Practice Patterns and Influential Factors of Nurse Practitioners Managing Chronic Pain

Chronic pain impacts 100 million adult Americans in their lifetime, comprises the third-highest category of all health spending, and is responsible for up to 20% of primary care visits. Chronic pain treatment guidelines: recommend a biopsychosocial, multimodal management approach that addresses the physical and mental aspects of chronic pain. Nurse practitioners (NPs) have a unique role to play in chronic pain, due to their biopsychosocial training in chronic disease management in primary care that aligns well with this recommended approach. However, little is known about how NPs manage chronic pain or factors that influence those patterns. These gaps have implications on NP regulation and workforce development, as well as primary care transformation and clinical practice. Therefore, the purpose of this dissertation is to understand primary care NPs’ opioid and non-opioid prescribing patterns and the patient, provider, and system-level factors that influence those patterns.This dissertation includes a scoping review in Chapter 2 that demonstrates the negative impact of NP regulatory restrictions on patient access to chronic pain care, as well as treatment for OUD. Chapter 3 features a systematic review that examines primary care chronic pain prescribing patterns among physicians, NPs, and physician assistants (PA). This chapter highlights the lack of literature on NP and PA prescribing patterns specific to primary care, as well as the lack of prescribing pattern literature on non-opioid and non-pharmacologic modalities, despite the recommendations of these therapies in multiple national chronic pain guidelines. Chapter 4 presents the findings of a 31-item survey, developed by the authors, of 128 NPs from across the U.S. This survey examined the challenges and experiences of NPs who manage chronic pain and analyzed the impact of those experiences on the frequency with which NPs prescribe various pharmacologic and non-pharmacologic pain therapies. Findings indicate that NPs strongly identified with a variety of chronic pain management challenges, including patient access and insurance coverage of non-pharmacologic care, regulatory restrictions, and concerns of misuse. Additionally, NP-level factors such as setting of practice and education level significantly impacted NPs’ prescribing patterns and their perception of difficulty in managing chronic pain. Finally, Chapter 5 utilized a national VA dataset, including 39,936 12-month summary records between patients and their primary care providers, to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs. After adjusting for patient factors, physicians had the highest odds of prescribing opioids and non-opioids compared to NPs and PAs. However, very small effect sizes may indicate that these differences do not hold significant clinical meaning. Patient factors, such as race/ethnicity, gender, age, level of education, number of comorbidities, number of chronic pain diagnoses, and self-reported health and mental health statuses, influenced prescription of opioid and non-opioid medications after adjusting for all other variables. Chronic pain is an exemplar of necessary primary care transformation priorities, including primary and behavioral health integration, value-based payment and delivery, team-based and well-coordinated care, and promotion accessible, equitable care. NPs are well-suited to address the complex needs of chronic pain patients. The findings of this dissertation indicate that NPs are slightly less likely than physicians to prescribe opioids and non-opioids; however, patient characteristics may increase the odds of a medication prescription more so than provider type. Furthermore, these findings identify patient, provider, and system-level challenges that NPs experience while managing chronic pain. The findings of this dissertation may contribute to important advancements in policy, practice, education, and research.