Nurse Practitioner Opioid Prescribing and Safety Measure Utilization Patterns in Ontario: An Explanatory Sequential Mixed Methods Study

Background: Across Canada, opioid-related hospitalizations, emergency department visits, and mortality have increased. A literature gap exists related to opioid prescribing and safety measure utilization patterns among nurse practitioners (NPs). Purpose: The objectives of this study were to (a) identify opioids prescribed by NPs in Ontario for pain, (b) examine safety measure utilization when prescribing opioids, (c) explore factors associated with safety measure utilization, and (d) survey NPs' opioid prescribing confidence. Methods: An explanatory sequential mixed method approach was used to measure quantitative and qualitative results in a sequential approach that achieves methodological triangulation. A survey was distributed to 2,094 NPs practicing in Ontario between May and August 2020. After quantitative analysis of 158 completed surveys, a qualitative phase was conducted that involved one-on-one semi-structured interviews with 14 NPs who completed the survey and agreed to follow up. Results: The top three opioids prescribed for acute and chronic pain reported by 158 NPs were hydromorphone followed by acetaminophen with codeine and oxycocet. The top three acute opioid-treated conditions were (1) fracture, (2) postoperative pain, and (3) joint or muscle strain/sprain. The top three chronic pain conditions were (1) cancer/palliative care, (2) chronic low back pain, and (3) osteoarthritis. Results from interviews demonstrated that inpatient NPs used safety measures less often than community NPs because of institutional policies that aid safe prescribing. NP preference for hydromorphone was rooted in its appealing side effect profile and ability to prescribe smaller doses. Limiting medication supply was considered the most effective opioid prescribing safety measure. NPs were more confident prescribing opioids with established diagnoses and less confident with unclear diagnoses, history of addiction, and chronic pain patients taking high dosages of opioids. Conclusion: Findings from this research can inform curricula changes to incorporate education related to opioid prescribing in the populations in which NPs expressed less confidence and opioid tapering for patients on high doses of opioids.