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Pain Management Nursing 22 (2021) 312e318

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Pain Management Nursing

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Research Article

Assessing Practice Patterns and Influential Factors for Nurse Practitioners Who Manage Chronic Pain

Jacqueline Nikpour, BSN, RN , Marion Broome, PhD, RN, Susan Silva, PhD Duke University School of Nursing, Durham, NC

a r t i c l e i n f o

Article history: Received 13 July 2020 Received in revised form 11 December 2020 Accepted 4 January 2021

This study was funded by the Duke University Sch Pilot Study Fund. Additioanlly, the primary author is su Johnson Foundation Future of Nursing Scholars progr Address correspondence to Jacqueline Nikpour, BSN

of Nursing, Durham, NC. E-mail address: jacqueline.nikpour@duke.edu (J. N

https://doi.org/10.1016/j.pmn.2021.01.001 1524-9042/© 2021 American Society for Pain Manage

a b s t r a c t

Introduction: Challenges exist in caring for chronic pain patients, such as preventing opioid-related adverse events, a lack of available non-pharmacologic alternatives, and limitations in prescriptive au- thority. Nurse practitioners are well-suited to manage chronic pain due to their holistic approach to care and growing numbers in primary care. Yet little is known about the chronic pain care given by NPs. As such, the purpose of this study was to understand the experiences of NPs who manage chronic pain, and to examine how these experiences impact NP prescribing patterns in chronic pain management. Methods: We developed the 31-item NP Chronic Pain Prescribing Practices survey. We collected data from N ¼ 128 NPs at the American Association of Nurse Practitioners (AANP) conference. Pearson chi- square and Fisher's exact tests were utilized for statistical analysis. Results: NPs reported high levels of agreement with nearly all the presented challenges. MSN-prepared NPs were more likely than DNP-prepared NPs to report difficulty in managing pain (x 2¼ 4.2, p¼ .04). There were no differences in prescription of chronic pain therapies between NPs of varying practice authority statuses. NPs in specialty care settings were more likely to utilize opioids (x 2 ¼ 13.6, p < .01), while primary care NPs were significantly more likely to use NSAIDs (x 2 ¼ 13.5, p < .01) and Tylenol (x 2 ¼ 3.9, p ¼ .05). Conclusions: Our findings demonstrate significant challenges NPs face in chronic pain management. More research is needed to better understand the complexities associated with chronic pain care given by NPs in order to effectively manage chronic pain while still preventing opioid-related adverse events. © 2021 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Chronic pain, defined by the National Academy of Medicine as persistent, unrelieved pain that lasts longer than 3 months, affects approximately 100 million Americans and is responsible for up to $635 billion in annual health care spending (Dieleman et al., 2016; Institute of Medicine, 2011a,b). This broad definition encompasses chronic pain-inducing conditions including chronic low-back pain, fibromyalgia, forms of arthritis, headache, chronic abdominal pain, and musculoskeletal degenerative changes; these conditions can have serious impacts on physical and mental functioning and significantly reduce quality of life (Institute of Medicine, 2011a,b). The prioritization of chronic pain reduction in the 1990s-2000s, along with drug makers labeling iatrogenic addiction as a very rare consequence, led to the proliferation of opioid therapy to decrease

ool of Nursing PhD Program pported by the Robert Wood am. , RN, Duke University School

ikpour).

ment Nursing. Published by Elsev

chronic pain and improve function (Institute of Medicine, 2011a; Merboth& Barnason, 2000; Zee, 2009). Howevermore recently, the onset of the opioid overdose crisis has caused health care providers to rethink and restrict their opioid provision in order to help pre- vent opioid-related adverse events (Han et al., 2015; Hulen et al., 2018; Kolodny et al., 2015; Paulozzi et al., 2012). Indeed, new guidelines for chronic pain management have included suggestions for providers to decrease their use of opioid medications and in- crease their usage of other nonopioid and nonpharmacologic strategies, such as muscle relaxants, physical therapy (PT), and topical treatments (Department of Veterans Affairs & Department of Defense, 2017; Dowell et al., 2016; Institute of Medicine, 2011a,b; Lin et al., 2020).

