Opioids and the challenges of managing chronic non-cancer pain in rural Australia: a qualitative study.

Objective: To investigate why rural general practitioners prescribe opioids for people with chronic non-cancer pain, with the aims of explaining geographic differences in opioid prescribing and improving pain management in rural areas.

Study design: Qualitative study; interviews with convenience sample of rural general practitioners.

Setting, participants: Seventeen rural general practitioners who had prescribed opioids for people with chronic non-cancer pain during the preceding twelve months; the interviews were undertaken during 11 September 2023 - 31 May 2024.

Major outcome measures: Contextual and individual factors that influence decision making by rural general practitioners about prescribing opioids for people with chronic non-cancer pain.

Results: We found that rural opioid prescribing is influenced more by health care system deficiencies than lack of knowledge among practitioners. Two major themes were identified: systematic constraints (insufficient time for alternative management strategies and the influence of Medicare remuneration); and limited access to multidisciplinary pain management (limited availability of non-pharmaceutical treatments, colleagues for consultation, and referral pathways). Participants described feeling trapped between brief consultations and complex deprescribing requirements; Medicare remuneration schedules encourage shorter appointments (and therefore continuing current management) rather than comprehensive pain management. Implementing evidence-based guidelines was difficult in rural areas with limited resources. The limited availability of allied health services further restricted alternative pain management approaches. Participants reported greater psychological pressure to justify opioid deprescribing than prescribing. Doctors acknowledged that the evidence for the value of opioids for managing chronic pain was limited but felt caught between inadequate system resources and patient demands.

Conclusion: We found a marked disparity between evidence-based guidelines for chronic pain management and the reality of rural medical practice. Rural doctors operating in a difficult context resort to prescribing opioids because of systemic inadequacies rather than lack of awareness of their limited value. Chronic pain management in rural areas could be improved by better Medicare support for longer pain management consultations, improved access to allied health, rural area-specific guidelines that take resource constraints into account, and improved support for general practitioners in pain management and deprescribing.