Access to primary healthcare is a benchmark of Canadian healthcare performance [1,2,3]. For patients, access to an ongoing healthcare relationship with a family physician (FP) is associated with receiving better preventative care, more timely access to care, less discomfort and disability, and fewer hospital admissions and emergency department visits [1, 4,5,6,7,8,9]. People without access to a regular FP are more likely to be young, male, of lower socioeconomic status, or recent immigrants, than those with access . While some qualitative studies describe challenges linking patients who request opioids prescriptions to a FP , little is known about the association between requiring opioids and acceptance as a new patient into family practice.
Opioid management by family physicians
The current opioid crisis has grown in Canada over the past several decades, and there were nearly 4000 opioid related deaths in 2017 [11,12,13]. The majority of opioid prescriptions for non-cancer chronic pain are issued and managed by FPs . When appropriately supported and trained, primary care teams are better able to provide care with improved outcomes for patients compared to more specialized opioid treatment programs . However, although Canadian FPs have three main treatment options (one of them being buprenorphine-naloxone, an opioid replacement option) [16, 17], many FPs in Canada express concerns regarding their ability to provide this service [18,19,20]. These concerns include uncertainty of their competence, knowledge, skills, and difficulty in accessing specialist support [18,19,20]. For their patients, FPs worry about potential dependence development and serious adverse events, including death [20,21,22]. FPs also fear being deceived by patients seeking opioids, potential opioid diversion for illicit use, and office disruption [18, 22,23,24].
There is also evidence of bias against unattached patients (i.e., patients who do not have a regular primary care provider) requiring opioids in Canada. A study in Ontario examined the effectiveness of the Health Care Connect (HHC) program, a program designed to help patients find a FP. Some physicians explicitly stated they would not accept certain kinds of patients, and HHC staff identified patients requiring opioids as the most difficult patients to link to providers .
Recent media accounts highlight challenges for patients who require opioid prescriptions from their FPs [25, 26]. Bergman et al. found patients taking opioids feel stigma, isolation, stress, and depression due to the perceived need to establish credibility with their FP . Patients requiring opioids describe experiences where their FPs avoid addressing opioid care concerns in favour of more familiar acute medical concerns .
Access to family physicians
The proportion of Nova Scotians over age 12 who do not have a regular FP grew from 6.4% in 2010 to 10.6% in 2014 . FPs may choose whom they accept into their practices based on their training and scope of practice, generating concern that complex patients may be refused [9, 28,29,30,31]. Acceptance and refusal of new patients must be made in good faith, and clinical competence and scope of practice arguments should not be used to unfairly refuse patients with complex care concerns [30,31,32]. Furthermore, the Canadian Medical Association asserts FPs are expected to take on new patients in a fair and equitable manner . However, there are reports of physicians appearing to accept new patients based on their social history (i.e., patients they believe to be easier to manage) . Additionally, ‘meet and greet’ appointments where FPs and prospective patients meet to establish a fit between patient needs and provider scope of practice are common in Canada, including in Nova Scotia . These meet and greet appointments often result in some patients not being accepted into practice .
While the challenges physicians face in caring for people who require opioids are well known, less is known about how opioid use affects access to care. Similarly, little is known about characteristics of FPs and practices that will, or will not, accept patients who require opioids, which may have broader implications for performance and innovation in family practice.
To our knowledge, this is the first population-based study to examine the reported willingness to accept new patients who require opioids and associated provider and practice characteristics. This work is part of a larger study, the Models and Access Atlas of Primary Care in Nova Scotia (MAAP-NS), designed to create a population database of all FPs and nurse practitioners in Nova Scotia (NS). The atlas includes details on models of care, scope of practice, provider and practice characteristics, and accessibility to services.
Main study objectives
To determine the proportion of family physicians in NS willing to accept patients who require opioids.
To identify family physician and practice characteristics associated with willingness to accept, or not, patients who require opioids.
To examine whether characteristics predicting willingness to accept opioid-requiring patients are also related to new patient acceptance in general.