However, challenges exist in meeting these guidelines and providing effective care. Patients who benefit from opioid therapy may experience restrictions on their prescriptions by providers, thereby reducing their medication and leading to unrelenting pain (Carlson et al., 2016; Cicero et al., 2014; Henry et al., 2019; Mack, 2018; Muhuri et al., 2013; National Institute of Drug Abuse, 2019; St. Marie, 2016). Some providers may then expand prescribed

ier Inc. All rights reserved.

J. Nikpour et al. / Pain Management Nursing 22 (2021) 312e318 313

treatment options to include nonpharmacologic therapies, such as PT, cognitive behavioral therapy (CBT), or acupuncture. However, barriers to nonpharmacologic pain management therapies, such as insurance coverage and patient willingness, may also impede the use of these modalities (Becker et al., 2017; Chou et al., 2017; Penney et al., 2017). Furthermore, the limitations in effectiveness and access among nonopioid options, and a mismatch between provider fears of opioid-related adverse events and patient fears of worsening pain, can create challenges even for experienced pro- viders in caring for chronic pain patients (Penney et al., 2017).

Nurse practitioners (NPs) represent one provider group taking on new roles as the management of chronic pain shifts. NPs are expert clinicians who can improve access to high-quality pain management while simultaneously maintaining or improving outcomes (Bodenheimer & Bauer, 2016; Geurts-Laurant et al., 2004; Horrocks et al., 2002; Institute of Medicine, 2011b; Kaasalainen et al., 2015, 2016; Roblin et al., 2017). The shortage of physicians in primary caredwhere chronic pain is often trea- teddhas led to expanded roles for NPs in this setting; in fact, over 80% of new NP graduates work in an ambulatory care setting (American Association of Nurse Practitioners [AANP], 2019; Association of American Medical Colleges, 2019; Buerhaus et al., 2015, 2017). As new guidelines on the management of chronic pain have emphasized the importance of a team-based approach, NPs have a unique role to play due to their education, holistic training, and high satisfaction scores among patients (Barnes et al., 2018; Buerhaus et al., 2018; Institute of Medicine, 2011a,b). Despite the expansion of NP-led care, little is known about the chronic pain care given by these providers. The purpose of this study was to understand the challenges and experiences of NPs who manage chronic pain, and to assess how these experiences impact NP chronic pain prescribing patterns. The following questions guided the study: (1) What challenges do NPs perceive in providing chronic pain care?, (2) What is the role of NP state practice envi- ronment in chronic pain management?, and (3) What factors in- fluence the frequency with which NPs prescribe various types of pharmacologic and nonpharmacologic therapies for chronic pain?

Methods

Design and Setting

This study used a descriptive, exploratory approach. We collected survey data from NPs who manage chronic pain in an outpatient setting using a convenience sample at the AANP annual conference in June 2019. Specifically, a data collection booth approved by the AANP was set up in a high-traffic area of the conference. This study was approved by the Duke University Health System Institutional Review Board.

Data Collection

Twoweeks prior to the conference, the researchers distributed a flyer announcing the study and providing relevant details to broad

Table 1 Likert-Style Questions Asked of Participants

“When I first manage a patient's chronic pain, I find it challenging to get the patient’s “When I first see a patient with chronic pain, I use opioid medications as a first-line fo “When I prescribe opioids, I am concerned about patient misuse and/or overdose of th “When I care for a patient with chronic pain, I also use nonopioid medications as a pr “I find that my patients do not have access to nonpharmacologic forms of pain manag “My patients' insurance does not reimburse for nonpharmacologic forms of pain mana “My patients are not willing to use nonpharmacologic forms of pain management, suc “Within my state's practice authority regulations for nurse practitioners, I am able to p “The prescriptive authority laws for nurse practitioners in my state inhibit me from m

