Findings of the quantitative and qualitative parts of this study are presented comparatively for the purpose of triangulation. Direct quotes from the qualitative data have been translated with due diligence and are presented with an indication of the alias (GP=General Practitioner, Number= number of interview).
Characteristics of the samples
Survey: The questionnaire was completed by n=131 GPs (estimated response rate of 0.45%, based on a sample of approximately 4700 directly contacted GPs). There was a balanced gender distribution, with 49% female and 51% male respondents. Mean age of physicians was 48 years, ranging from 24 to 74 years. Physicians had an average of 20.5 years of professional experience, ranging from 1 to 44 years. Among physicians, 94% were GPs and 6.1% were physicians in specialist training in general practice.
Interviews: Of the 4,700 GPs contacted, 27 were interested in an interview. In the end, telephone interviews were conducted with n= 21 GPs (52.4% female / 47.6% male). Mean age was 51.4 years with 21.3 years of professional experience. 90.5% of the participants were fully trained GPs. The sociodemographic characteristics are detailed in Table 1. The average length of an interview was 51.53 minutes.
Table 1: Sample characteristics
General Practitioners
|
Survey
|
Interviews
|
Total
|
Missings
|
Total n
|
131
|
21
|
152
|
|
Selfreported sex (f/m) n (%)
Missings
|
49/51
(49%/51%)
31
|
11/10
(52,4%/47,6%)
0
|
121
|
31
|
Age in years: (mean ±SD) (min-max)
Missings
|
48±12.8 (24-74)
32
|
50,6 ± 13.5 (31-74)
0
|
120
|
32
|
Years of working experience: mean ±SD
(min-max)
Missings
|
20,5±12.1 (1-44)
33
|
21,3±11.9 (4-42)
0
|
119
|
33
|
General Practitioners n (%)
|
123
(94%)
|
19
(90.5%)
|
152
|
|
Physicians in specialized training in
general practice n (%)
|
8 (6.1%)
|
2 (9.5%)
|
10
|
|
Implementation of LONTS recommendations
The results of the participants are generalized as GPs. Data from physicians in further training to become specialists in general practice are included.
Recommendation 1: Set realistic treatment goals
Figure 1 shows, on a Likert scale ranging from "never" to "very often”, GPs rated how often they set agreements on realistic treatment goals with patients with CNTP. 48.1% (n= 51) of GPs stated that they never or rarely agree on realistic treatment goals with their patients. 19% (n= 25) did not answer this question.
The qualitative data also indicated that GPs do not routinely set individualized and realistic treatment goals as part of pain management. Most GPs stated that their primary goal was to reduce pain with medication. The most commonly mentioned tool to assess success was the Visual Analog Scale (VAS) or the Numerical Rating Scale (NRS). Reasons given by GPs for not setting realistic treatment goals were that GPs assumed patients had their own treatment goals which they kept to themselves and were not the physician's business. In addition, it was mentioned that the formulation of common, realistic treatment goals was not integrated into daily routines and therefore frequently forgotten in everyday life.
"I don't think it [the therapy goal] is explicitly stated [...] we talk about whether the patient feels the need for the pain to be less than it is now and then I suggest taking this or that medication [...]". [GP_16]
Recommendation 2: Use of long acting opioids
Figure 2 shows the GPs responses to the question which release form they would prefer in the given case scenario or comparable situation. While most participants opted for a combination of a LAO and a SAO (50.8%, n= 64), 17.5%, (n= 22) opted for a (not recommended) treatment with a SAO monotherapy. 5.7% (n= 7) did not answer this question.
In order to explore determinants associated with a SAO monotherapy, a correlation analysis was conducted with the metric variables "age" and "years of working experience," alongside the independent dichotomous variable "SAO monotherapy".
Table 2 (column 1) indicates a correlation between the metric variable "age" and the dichotomous independent variable "SAO monotherapy". The correlation was carried out with n= 99 GPs, the missings were n=31. The correlated R2 value is 0.26, which means that 26% of the variance in GP age can be explained by the choice of SAO monotherapy. Visualization of the correlation through a scatterplot (Figure 3 (Additional file 3: Suppl.3.) reveals that more GPs between ages 25 and 39 opted for treatment with a SAO alone, while older GPs did not mark this option.
Table 2 (column 2) demonstrates a correlation between the dependent metric variable "years of experience" and the independent dichotomous variable "SAO monotherapy". Correlation was performed on n= 98, with n= 31 missing. The correlated R2 value is 0.31, suggesting that 31% of the variance in GPs' work experience can be accounted for by the choice of SAO monotherapy. Visualizing the correlation through a scatterplot (Figure 4 (Additional file 4: Suppl.4.) reveals that GPs with less work experience tend to utilize SAO monotherapy, particularly within the 1-7 years range, and occasionally within the 9-15 years range. Conversely, GPs with more years of experience were less inclined to select SAO monotherapy.
