Document Type
Dissertation
Date of Degree
4-8-2025
Primary Advisor
Kenneth Harwood PT, PhD, FAPTA
Keywords
Chronic Pain Management; Persons with Bleeding Disorders; Medical and Scientific Advisory Council; Mixed-Methods Study
Abstract
Background: Chronic pain affects the majority of individuals with bleeding disorders (PWBD), diminishing functional abilities, community participation, mental health, and autonomy while increasing opioid usage and healthcare expenses. Despite calls for integrated care models, evidence-based guidelines tailored to PWBD have historically been insufficient. In early 2020, the Medical and Scientific Advisory Council (MASAC) of the National Bleeding Disorders Foundation (NBDF) published the first evidence-based recommendations for chronic pain management, incorporating the 2016 Centers for Disease Control and Prevention (CDC) prescribing guidelines along with additional suggestions for healthcare providers (HCP). The extent of their implementation at U.S. Hemophilia Treatment Centers (HTC) remains unknown.
Study Objectives: This study examined the implementation of the MASAC recommendations for chronic pain management in PWBD at U.S. HTCs, identified barriers and facilitators, and compared adherence to the recommendations among (1) prescribing providers and nurses, (2) physical therapists, and (3) psychosocial personnel.
Method: This study employed an explanatory sequential mixed-methods design, integrating surveys and semi-structured interviews, and was guided by the Knowledge to Action (KTA) framework, the biopsychosocial model, and concepts of integrated care. The quantitative phase included confidential online surveys of 201 healthcare professionals (HCPs)- physicians, advanced practice providers, nurses, physical therapists, social workers, and psychologists- assessing their awareness, adaptation, and adoption of the MASAC recommendations. The qualitative phase utilized purposeful sampling from various HCP groups to explore individual, contextual, and external barriers to implementing the MASAC recommendations. Seventeen interviews were recorded via WebEx, and transcription along with thematic inductive analysis was conducted using NVivo. The qualitative results were mapped against the Tailored Implementation in Chronic Disease (TICD) framework to aid in the development of mitigation strategies.
Results: The surveys were completed by 201 participants, yielding an 18.19% response rate. Adherence to the MASAC recommendations varied. Screening and risk assessment showed the highest compliance, with 95.60% screening for acute and chronic pain, 78.98% for anxiety and depression in PWBD with pain, and 86.49% assessing opioid use disorder risks. In opioid initiation and continuation, adherence was higher for prescribing non-opioid medication first (90.67%) and evaluating opioid risks (96.67%), but lower for multimodal treatment plans (43.87%), general education on non- pharmacological options (13.16%), and goal setting (30.00%). In opioid selection and dosage, 82.74% preferred immediate-release opioids, and 90.00% limited the prescription duration; however, reassessment rates were low (59.29%), and only 17.24% used morphine equivalent dosing. In opioid monitoring, 73.33% assessed treatment benefits, 76.67% reviewed Patient Drug Monitoring Program (PDMP) data, but only 46.67% conducted ongoing monitoring or urine drug testing. Additionally, only 44.78% of participants reported patient access to MAT, while 19.40% were unfamiliar with it. The interviews were completed by 17 HCPs, with six participants each from groups 1 and 2 and five participants from group 3. Across all domains, key facilitators of adherence included effective interdisciplinary collaboration, strong organizational commitment, telehealth, ongoing educational programs, and easier access to the MASAC recommendations. However, common barriers hindering implementation included a lack of awareness and knowledge, negative perceptions and stigma regarding opioid use, limited access to care, non-supportive work environments, inefficient organizational processes, HCP licensure limitations, and HTC sustainability issues.
Conclusion: This study was the first to assess the implementation of MASAC recommendations for chronic pain management in PWBD within U.S. HTCs. While screening for pain, anxiety, depression, and opioid risks has been widely adopted, adherence to resource-intensive recommendations has been lower due to gaps in provider knowledge, access barriers, and organizational constraints. Balancing evidence-based care with patient-centered approaches remains crucial, while unintended restrictive opioid policies create additional challenges. Strengthening HCP education, clarifying allied health roles, and advocating for sustainable funding can support implementation initiatives. By addressing barriers and leveraging facilitators, HTCs can advance a more integrated, patient-centered model, improving outcomes and quality of life for PWBD.
Recommended Citation
Volland, Lena M., "Implementation of the MASAC Recommendations for the Practical Application of the CDC Opioid Prescription Guidelines for Chronic Pain Management in Persons with Bleeding Disorders (PWBD): A Mixed-Methods Study" (2025). Doctor of Philosophy in Translational Health Sciences Dissertations. Paper 39.
https://hsrc.himmelfarb.gwu.edu/smhs_crl_dissertations/39
Open Access
1
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©2025 by Lena M. Volland. All rights reserved.