professional networks. At the conference, a recruitment poster was set up to attract attendees’ attention; as attendees stopped by the booth, they were asked if they were interested in participating in a study on chronic pain prescribing practices. Eligible participants were NPswhomanaged some form of chronic pain in adult patients at least twice aweek. All participants received an information sheet describing the purpose of the survey, risks and benefits of partici- pating, and investigator contact information Participants had the option to complete the survey on paper or electronically using REDCap electronic data tools hosted at Duke University. REDCap is a secure, web-based software tool to facilitate research data collec- tion. If the survey was completed electronically, the information sheet appeared on the first page. By filling out the survey, partici- pants indicated their consent to take part in the study.

Survey

The authors developed the 31-item NP Chronic Pain Prescribing Practices survey designed for NPs who manage chronic pain in an outpatient settings that collected information about the frequency with which NPs prescribed or referred for a broad array of chronic pain management strategies. Chronic pain was defined to partici- pants as persistent, unrelieved pain that lasts longer than three months, as defined by the National Academy of Medicine (Institute of Medicine, 2011a). We established face validity and content val- idity by reviewing our surveymeasures with NPsmanaging chronic pain, survey design experts, and chronic pain researchers. This survey was designed in conjunction with experts in chronic pain, NP practice and education, and survey methodology, and was approved for usage and appropriateness by the AANP. Literature on physicians’ experiences in chronic pain management was also consulted (Rasu & Knell, 2018; Roy et al., 2017; Becker et al., 2017).

The survey included 11 questions regarding how much the participant agreed or disagreed with a number of statements regarding their experiences when managing patients with chronic pain. These items asked the participants to rate how frequently they ran into challenges managing their patients’ chronic pain, as displayed in Table 1. The responses to these items were assessed using a five-point Likert scale: “Strongly Disagree,” “Disagree,” “Neither agree nor disagree,” “Agree,” and “Strongly Agree.”

Eleven items measured the self-reported frequency of pre- scription for a particular chronic pain therapy. The 11 chronic pain treatment strategies assessed included opioids, nonsteroidal anti- inflammatory drugs (NSAIDs), Tylenol, antidepressants, multi- modal medications (e.g., Tramadol and gabapentin), acupuncture, chiropractic care, PT, CBT, massage, and progressive muscle relax- ation. These items were assessed using a five-point Likert scale: “Never,” “Rarely,” “Some of the time,” “Most of the time,” and “All of the time.” Demographic questions included the NP's practice setting (primary care, pain management clinic, orthopedics, oncology, or palliative care), years of experience, gender, race, educational preparation (Master's, D.N.P., or Ph.D.) and state prac- tice environment as defined by AANP (full, reduced, or restricted practice).

pain under control.” rm of treatment.” e opioids.” imary adjunctive form of treatment.” ement, such as acupuncture, physical therapy, or chiropractic care.” gement, such as acupuncture, physical therapy, or chiropractic care.” h as acupuncture, physical therapy, or chiropractic care.” ractice to the full extent of my education and training.” ost effectively managing my patients' chronic pain”

J. Nikpour et al. / Pain Management Nursing 22 (2021) 312e318314

Data Analysis

Study data were collected and managed using REDCap; paper responses were inputted into REDCap for data archival and im- ported in SAS Version 9.4 for the purpose of data analysis. Descriptive statistics were used to detail the sample characteristic and Likert-scale responses to each question. Next, we dichotomized each Likert-scale response to indicate “yes” or “no” responses to each question. For frequency questions, we dichotomized re- sponses into “Some of the time or less” and “Most of the time or more.” For agreement questions, we dichotomized responses into “Neither agree nor disagree, disagree, or strongly disagree” and “Agree or strongly agree.”

