1
Figure 1.:
PRISMA flow diagram. The PRISMA flow diagram details our search screening and selection process applied during the overview of the integrative review.

Initially, 635 articles were identified that met the eligibility criteria and their citations were imported into RefWorks reference software. RefWorks detected 27 duplicates that were eliminated. The titles and abstracts of the remaining 594 articles were then screened, and the full text of 30 articles was examined in detail. The reference lists of these articles were also checked for additional relevant studies. Two reviewers independently performed the screening and article selection process. Discrepancies and differences of opinion were discussed until consensus was reached on the articles to be included. These procedures identified nine relevant articles to be included in the review. This integrative review was not registered with PROSPERO, which is limited to systematic reviews.

Quality appraisal and data synthesis

The Johns Hopkins Nursing Evidence-based Practice Research Appraisal Tool (2017) was used to evaluate the level of evidence provided by the selected articles. The tool has three sections that address five levels of evidence, with the highest level designated as I, and three categories of evidence quality are high, good, and low. The level of evidence is determined according to the type of research design, and the quality of evidence is determined based on critical appraisal of study methods for validity and reliability (Dang & Dearholt, 2017).

The data synthesis was guided by Gerrard's matrix method (Gerrard, 2017). During the process of data extraction, both qualitative and quantitative data were obtained. The characteristics of the selected nine included studies are presented (see Supplemental Table 1, Supplemental Digital Content 1, https://links.lww.com/JAANP/A176). Specifically, in the Supplemental Table 1 (Supplemental Digital Content 1, https://links.lww.com/JAANP/A176), the information collected from each study included name of the author(s), year of publication, purpose, research design, sample characteristics, setting, inclusion and exclusion criteria, barriers and facilitators for opioid management, conclusions, and level of evidence. After completion of data collection, analysis and synthesis took place to reveal themes that illuminated barriers and facilitators for NPs' opioid management. The theme categorization process was independently reviewed and verified to further enhance rigor.

Results

The nine selected articles documented studies based in the United States. Both quantitative and qualitative studies were reviewed, and they included a total of 3,360 participants, most of whom were NPs and APRNs (N = 2,636). Most articles merged Doctor of Osteopathic Medicine (DO) and MDs into the general category of physicians, and both are referred to as physicians below. After application of the appraisal tool, the evidence provided by each of the nine articles was rated as level Ⅲ, and the quality of the nine articles was either good or high. Because no relevant experimental studies addressing the review's purpose were available, nonexperimental studies (categorized as level Ⅲ evidence) were included. Seven studies were excluded because of low scores on the appraisal tool. For example, a study by Tierney et al. (2015) was considered for inclusion, but its level of evidence scored as level Ⅳ on the appraisal tool, so it did not meet our inclusion criteria. Six themes emerged from the review: nurse practitioner education, patient subjectivity and patient education, systemic change and alternative treatment access, interprofessional collaboration, nurse practitioner prescriptive authority, and practice environment (see Supplemental Table 2, Supplemental Digital Content 2, https://links.lww.com/JAANP/A177, which denotes the themes in the nine articles).

Nurse practitioner education

Six of nine articles identified professional education as either a barrier or a facilitator for NPs' management of chronic pain (Craig-Rodriguez et al., 2017; Franklin et al., 2013; Mazurenko et al., 2020; Nikpour et al., 2021; Spitz et al., 2011; St Marie, 2016). As barriers to opioid prescription for older adults, 77% of NPs and physicians in one study identified fear of causing harm from adverse effects, and 35% identified insufficient pain management education (Spitz et al., 2011). Florida APRNs lacking previous training in opioid prescription or Drug Enforcement Administration registration showed significant gaps in knowledge in the areas of federal and state guidelines (Craig-Rodriguez et al., 2017). Web-based continuing educational training was identified as a facilitator for opioid prescription by 90% of 856 primary care providers, including 425 APRNs (Franklin et al., 2013). The need for education was not limited to NPs alone. Physicians suggested educating medical staff, including physicians and NPs, about appropriate opioid prescription practices, particularly for patients with complex chronic conditions (Mazurenko et al., 2020).

