Table 2 Emergent Themes with Illustrative Quotes

Hospital contributes to the opioid epidemic

I think definitely inpatient medicine has a significant role. I think it starts in the emergency department. You know, it’s, God love em, cause I want to do that ER job, but you know folks come in and they are hurting. Once again, if they are truly hurting and you are treating them appropriately, I think it is okay. I think, however, if you are kind of coming in and maybe there is secondary gain and you are getting big doses of a strong narcotic, then you realize, well I don’t have to buy it off the street, I will just go the ER, which we see those patients that are going around (Hospitalist, #2).

Hospital plays a huge role. You see somebody for IV drug use and say, “How did you get started?” “Oh, I had surgery. I was prescribed oxycodone. I started to get a number of refills, next thing you know, I was buying heroin on the street.” And so I think pills are a starting point. So I think the hospital plays a huge role (Hospitalist, #11).

I think they [hospitals] can be. For instance, when we were the previous hospital, we had certain doctors. The patients would call in and ask what doctor was on because they knew certain doctors would give them things, other doctors wouldn’t. I could definitely see how it could be a factor (Nurse, # 5).

 • Concerns about CMS reimbursement policy tied to patient care experience and Joint Commission’s report

You have someone who... gastroparesis, and instead of following up with their primary care doctor, they just keep returning to the emergency room. For the sake of patient satisfaction scores, we give in and we just keep giving them pain medicine (Nurse #10)

 • Opioids are inappropriately administered in emergency department (ED)

I believe that ED is the place that is contributing to the opioid epidemic, because they treat them and street them, you know, they have to get them out. They do not meet the criteria for admission, maybe they are self-pay, they have no insurance at all, so what can we do to get them out the door? (Nurse, #7)

ED often gives patients very large doses of pain meds and we try to break the cycle, but often they end up having to go home on opioids. I think it is definitely part of the circle (Hospitalist, # 9)

I think the emergency department really freely gives a lot of narcotics, especially even IV narcotics (Nurse practitioner, #2)

 • Using opioids is a pragmatic tool to facilitate discharge and prevent re-admission

This is prescription for your 60 pills, don’t come back to the hospital within a month because we know that if a patient comes back within 30 days it’s like the re-admission and it’s, it’s for hospitalists, another hit. So we tend to give them a 30 day supply so that even if you run out the medication, it will be after 30 days. Even if you come back, it doesn’t affect hospital (Hospitalist, #3).

 • Overreliance on pre-populated pain care orders for surgical (orthopedic) patients

Like if some people who go through elective surgeries... I mean, there are batches of people who are probably higher risk for addiction that others and those batches who end up going through elective surgery, whether it is justified or not justified, they get... they will end up leaving with an opioid, like for sure (Hospitalist, #8)

And it is just I think the surgeon is like, here, you need to take this medicine when you’re done with surgery because it will help with the pain. Instead of educating them and talking to them (Nurse #6)

 • Using opioids for opioid-naïve patients, especially following a surgery

I know several personal friends that have you been in that situation. Who were given opioids, OxyContin or other stuff while they were in the hospital and then they would never be able to get off of that. (Nurse, #4)

I have seen it where people come in for pain control and I get that, but when they have like high doses of Dilaudid every two hours as needed and then they get sent home the next day, like going from IV to whatever. I mean, patients talk about having the withdrawal from it (Nurse, #8).

If some people who go through elective surgeries... I mean, there are batches of people who are probably higher risk for addiction than others and those patients who end up going through elective surgery, whether it is justified or not justified, they get... they will end up leaving with an opioid, like for sure. Then that is sort of the start of a cascade of their problems along the way (Hospitalist, #8).

 • Educating patients about negative consequences of using opioids long term and setting realistic pain expectations

A lot of the patients that I say that very same thing to say, “Oh, well my primary doctor just gives it to me, so I thought it was fine.” I say, “Well, they have side effects and your body gets used to those, and they’re also not the best medication for chronic pain.” I do, I feel like a lot of people just haven’t been educated. They don’t understand things that go on, the bad side effects that go along with taking narcotics (Nurse Practitioner, #2)

Some people are like they-- when we educate them, they understand. Okay, what’s the complication of these opioids? So then they prefer non-opioids. So they try to say can you give me some tramadol, ibuprofen, and that’s still despite that if they are in immense pain and then during the hospital course, it’s like how effectively we’ve been able to treat the pain. And they will be willing to do anything to get back to their normal life. So when we tell them with these opioids, you can have these side effects, and they will be oh, no. I don’t want opioids. I will just take this (Physician #7).

Patient education is essential. On the risks of continued dependence that can lead to addiction, that can lead to such deleterious effects that can be deadly (Nurse #7)

 • Educating medical staff about appropriate opioid prescribing practices, particularly for patients with complex chronic conditions (chronic pain; opioid use disorder);

I would start from med school. I would first start from teaching moralities to all the med students because they are going to be the coming physicians. And then educate nursing students too because they will be like frontline workers administering opioids. And then at the same time also, educating the medical field. Everybody has to understand what opioid tolerance is (Hospitalist, #7)

Put in education both for public and providers to be able to say, this is not okay to be able to prescribe quantities or be on medicines indefinitely and so forth, that there is sort of an upper limit or you have to jump through higher and higher levels of thresholds to be able to, like there are drugs that I don’t prescribe as a doctor that are available to a cardiologist, because they have got some extra training and we want to limit it to a certain.... I don’t prescribe any chemotherapy. We limit that to the oncologists. They have the additional training (Physician #4)

• Having a hospital leadership

I think you have to have interest from the frontline technicians and you would definitely have to have support and alignment from leadership to make it happen (Hospitalist, #12)

I think just putting things in the limelight and giving it attention, may change it. Narcotic stewardship, has never had the limelight. No one’s really cared. so I think understanding that it’s a problem and giving it resources and giving it the limelight will help (Hospitalist, #11)

I think, you know, having some leadership into, hey, this is a problem to work on, and I don’t think it quite exists in the political structure of local, state, national (Hospitalist, #5)