Outcomes of interest were (1) finding it difficult to manage chronic pain, for reasons including challenges in NP regulation (e.g., ability to practice to the full extent of one's education and training) and (2) prescription or referral of each chronic pain strategy. We were also interested in whether these outcomes were related to NP-level factors, such as practice setting, education level, treatment of patients older than 65, and years of experience, as well as NP agreement or disagreement with each challenge. Pearson chi- square tests (alternatively, Fisher's Exact Test) were conducted to test the association between each NP-level factor and binary out- comes. Nondirectional statistical tests were performed, with the level of significance set at .05 for each test.

Results

Sample Characteristics

Table 2 summarizes the characteristics of 128 participants who responded to the survey. Of these, the majority identified as White (77.5%) and female (95.5%). About two-thirds of the participants were prepared at the M.S.N. level (62.5%) and worked in a primary care setting (62.5%). However, a significant proportion were pre- pared at the D.N.P. level (22.7%) and practiced at a pain clinic or orthopedic setting (12.5%). The majority reported 10 or more years of experience as an NP, and the median was 8 years (range 1-39).

Table 2 Sample Characteristics (N ¼ 128)

Characteristic n (%)

Race (N ¼ 111) Black/African American 15 (13.5%) White 86 (77.5%) Hispanic/Latino 6 (5.4%) Asian 4 (3.6%)

Gender (N ¼ 112) Male 5 (4.5%) Female 107 (95.5%)

Highest education level (N ¼ 114) M.S.N. 80 (70.2%) D.N.P. 29 (25.3%) Ph.D. 5 (4.4%)

Age groups cared for (N ¼ 128) 13-22 22 (17.2%) 22-64 102 (79.7%) 65þ 41 (32.0%)

Setting of care (N ¼ 128) Primary care 80 (62.5%) Pain clinic/orthopedics 16 (12.5%) Palliative care (noncancer) 6 (4.7%) Palliative care (cancer) 3 (2.3%) Other 27 (21.1%)

Years of experience (N ¼ 112) 0-5 years 40 (35.7%) 6-10 years 22 (19.6%) 10þ years 50 (44.6%)

Most participants (79.7%) cared for young to middle-aged adults, andmany NPs in primary care practices reported caring for children and adults across the lifespan. Five Ph.D.-prepared NPs were excluded from the sample characteristics and subsequent analyses, as this sample size was not large enough to detect meaningful educational level differences.

Role of NP State Practice Environment

A key research question of this study was to understand the influence of state practice environment on NP chronic pain pre- scribing practices. A total of 110 (85.9%) of the 128 NPs provided practice authority information. Among the 110 NPs, 36 (32.7%) re- ported full, 47 (42.7%) reported reduced, and 27 (24.6%) reported restricted practice authority status. Furthermore, we found that 21 (19.1%) of participants reported a practice authority status in their state that was inconsistent with AANP's definition for that state (for example, reporting full practice in a state that AANP classifies as reduced practice). Of those 21 reporting inconsistent practice au- thority, eight (38.0%) reported having full practice yet practiced in either a reduced or restricted state, nine (43.0%) reporting having reduced practice while in a restricted state, and four (19.0%) re- ported having restricted practice while in a reduced state. No par- ticipants reported having reduced or restricted practice while in a full practice state. Table 3 displays the corrected numbers and percentages of participants with full, reduced, and restricted practice, as well as the numbers and percentages who reported practicing within each level.

Approximately two-thirds of the participants (n ¼ 84, 68.9%) reported either “Agree” or “Strongly agree” in response to the statement “Within my state's practice authority regulations for nurse practitioners, I am able to practice to the full extent of my education and training.” NPs with full practice authority weremore likely to report being able to practice to their full extent than NPs without full practice (c2 ¼ 8.6, df ¼ 1, p < .01).