The need for systemic changes in current forms of opioid-related education, such as education on addiction treatment and its accessibility and training on nonpharmacologic mechanisms of care in nursing school and beyond, was addressed in two articles (Nikpour et al., 2021; St Marie, 2016). Master's degree–prepared NPs were more likely than doctoral degree–prepared NPs to report difficulty with managing pain (p = .04) (Nikpour et al., 2021). Safe practice and educating colleagues about strategies for reducing risk by providing them with uniform knowledge about pain management were emphasized for managing patients' pain. Advanced Practice Registered Nurses also recommended mandatory education on risk evaluation and mitigation strategies for health care providers prescribing opioids (St Marie, 2016).

Patient subjectivity and patient education

Five of nine articles addressed patient subjectivity and patient education as major factors affecting NPs' opioid prescription (Mazurenko et al., 2020; Merline et al., 2019; Nikpour et al., 2021; Spitz et al., 2011; St Marie, 2016). Among NPs and physicians, 62% stated that the subjectivity of patients' pain reports was often associated with an inability to establish an organic cause for their pain (Spitz et al., 2011). One provider remarked that patients' pain complaint scores often did not correspond with their behavior during visits and that this inconsistency contributed to reluctance to prescribe opioids (Spitz et al., 2011). Difficulties with applying alternative treatments to opioids were described because of patients' subjective choices for their treatment. For example, some patients did not want treatments that took extra time and effort, such as nonmedical treatment for managing pain (St Marie, 2016). Patients' unwillingness to try nonpharmacologic strategies was significantly associated with NPs' referring patients only some of the time or less for acupuncture (p = .03), chiropractic care (p < .01), and massage (p = .03) (Nikpour et al., 2021). Patients' or family members' reluctance to try opioid treatment because of concern about opioid abuse and patients' perceived stigma regarding opioid use were other barriers to proper prescription of opioids (Merlin et al., 2019).

Patient education could be a facilitator for opioid management. Education of patients was emphasized as an essential practice component to manage opioid prescription by all participating APRNs in the study by St Marie (2016). This education included how patients were to take the opioid medications prescribed and the kinds of monitoring that would occur (St Marie, 2016). Nurse practitioners and physicians suggested educating patients about the negative consequences of long-term opioid use as well as establishing realistic pain management goals; one NP said that their work should include more education of patients, especially about the dangers of using narcotics to manage chronic pain. Physicians stated that educating patients about the negative consequences of long-term opioid use could help to mitigate the opioid epidemic (Mazurenko et al., 2020). Among NPs and physicians, 54% believed that patient and family education about opioids was a facilitator for prescribing opioids to older patients with chronic pain (Spitz et al., 2011).

Systemic change and alternative treatment access

Seven of nine articles presented systemic change and difficulty accessing opioid alternatives as significant factors in NPs' opioid management (Andrilla et al., 2020; Mack, 2018; Mazurenko et al., 2020; Merline et al., 2019; Nikpour et al., 2021; Spitz et al., 2011; St Marie, 2016). First, the need for systemic changes was described in the articles. For example, palliative care providers, including both NPs and physicians, identified the lack of system-based approaches and training for addiction treatment as a persistent challenge (Merlin et al., 2019). Specifically, they described barriers to chronic pain management resulting from limited system access to providers with expertise in complementary approaches to palliative care, such as means of managing addiction and pain. Among NPs and PAs, clinical policies and resistance from practice partners were the main barriers to incorporating buprenorphine prescription (p < .0001) (Andrilla et al., 2020). A state monitoring program for drug prescriptions and strengthening of hospital leadership efforts were identified as decreasing inappropriate opioid prescription (Mazurenko et al., 2020). Use of validated risk assessment tools and improved evidence-based methods to help calculate appropriate starting doses for older patients with comorbidities was identified as a facilitator of opioid management (Spitz et al., 2011).

Payment for alternative pain management treatments was not easily reimbursed, creating a barrier to NPs' effective opioid management. For example, individuals working in outpatient settings reported lack of reimbursement for nonpharmacologic therapies because insurance companies would pay only for opioids (Merlin et al., 2019; St Marie, 2016). Most NPs (71.6%) reported that their patients had low access to nonpharmacologic methods as well as low insurance coverage (68%) most of the time (Nikpour et al., 2021). As an additional barrier to use of alternatives to opioids, rural location and associated difficulties accessing nonmedical pain management methods created a barrier to prescribing opioid alternatives (St Marie, 2016). Limited prescriptive authority was sometimes a barrier to APRNs' use of alternative treatments for opioids because they needed signatures of collaborating physicians to prescribe these treatments (Mack, 2018).

