• Shannon Satterwhite, Kelly R Knight, Christine Miaskowski, Jamie Suki Chang, Rachel Ceasar, Kara Zamora, and Margot Kushel.
• From Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, (SS, KRK, KZ); UCSF Medical Scientist Training Program, San Francisco (SS); School of Nursing, University of California San Francisco, San Francisco (CM); Public Health Program, Santa Clara University, Santa Clara, California (JSC); Department of Anthropology, University of California, Berkeley, Berkeley, (RC); San Francisco Veterans Affairs Medical Center, San Francisco, California, (KZ); UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California, (MK); Division of General Internal Medicine, University of California, San Francisco/San Francisco General Hospital, San Francisco, (MK).
• J Am Board Fam Med. 2019 May 1; 32 (3): 375-382.

PurposeThis study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care.MethodsWe qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology.ResultsClinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP.ConclusionsTime pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.© Copyright 2019 by the American Board of Family Medicine.

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