Less than 20% of NPs reported “Agree” or “Strongly agree” in response to the statement “The prescriptive authority laws for NPs in my state inhibit me frommost effectively managing my patients' chronic pain” (n¼ 24,19.7%). Yet 2� 2 chi-square analyses revealed that NPs with full practice authority were less likely to report being inhibited by prescriptive authority laws than NPs without full practice authority, and the difference approached significance (c2 ¼ 3.5, df ¼ 1, p ¼ .06). There was no significant relationship between practice authority status and response to the question “New regulations on opioid prescribing have inhibited my ability to effectively manage my patients’ chronic pain,” though the rela- tionship also approached significance (c2 ¼ 3.3, df ¼ 1, p ¼ .07).

Perceived Challenges in NPs’ Chronic Pain Practice

Table 4 displays responses related to questions regarding influential factors on howNPsmanage chronic pain. Approximately one-third (31.5%) of NPs reported finding it difficult most or all of the time to manage chronic pain. Two-thirds (66.7%) reported be- ing concernedmost or all of the time about the potential for misuse of opioid medications.

Chi-square analyses revealed that M.S.N.-prepared NPs were significantly likely to report finding it difficult to manage pain most or all of the time when compared to D.N.P.-prepared NPs (c2 ¼ 4.2, df ¼ 1, p ¼ .04). Additionally, education level was significantly associated with NPs reporting feeling prepared by their education and training to manage chronic pain (c2 ¼ 8.1, df ¼ 1, p ¼ .004). Despite this, feeling prepared by education and training to manage chronic pain was not associated with reported difficulty managing chronic pain (c2 ¼ 2.4, df ¼ 1, p > .05). Setting of care (primary care

Table 3 State Practice Environment (Reported by Participants and Corrected to Fit AANP Definitions; N ¼ 110

Had Full Practice Authority (N ¼ 28) Had Reduced Practice Authority (N ¼ 48) Had Restricted Practice (N ¼ 34)

Reported full practice (N ¼ 36) 28 (100.0%) 6 (12.5%) 2 (5.9%) Reported reduced practice (N ¼ 47) 0 (0.0%) 38 (79.2%) 9 (26.5%) Reported restricted practice (N ¼ 27) 0 (0.0%) 4 (8.3%) 23 (67.7%)

Number (n) and percent (%) reported are for each column. AANP ¼ American Association of Nurse Practitioners.

J. Nikpour et al. / Pain Management Nursing 22 (2021) 312e318 315

versus specialty care, which included all of the included non- primary care settings), years of experience (0-5 years, 5-10 years, and more than 10 years), treating patients ages 65 and up, and finding chronic pain difficult to manage were not significantly associated with any of the reported chronic pain challenges.

A majority of NPs reported their patients having low access to nonpharmacologic methods of pain care (n ¼ 71, 56.8%), as well as low insurance coverage (n ¼ 85, 68.0%) most or all of the time. Indeed, greater access was associated with having insurance coverage (c2 ¼ 41.9, df¼ 1, p < .01). Additionally, a large majority of NPs reported that patients were unwilling to use non- pharmacologic strategies most or all of the time (n ¼ 88, 71.5%). Patient unwillingness to try nonpharmacologic strategies was significantly associated with NPs reporting refering patients some of the time or less to acupuncture (Fisher's exact, p ¼ .03), chiro- practic care (Fisher's Exact, p < .01), andmassage (c2 ¼ 4.9, p¼ .03). However, patient unwillingness was not associatedwith referrals to PT, CBT, or progressive muscle relaxation. Despite high rates of both low access to nonpharmacologic care and patient unwillingness to use these strategies, patient unwillingness was not associated with access to nonpharmacologic care or insurance reimbursement for nonpharmacologic care.