Interprofessional collaboration

Six of nine articles presented interprofessional collaboration as a facilitator for opioid management (Andrilla et al., 2020; Franklin et al., 2013; Mack, 2018; Merlin et al., 2019; Spitz et al., 2011; St Marie, 2016). Studies stated that innovative consultation or expert assistance along with a team-based approach and peer support would facilitate opioid management (Franklin et al., 2013; Merlin et al., 2019; Spitz et al., 2011). Conversely, in two studies, having little support from experts was a barrier to managing chronic pain (Merlin et al., 2019; St Marie, 2016). Nurse practitioners' differing perspectives toward opioid management with access to this expertise acted as a barrier to opioid management (Merlin et al., 2019).

Barriers to providing buprenorphine treatment for opioid disorder patients included lack of specialized collaboration and backup support, such as mental health and psychosocial support (p < .05) (Andrilla et al., 2020). More NPs working in less-restricted authority states identified lack of specialty backup support as a barrier to opioid management (p = .0074). Not only in such states but also in more-restricted authority states such as Oklahoma, having on-site backup support from experts was a facilitator for managing chronic pain without opioids (Mack, 2018).

Nurse practitioner prescriptive authority

Four of nine articles reported that NPs' restricted prescriptive authority was a barrier to managing opioid issues (Craig-Rodriguez et al., 2017; Mack, 2018; Nikpour et al., 2021; Spitz et al., 2011). Restricted authority in Florida was initially a barrier for APRNs. Legislation to schedule II–IV prescriptive authority did not lead to adoption of schedule II–IV because 50% of state APRNS did not possess Schedule II–IV Drug Enforcement Administration registration 2 years after the legislation's passage (Craig-Rodriguez et al., 2017). In restricted prescription authority states, the Food and Drug Administration upscheduling of hydrocodone combination medication created great barriers to pain management for APRNs and led them to make more referrals (Mack, 2018). Specifically, most APRNs had to refer patients needing pain management to specialists, and the referral process resulted in long waiting periods. Restricted prescriptive authority resulted in NPs working in New York City being concerned about regulatory and legal sanctions. Specifically, they were concerned about needing to write a large volume of prescriptions, often including opioid refill prescriptions, when patients' physicians were not present (Spitz et al., 2011).

However, Nikpour et al. (2021) observed no significant differences in chronic pain therapies among NPs with varying levels of practice authority. However, NPs with full practice authority were less likely to report being restricted by prescription authority laws than those without such authority (p = .06).

Practice environment

Three of nine articles identified relationships between NPs' work environment and opioid prescription (Mazurenko et al., 2020; Nikpour et al., 2021; Spitz et al., 2011). One study reported a significant difference in opioid prescription between specialty care (e.g., emergency department) and primary care settings (Nikpour, Broome, and Silva., 2021). Specifically, NPs in specialty care settings were significantly more likely to prescribe opioids (p < .01), whereas primary care NPs were more likely to use nonsteroidal anti-inflammatory drugs (p < .01) and acetaminophen (p = .05). Most NPs and physicians believed that the hospital system contributed to the opioid epidemic through several mechanisms (Mazurenko et al., 2020). For example, numerous study participants stated that opioids were inappropriately administered in the hospital emergency department, potentially as a way to increase discharges and avoid readmissions. Multiple NPs and physicians stated that the Center for Medicare and Medicaid Services' reimbursement policy and the Joint Commission's report were drivers of inappropriate opioid prescription in hospitals (Mazurenko et al., 2020). Among physicians and NPs, 73% reported being much more comfortable prescribing opioids to patients receiving palliative or hospice care than to patients receiving chronic pain treatment (Spitz et al., 2011).

Discussion

This integrative review identified barriers, facilitators, and other factors influencing NPs' chronic pain management with opioids. First, increased opioid management educational needs were identified among NPs. In the past, Kaplan et al. (2010) found that lack of educational preparation resulted in a mental barrier that adversely affected NPs' prescription of opioids (Kaplan et al., 2010). More recently, most articles reviewed continued to describe a need for further education for NPs who prescribe opioids. Given that fear of causing harm was reported by NPs as hindering their initiation of opioid therapy (Andrilla et al., 2020; Franklin et al., 2013; Spitz et al., 2011), their knowledge gap needs to be reduced through enhanced education to increase their confidence in opioid prescription. This could be accomplished by providing NPs with a greater amount of evidence-based education.