Analysis of the qualitative data showed that the majority of GPs did not make a difference in opioid treatment for tumor versus non-tumor pain. They stated to prefer a combination therapy of LAO and SAO since this is a common treatment strategy in cancer patients. With regards to prescribing SAOs, GPs provided various responses. Mostly the use of SAO was justified with good personal experiences: Some reported positive experiences with intranasal or buccal ROOs as adjunctive therapy, while others noted that depending on the patient population, SAOs in tablet form are also effective.
"Then there are younger patients who say they manage well with this nasal spray as a demand. And then there are older patients who say, yes, I manage quite well with short-acting [...] tablets”. [GP_19]
Some GPs noted the flexibility of treatment with SAOs alone, particularly positive results with low-potency opioids such as tilidine and tramadol. They mentioned that a perceived advantage of using SAOs was the flexibility of dosing, allowing a lower dosage regimen compared to LAOs. In general, GPS did not recommend treatment with high-potency SAOs alone due to a dependency risk.
Recommendation 3: Adhere to fixed dosing schedules
Figure 5 depicts GPs' prescribing decisions regarding opioid dosage regimens. Most GPs (50.8%; n= 64) chose a combination therapy involving scheduled opioid administration alongside opioid use on demand. 16.7% (n= 21) of GPs preferred opioid use on demand alone. 5.7% (n= 7) did not answer this question.
A correlation analysis performed with the metric variables "age" among surveyed GPs utilized the variable "one opioid at fixed times and on demand."
Table 3 demonstrates a correlation between the dependent metric variable "age" and the independent dichotomous variable "opioid use at fixed times and on demand." Correlation was performed on n= 99, with n= 32 missing. The corrected R2 value of 0.09 suggests that only 9% of the total variability in GPs age can be explained by scheduled and on-demand opioid use. When visualizing this relationship in a scatterplot (Figure 6 (Additional file 6: Suppl.6.), it becomes apparent that GPs in the younger age group (25-41) were less likely to use combination therapy. In contrast, GPs in the middle to older age group (40-70) were more inclined to choose combination therapy.
In the interviews, GPs gave several reasons for preferring a treatment with opioids solely on demand. Some were identical with the reasons given for the use of SAO (referring to guidelines for tumor therapy, feasibility, good personal experiences). In addition, it was mentioned that patients may find it challenging to comprehend why they should adhere to a fixed intake schedule if they're not consistently experiencing pain. On-demand therapy was considered to potentially prove beneficial and reduce side effects of opioid therapy. Regarding on-demand therapy, GPs noted that weaker opioids such as tilidine or tramadol could be used as needed by patients, which is particularly beneficial for older individuals with chronic pain.
“I have a form of treatment that works particularly well for older patients [...] and that is low-dose Tramal in drop form. [...] They take five drops of Tramal two or three times a day as they need it and it helps them.” [GP_04]
Recommendation 4: Consider reduction and discontinuation in responsive patients
Missings: n= 28 (27.1%) from n= 131
Figure 7. Consider reduction and discontinuation in responsive patients/ Responses from GPs
Figure 7 details responses regarding how frequently GPs stated they would discuss a reduction or discontinuation of opioid treatment within 6 months in the given case scenario or similar situations (Likert scale consisted of never, rarely, rather often, very often). The option "Never/Rarely" was most frequently selected (56.3% of participants; n=58). 27.1% (n=28) did not answer this question.
From the qualitative data, several reasons could be identified for GPs reluctance to discuss discontinuation of opioid therapy proactively: They often mentioned a lack of a structured care process to monitor opioid therapy in their practices, making it challenging to initiate and track reduction efforts. Some GPs observed that in cases of severe chronic pain, where finding effective therapy was challenging, opioid therapy was usually not reduced. Reasons given included patients' fear of pain recurrence or feeling to be deprived of a crucial treatment. GPs considered it particularly difficult to discontinue opioid therapy in geriatric and nursing home patients, who were perceived to rely on it for pain relief due to a lack of alternative resources. GPs expressed contentment when patients experienced pain relief and improved symptoms under opioids and reluctance to initiate an opioid reduction after having found an effective treatment together with the patient.
“It's like with blood pressure therapy, if I'm doing well with blood pressure therapy, then the patients say, yes, now the blood pressure is good [...] and if I'm doing well now, then I think it's working because it's well-adjusted [opioid medication] [...] and if I stop doing it, then I don't think it's going to be good again because then the effect is gone, so all the success that I've built up before [the GP] is gone rather than remaining.” [GP_15]