NP Use of Pain Management Strategies

The frequency with which participants reported using a certain strategy most or all of the time varied widely across the various pain therapies. NSAIDs (n ¼ 89, 71.2%) and Tylenol (n ¼ 75, 65.8%) were the most frequently used pharmacologic strategies, while PT (n ¼ 91, 72.8%) was the most frequently used nonpharmacologic strategy. Opioids were the least frequently used pharmacologic strategy (n ¼ 25, 20.3%), while more participants reported frequently using antidepressants (n ¼ 48, 38.4%) and multimodal medications such as Tramadol (n ¼ 31, 24.8%). For

Table 4 Challenges in Chronic Pain Management (N ¼ 128)

Question

“When I first manage a patient's chronic pain, I find it challenging to get the patient's control.”

“When I first see a patient with chronic pain, I use opioid medications as a first-line fo treatment.”

“When I prescribe opioids, I am concerned about patient misuse and/or overdose of th “When I care for a patient with chronic pain, I also use nonopioid medications (e.g., N

primary adjunctive form of treatment.” “I find that my patients do not have access to nonpharmacologic forms of pain managem

acupuncture, physical therapy, or chiropractic care.” “My patients' insurance does not reimburse for nonpharmacologic forms of pain manag

as acupuncture, physical therapy, or chiropractic care.” “My patients are not willing to use nonpharmacologic forms of pain management, suc

acupuncture, physical therapy, or chiropractic care.”

nonpharmacologic strategies, CBT was used most or all of the time by 28 participants (22.4%), massage by 21 participants (16.9%), and progressive muscle relaxation by 19 participants (15.8%). Acupuncture (n ¼ 10, 8.0%) and chiropractic care (n ¼ 9, 7.3%) were the least frequently used strategies.

NPs in specialty care settings were significantly more likely to use opioids (p < .01), while primary care NPs were significantly more likely to use NSAIDs (c2 ¼ 13.5, p < .01) and Tylenol (c2 ¼ 3.9, p ¼ .05). Years of experience as an NP was associated with NSAID prescription; NPs with more experience prescribed significantly fewer NSAIDs than those with less experience (p ¼ .03). Years of experience were not associated with prescription of any other pain medication. Education level, treatment of patients 65 and older, and practice authority were also not significantly associated with any pain medication prescription.

Table 5 outlines the NP-level factors significantly associated with pain medication prescriptions. No NP-level factors were associated with prescription of antidepressants, multimodal med- ications, or any nonpharmacologic strategy, except for the associ- ation between treatment of patients 65 and older and use of acupuncture. Fisher's Exact tests revealed that NPs who treated patients younger than 65 only were significantly more likely to use acupuncture than NPs who treated patients 65 and older (p ¼ .03).

Discussion

Our findings demonstrate significant challenges that NPs face in chronic pain management, some of which may be experienced by other providers and some of which may be unique to NPs. From a regulatory standpoint, NPs with limitations in their state practice environment may not be able to practice to the full extent of their education and training and may be inhibited from prescribing pain medications when clinically indicated. Indeed, we found no dif- ferences in opioid prescribing, or use of opioids as first-line

N “Most of the Time” or “Always” Responses n (%)

pain under 124 39 (31.5%)

rm of 125 3 (2.4%)

e opioids.” 123 82 (66.7%) SAIDs) as a 125 115 (92.0%)

ent, such as 125 71 (56.8%)

ement, such 125 85 (68.0%)

h as 123 88 (71.5%)

Table 5 NP-Level Factors Associations With Pain Medication Prescriptions

Opioids Prescribe Some of the Time or less Prescribe Most of the Time or More c2 p

Setting Primary care 60 (69.0%) 7 (28.0%) 13.6 < .01 Specialty care 27 (31.0%) 18 (72.0%)

Education M.S.N. 60 (71.4%) 18 (78.3%) 0.4 .51 D.N.P. 24 (28.6%) 5 (21.7%)

Patient age groups No 65þ patients 64 (65.3%) 18 (72.0%) 0.4 .53 65þ patients 24 (34.7%) 7 (28.0%)

Years of experience 0-5 years 31 (36.1%) 9 (37.5%) 0.7 .54 6-10 years 16 (18.6%) 6 (25.0%) 11þ years 39 (45.4%) 9 (37.5%)