Savage et al. (2018) reported that most NP curricula contain less than 8 hours of education even on general substance use. The deficiency in NPs' educational preparation eventually places them at a disadvantage with respect to delivery of evidence-based care for substance users. With respect to NP education, systemic change may be required to address NPs' opioid management needs. The American Association of Colleges of Nursing (2018) identified adoption of curricula related to chronic pain as a key goal for all schools of nursing, and such curricula should be increasingly incorporated at the doctoral level of advanced practice nursing education. Given that educational level was significantly associated with NPs' confidence in managing chronic pain (Nikpour et al., 2021), changes in educational programs could help meet NPs' knowledge needs with respect to opioid prescription. Education on addiction treatment as well as the mental health impacts of chronic pain, documentation of opioid prescription policies and guidelines, and training in opioid prescription could all be included in educational change for NPs. According to Kameg et al. (2020), barriers to curricular modification included limited faculty time, lack of faculty expertise or confidence, and stigma regarding opioid use. However, these researchers also identified curricular change facilitators such as the presence of faculty champions, the availability of external educational resources, student interest, and financial incentives. By accounting for these factors, graduate NP programs can ensure that their curricula include adequate instruction on opioid management.

The need for opioid management education is not limited to NPs but extends to their patients because patient subjectivity and patient education constitute another factor affecting NPs' opioid management. Some patients do not want a nonmedical treatment that requires extra time and effort to manage their pain. To reduce such patient subjectivity, NPs can play a more active role in educating patients about the negative consequences of long-term opioid use and about alternative pain management methods. Lack of NP familiarity with patient education recommendations in current guidelines may be an obstacle to NPs' assuming this expanded role. To overcome the possible barrier, NPs may benefit from guideline-based training on how to communicate about common opioid-related adverse effects and potential long-term harm with patients. As a separate issue, patient education tends to be underreported in medical records compared with other aspects of medical care, so it is uncertain how much NPs are currently educating patients about opioids (Anil et al., 2021). Therefore, additional research is needed on NPs' practices with respect to patient education on opioids.

Systemic challenges and difficulty of accessing opioid alternative treatment were described as a significant factor for NPs' opioid management. In the study by Franklin et al. (2013), more physicians than NPs had access to opioid prescription policies and tools in their clinics (p < .01) that could assist in appropriate opioid prescription. Hospital leadership efforts to decrease inappropriate opioid use by providing current opioid prescription guidelines and by participating in state prescription-drug monitoring programs would support NPs' opioid management (Mazurenko et al., 2020). Additionally, it is imperative that NPs implement safe pharmacological and nonpharmacological interventions when treating patients with chronic pain while also following recommended practice guidelines to prevent prescription-related opioid addiction. Difficulty with accessing alternative treatment was described as another barrier to NPs' opioid management. Therefore, policy changes are needed among health insurance providers. For example, offering payment reimbursements for nonpharmacologic therapies may reduce opioid overprescription among NPs. Also, NPs should be aware of the insurance coverage available for alternative pain management because insurance coverage would allow them to seek chronic pain treatment options other than opioids.

Interprofessional support and enhanced access to experts are needed to allow NPs to be more confident in their opioid prescription management. The need for interprofessional collaboration does not differ depending on NPs' prescriptive authority. For example, in the study by Andrilla et al. (2020), compared with those working in restricted-practice states, significantly more NPs in less restrictive practice states identified lack of backup support as a barrier to managing opioid prescriptions (p = .0074). Even where NPs have full authority, a gap in the prescription of opioids exists between physicians and NPs. For example, in one study in Washington state, physicians were more likely to report prescribing opioids than NPs (p < .01). Also, compared with physicians, fewer NPs had access to opioid prescription support tools (p < .01; Franklin et al., 2013). To overcome lack of support, innovative methods of obtaining consultation or assistance such as telephone or video conferencing with experts would facilitate opioid management (Franklin et al., 2013). For example, various types of continuing education such as academic detailing can be provided both in-person and remotely to better educate NPs in opioid management.

