BMC Health Serv Res 2022 (Nov 3); 22 (1): 1313

Table 3.

Joint display of the quantitative associations of visit frequency and calendar year with prescription opioid use at the Langs Community Health Centre, representative qualitative interview quotes, and meta-inferences

Variable	Quantitative results	Qualitative interview quotes	Meta-inferences
Higher frequency of healthcare visits (n = 210) ^a	• Positive association with total number of opioid refills ^b (adjusted IRR = 1.06) • Positive association with higher opioid dosage at: 3-month follow-up (adjusted OR = 1.11) 6-month follow-up (adjusted OR = 1.09) 9-month follow-up (adjusted OR = 1.10) 12-month follow-up (adjusted OR = 1.12)	Passive pain management strategies: • “I found, like, after I’d been in [for chiropractic treatment] on a Tuesday and they’d put me all back in shape again, and put my shoulder back in, I felt great by Thursday. Thursday it was time to come back in. So, it kept me even. It kept the pain down. … With me comin’ in twice a week, I knew at least for four days out of the week I was going to be fine.” DC Patient 7 • “You expect the doctor to fix it, ‘cause that’s how we were brought up.” Non-DC Patient 6 • “Some of our people are just rather passive in their approach to their care.” GP 1 • “Everything is short-term. [My pain is] chronic. It’s there to stay because I try everything. … I’ve tried physio, chiro, … I even have steroid needles [at the] pain clinic, … and saw a sport therapist person [physiatrist] for a different type of needle [epidural injection]. … I take the Robaxacet if I’m in too much pain, or Advil. … They gave me Percocet. … [Even with regular] massage therapy [and] osteopathy, I go to bed and the day after and it’s still there. … I wish somebody could go inside and just fix [it]. It’s just a hard place to be fixed, it’s not made to be fixed – the back.” Non-DC Patient 2	Patients with a higher frequency of healthcare visits had a higher rate of refilling opioid prescriptions and were more likely to be receiving higher dose (≥ 50 mg MED) opioids over 12-month follow-up. Patients who relied on passive pain management strategies may have been more likely to visit their healthcare providers more often and obtain opioid prescriptions on a more frequent basis and at higher doses.
Index visit in more recent calendar year (n = 210)	• Negative association with total number of opioid refills ^b (adjusted IRR = 0.82) • Negative association with higher opioid dosage at: 3-month follow-up (adjusted OR = 0.73) 6-month follow-up (adjusted OR = 0.78)	Reduced opioid prescribing in recent years: • “When I graduated [from medical school] in 1996, the overwhelming message to us was that we weren’t treating pain adequately; we weren’t treating it aggressively enough. And then of course, OxyContin was just the ‘new guy’ on the block and all that was wonderful and there was no ceiling dose, and you know the rest of that story.” GP 7 • “In the last four or five years [here at Langs], we’ve worked even harder at getting people off opioids.” GP 3 • “The goal is that opioids are not used for chronic non-cancer pain. I think over the last five [or] 10 years we’ve seen [a] reduction in use, and a lot of patients have been titrated down in their doses and are using more appropriate [levels of opioid] medications now.” GP 8 • “Having followed the sort of structure that we normally do here now in the last five years [with opioid prescribing], there’s much fewer people on [high doses].” GP 3	Patients whose index visit date was in a more recent calendar year had a lower rate of refilling opioid prescriptions and were less likely to be receiving higher dose (≥ 50 mg MED) opioids at 3- and 6-month follow-up. GPs at Langs have made a concerted effort in recent years to reduce opioid prescribing.

Variable

Quantitative results

Qualitative interview quotes

Meta-inferences

Higher frequency of healthcare visits
(n = 210) ^a

• Positive association with total number of opioid refills ^b (adjusted IRR = 1.06)

• Positive association with higher opioid dosage at:

3-month follow-up (adjusted OR = 1.11)

6-month follow-up (adjusted OR = 1.09)

9-month follow-up (adjusted OR = 1.10)

12-month follow-up (adjusted OR = 1.12)

Passive pain management strategies:

• “I found, like, after I’d been in [for chiropractic treatment] on a Tuesday and they’d put me all back in shape again, and put my shoulder back in, I felt great by Thursday. Thursday it was time to come back in. So, it kept me even. It kept the pain down. … With me comin’ in twice a week, I knew at least for four days out of the week I was going to be fine.” DC Patient 7

• “You expect the doctor to fix it, ‘cause that’s how we were brought up.” Non-DC Patient 6

• “Some of our people are just rather passive in their approach to their care.” GP 1

• “Everything is short-term. [My pain is] chronic. It’s there to stay because I try everything. … I’ve tried physio, chiro, … I even have steroid needles [at the] pain clinic, … and saw a sport therapist person [physiatrist] for a different type of needle [epidural injection]. … I take the Robaxacet if I’m in too much pain, or Advil. … They gave me Percocet. … [Even with regular] massage therapy [and] osteopathy, I go to bed and the day after and it’s still there. … I wish somebody could go inside and just fix [it]. It’s just a hard place to be fixed, it’s not made to be fixed – the back.” Non-DC Patient 2

Patients with a higher frequency of healthcare visits had a higher rate of refilling opioid prescriptions and were more likely to be receiving higher dose (≥ 50 mg MED) opioids over 12-month follow-up. Patients who relied on passive pain management strategies may have been more likely to visit their healthcare providers more often and obtain opioid prescriptions on a more frequent basis and at higher doses.

Index visit in more recent calendar year

(n = 210)

• Negative association with total number of opioid refills ^b (adjusted IRR = 0.82)

• Negative association with higher opioid dosage at:

3-month follow-up (adjusted OR = 0.73)

6-month follow-up (adjusted OR = 0.78)

Reduced opioid prescribing in recent years:

• “When I graduated [from medical school] in 1996, the overwhelming message to us was that we weren’t treating pain adequately; we weren’t treating it aggressively enough. And then of course, OxyContin was just the ‘new guy’ on the block and all that was wonderful and there was no ceiling dose, and you know the rest of that story.” GP 7

• “In the last four or five years [here at Langs], we’ve worked even harder at getting people off opioids.” GP 3

• “The goal is that opioids are not used for chronic non-cancer pain. I think over the last five [or] 10 years we’ve seen [a] reduction in use, and a lot of patients have been titrated down in their doses and are using more appropriate [levels of opioid] medications now.” GP 8

• “Having followed the sort of structure that we normally do here now in the last five years [with opioid prescribing], there’s much fewer people on [high doses].” GP 3

Patients whose index visit date was in a more recent calendar year had a lower rate of refilling opioid prescriptions and were less likely to be receiving higher dose (≥ 50 mg MED) opioids at 3- and 6-month follow-up. GPs at Langs have made a concerted effort in recent years to reduce opioid prescribing.

DC doctor of chiropractic,
GP general practitioner,
IRR incidence rate ratio,
MED morphine equivalents daily,
OR odds ratio

^a Healthcare visits constitute GP and chiropractic visits

^b Prescription opioid refills were measured in 30-day equivalents