NSAIDs

Setting Primary care 12 (34.3%) 56 (70.9%) 13.5 < .01 Specialty care 23 (65.7%) 23 (29.1%)

Education M.S.N. 25 (78.1%) 55 (71.4%) 0.5 .47 D.N.P. 7 (21.9%) 22 (28.6%)

Patient age groups No 65þ patients 26 (72.2%) 58 (65.2%) 0.6 .45 65þ patients 10 (27.8%) 31 (34.8%)

Years of experience 0-5 years 8 (22.9%) 32 (41.6%) 6.9 .03 6-10 years 5 (14.3%) 17 (22.1%) 11þ years 22 (62.9%) 28 (36.4%)

Tylenol

Setting Primary care 18 (47.4%) 50 (66.7%) 3.9 .05 Specialty care 20 (52.6%) 25 (33.3%)

Education M.S.N. 28 (80.0%) 51 (69.9%) 1.2 .27 D.N.P. 7 (20.0%) 22 (30.1%)

Patient age groups No 65þ patients 24 (61.5%) 49 (65.3%) 0.2 .69 65þ patients 15 (38.5%) 26 (34.7%)

Years of experience 0-5 years 9 (24.3%) 31 (41.9%) 3.8 .17 6-10 years 7 (18.9%) 14 (18.9%) 11þ years 21 (56.8%) 29 (39.2%)

NP ¼ nurse practitioner; NSAID ¼ nonsteroidal anti-inflammatory drug. Bold indicates significant p-value <.05.

J. Nikpour et al. / Pain Management Nursing 22 (2021) 312e318316

treatment, between full, reduced, and restricted state practice en- vironments. This is consistent with other studies (Ladd et al., 2019), yet contradicts a common concern that, in independent practice environments, NPs may drive up opioid prescriptions (Florida Medical Association, 2014; Myers & Ailman, 2018; VanBeuge & Walker, 2014).

It is also worth noting that many NPs may not be aware of their state practice environment. This could be due to NPs not viewing themselves as being limited by state-level scope of practice. For example, an NP who works in a legally required supervision rela- tionship with a physician may not see their practice authority as being reduced or restricted, particularly if they have full diagnosing and prescribing capabilities and a mutual respect with the physi- cian (Poghosyan & Liu, 2016). Furthermore, previous literature suggests that NPs may be less likely to use opioids than other providers (Muench et al., 2019), in which case such regulation may not affect NP practice patterns. However, given the finding of a significant relationship between a limited state practice environ- ment and being inhibited from effectivelymanaging chronic pain, it is likely that some NPs may feel unable to properly care for chronic pain patients. Future research should investigate if differences exist between NPs who do and do not feel limited by their reduced or restricted state practice environment. Additionally, regional NP

professional organizations should seek to provide policy trainings and resources related to state practice, and to advocate for legis- lation that would allow NPs to care for patients to the full extent of their education and training.

Despite high levels of agreement among NPs regarding chal- lenges they faced in treating chronic pain, such as access to non- pharmacologic care, patient willingness to try nonpharmacologic strategies of pain management, and an overarching concern about opioidmisuse, few factors were associatedwith whether NPs found chronic pain difficult to manage. Setting of care, treatment of pa- tients aged 65 and older, level of concernwith opioid misuse, and a lack of nonpharmacologic care access were all not associated with finding chronic pain a challenge to manage. Our finding of signifi- cant opioid prescribing differences between NPs in primary versus specialty care settingsmaybe attributable to the increase inpatients being referred to specialty care for chronic pain treatment (Institute of Medicine, 2011a). A primary care provider may see a new patient with a complex chronic pain issue and choose to refer them to a pain management specialty clinic for longer-term opioid therapy.