The limited authority of NPs to prescribe opioids for pain management and medications for opioid use disorder is an ongoing problem throughout the United States. Despite the availability of evidence-based pharmacotherapies, only 20% of patients diagnosed with opioid use disorder received evidence-based treatment from NPs and other health care providers (Saloner & Karthikeyan, 2015). In this regard, one critical problem was the shortage of providers authorized to prescribe treatment for opioid use disorder, including buprenorphine (Kameg et al., 2020). The Institute of Medicine (now the National Academy of Medicine) suggested that if NPs were permitted to practice to the full extent of their training, they could help build the workforce necessary to meet the country's primary health care needs and contribute to delivery of patient-centered, community-based health care (Institute of Medicine, 2011). However, NPs are still transitioning to independent authority to manage opioid prescriptions. Currently, in the United States and its territories, NPs in 27 locations have full practice authority, those in 17 locations have reduced prescriptive authority, and NPs in 11 locations have restricted prescriptive authority (American Association of Nurse Practitioners, 2021). Nikpour and Broome (2021) reported that NPs viewed limitations on their scope of practice and prescriptive authority as a major barrier to managing chronic pain (Nikpour & Broome, 2021). Additionally, based on the themes observed in the reviewed articles, limited authority is still the predominant issue faced by NPs, especially for opioid prescription. For example, in Oklahoma, the Food and Drug Administration upscheduling of hydrocodone limited the number of providers who can prescribe hydrocodone in primary care settings, resulting in more referrals and increased costs. For these reasons, enhanced APRN authority would increase patient access to care and decrease health costs (Mack, 2018).

Along with the prescriptive authority issue, the practice environment is a significant factor affecting NPs' opioid management. Not surprisingly, NPs in specialty care settings are more likely to prescribe opioids than NPs working in primary care settings (Mazurenko et al., 2020). Given the significance of the practice context in this regard, educational enhancements and other forms of NP support should be tailored to the NP's practice environment. For example, unlike NPs working in emergency departments, where most opioids are prescribed, those practicing in primary care settings would likely benefit from education on the need for caution in prescribing opioids.

Limitations

This review's limitations should be noted. First, few scholarly articles met the eligibility criteria. Some reviewed studies had nonrandomized samples and/or small sample sizes, and some showed nonresponse bias. Furthermore, the level Ⅲ evidence provided by the studies does not include experimental research results, which are considered stronger evidence. In addition, only studies in English were included, and this limited the scope of the review findings. However, this review does include both qualitative and quantitative studies whose results were systematically analyzed, and the findings revealed meaningful factors influencing NPs' opioid prescription for chronic pain management. To our knowledge, this is the first integrative review that assesses factors affecting NPs' opioid prescription, and as such it serves as a useful foundation for understanding how NPs can help mitigate the opioid crisis while treating patients' chronic pain. Future studies should explore how the health care complexities of the COVID-19 pandemic affected the opioid crisis as well as NPs' opioid prescription behaviors.

Conclusion

This integrative review highlights barriers, facilitators, and other influencing factors pertaining to NPs' opioid management. Nurse practitioners have been trained to treat chronic pain with opioids, but educational gaps and other factors reduce their ability to do so effectively and safely. Overall, NPs' prescription competencies in clinical settings can be enhanced by providing them with additional education on opioid management, including opioid prescription for pain management and opioid detoxification medications. That education could be included in improved nursing school curricula or as part of continuing education and training, especially for NPs working in specialty settings. In turn, NPs would be better equipped to provide patients and families with education about opioid side effects and the risk of opioid use disorder, which could reduce opioid misuse. To reduce opioid misuse rates, organizational support along with interprofessional support that enhances access to experts can improve NPs' opioid management. Potentially helpful systemic support includes opioid prescription monitoring programs, provision of current insurance reimbursement information for alternative treatment methods, supplying expert consultation, and issuance of relevant policy and guidelines by states and health professional organizations. Additionally, the issues created by limits on NPs' prescription authority should be addressed. State legislatures and regulatory agencies as well as schools of nursing should implement changes in policy and curricula to better support NPs' role in opioid management and reduce the opioid prescription barriers NPs face.

The small number of studies addressing NPs' opioid management limits the information available to address the barriers they face in their opioid management. Future studies should more comprehensively examine both barriers and facilitators for NPs' opioid management, including the impacts of diverse working environments. Finally, the facilitators identified in this review should be used as a starting point for development and testing of strategies for enhancing NPs' chronic pain management with opioids.

Acknowledgments:The authors express their appreciation to Rebecca Raszewski, MS, AHIP, Library of the Health Sciences-Chicago, University of Illinois Chicago (UIC), for her assistance with database search strategies. Also, the authors thank Dr. Stephanie Cooper, PharmD and Donna Clay, BSPharm from the UIC College of Pharmacy for their insights regarding the use of academic detailing to impact nurse practitioners' opioid-prescribing behaviors.

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    Keywords:

    Barriers or facilitators; chronic pain management; nurse practitioners; opioids; prescription

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