ORIGINAL ARTICLE – HEALTH SERVICES RESEARCH AND GLOBAL ONCOLOGY
Opioid Prescribing After Curative-Intent Surgery: A Qualitative
Study Using the Theoretical Domains Framework
Jay S. Lee, MD
, Vartika Parashar
, Jacquelyn B. Miller, MA
, Samantha M. Bremmer
, Joceline V. Vu, MD
Jennifer F. Waljee, MD, MPH, MS
, and Lesly A. Dossett, MD, MPH
Division of Surgical Oncology, Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann
Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI;
Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI;
Division of Surgical Oncology,
University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
Background. Excessive opioid prescribing is common
after curative-intent surgery, but little is known about what
factors inﬂuence prescribing behaviors among surgeons.
To identify targets for intervention, we performed a qual-
itative study of opioid prescribing after curative-intent
surgery using the Theoretical Domains Framework, a well-
established implementation science method for identifying
factors inﬂuencing healthcare provider behavior.
Methods. Prior to data collection, we constructed a semi-
structured interview guide to explore decision making for
opioid prescribing. We then conducted interviews with
surgical oncology providers at a single comprehensive
cancer center. Interviews were recorded, transcribed ver-
batim, then independently coded by two investigators using
the Theoretical Domains Framework to identify theoretical
domains relevant to opioid prescribing. Relevant domains
were then linked to behavior models to select targeted
interventions likely to improve opioid prescribing.
Results. Twenty-one subjects were interviewed from
November 2016 to May 2017, including attending sur-
geons, resident surgeons, physician assistants, and nurses.
Five theoretical domains emerged as relevant to opioid
prescribing: environmental context and resources; social
inﬂuences; beliefs about consequences; social/professional
role and identity; and goals. Using these domains, three
interventions were identiﬁed as likely to change opioid
prescribing behavior: (1) enablement (deploy nurses during
preoperative visits to counsel patients on opioid use); (2)
environmental restructuring (provide on-screen prompts
with normative data on the quantity of opioid prescribed);
and (3) education (provide prescribing guidelines).
Conclusions. Key determinants of opioid prescribing
behavior after curative-intent surgery include environmental
and social factors. Interventions targeting these factors are
likely to improve opioid prescribing in surgical oncology.
Prescription opioid misuse and abuse remains a national
public health crisis. In 2015, deaths attributable to opioids
continued to increase, with over 33,000 fatalities from
Surgeons play a crucial role in this
epidemic, providing 10% of opioid prescriptions in the
In fact, 6% of previously opioid-naive patients who
underwent surgery subsequently transitioned to new per-
sistent opioid use after surgery.
Patients with cancer are at
even higher risk, with 10% developing new persistent
opioid use after curative-intent surgery.
Opioid prescribing after curative-intent surgery is
complex due to multiple potential sources of pain,
including invasive procedures and side effects of
Patients with cancer also report high
levels of psychological distress,
which is associated
with increased postoperative opioid consumption.
need for multidisciplinary cancer care also creates the
potential for uncoordinated prescribing from multiple
Given these factors, it is not surprising that
excessive opioid prescribing is common after surgical
oncology procedures. For example, over 70% of prescribed
opioids remain unused after partial mastectomy with sen-
tinel lymph node biopsy.
Unfortunately, little is known
Ó Society of Surgical Oncology 2018
First Received: 2 January 2018;
Published Online: 10 April 2018
L. A. Dossett, MD, MPH
Ann Surg Oncol (2018) 25:1843–1851