Notably, D.N.P.-prepared NPs were less likely than M.S.N.- prepared NPs to report finding chronic pain a challenge. In addi- tion, education level was associated with feeling prepared by one's education and training. The American Association of Colleges in

J. Nikpour et al. / Pain Management Nursing 22 (2021) 312e318 317

Nursing (2018) identified adoption of curricula related to chronic pain as a key goal for all schools of nursing; such curricula may be increasingly incorporated at the doctorate level of advanced prac- tice nursing education. Similarly, we found that more experienced NPs prescribed fewer NSAIDs and Tylenol and more opioid medi- cations, potentially suggesting that increased education and expe- rience better prepare NPs to safelymanage chronic painwith opioid medications. However, the specific reasons for these differences remain unknown, and further investigation is needed. Additionally, as academic nursing leaders seek to expand chronic pain education in the midst of the opioid crisis, an understanding of the key components of a successful pain management curriculum is crucial (Compton & Blacher, 2020).

A strong majority of NPs reported finding patients unwilling to use nonpharmacologic methods of pain care, a finding consistent with previous studies (Becker et al., 2017). However, patient un- willingness to use nonpharmacologic strategieswas only associated with lower use of acupuncture, chiropractic care, and massage, which are typically services not covered by insurance. PT, CBT, and progressive muscle relaxation use were not associated with patient unwillingness. This potentially suggests that such strategies may already be incorporated into many organizations’ practice guide- lines. For example, many pain practices require a patient-provider “contract” specifically stating that patients must attempt non- opioid strategies for their chronic pain. As PT and CBT may have greater insurance coverage than strategies such as acupuncture, and progressive muscle relaxation is a free technique that can be done at home, these methods may be more readily available to patients.

Lastly, in terms of actual use of chronic pain treatments, NSAIDs, Tylenol, and PT were the most commonly used strategies. Acupuncture and chiropractic care were the least commonly used, likely due to a lack of patient access and insurance reimbursement. With a few exceptions, however, most factorsdsetting, education, years of experience, and treatment of patients 65 and olderdwere not associated with use of any pain management strategy. This finding could suggest that NP factors rarely influence prescriptions, and future studies should investigate in detail what fac- torsdincluding patient-level and system-leveldinfluence use of various chronic pain management strategies.

Our study had notable strengths and limitations. To our knowledge, this is the first survey of NPs across the country to identify the challenges, experiences, and prescribing practices associated with chronic pain management. Our findings may be useful as clinicians, researchers, educators, and policymakers work to effectively manage chronic pain while preventing opioid-related adverse events. While we included a variety of pharmacologic and nonpharmacologic chronic pain strategies as identified by a team of NPs and chronic pain experts, our survey does not capture every possible type of chronic pain therapy. Less typical therapies, such as tai chi, yoga, and guided imagery may have important value in chronic pain management and should be assessed in future studies (Geisler et al., 2015). Furthermore, deeper understanding of the practice characteristics (e.g., hospital affiliation status) and patient characteristics (e.g., patient demographics) may be valuable to explain prescribing patterns. Lastly, future studies should examine how provider adherence to prescribing guidelines influences pre- scribing patterns.

Conclusion

NPs experience a variety of challenges inmanaging chronic pain, including regulatory barriers, difficulties pursuing non- pharmacologic methods of care, and concern about opioid-related adverse events. NPs in specialty care settings are more likely to

prescribe opioid medications, while NPs in primary care settings are more likely to use NSAIDs and Tylenol. D.N.P.-prepared NPsmay view chronic pain as less of a challenge than M.S.N.-prepared NPs, and may have been more prepared to manage chronic pain in their education and training. Practice authority, education level, years of NP experience, and treatment of patients aged 65 and older did not influence NP use of any chronic pain strategy. Furthermore, despite many reports of challenges in chronic pain, such issues were not associated with whether NPs reported chronic pain to be a chal- lenge. Future research is needed to understand the factors that make chronic pain difficult to manage, as well as what factors in- fluence use of specific pain management strategies.

Conflict of Interest

None.

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