change management at general motors case study

• Corpus ID: 197863540

Resistance to Change in Organizations : A Case of General Motors and Nokia

• Sundus Khan , S. S. Raza , Shaju George
• Published 2017
• Business, Environmental Science

5 Citations

Influence of human disposition on change implementation communication : a study selected food and beverage companies in nigeria, role of psychological factors in employee well-being and employee performance: an empirical evidence from pakistan, study on the longevity mechanism of a company through analogy of human aging, efek penolakan perubahan terhadap niat menggunakan aplikasi apotek k24klik, “generation z reaching adulthood in society.” perceptions of generation z's impact on the construction of societal challenges and organisational changes in western europe: a qualitative exploration, 40 references, harnessing resistance: using the theory of constraints to assist change management, strengthening organizational change processes, challenging “resistance to change”, kurt lewin and the planned approach to change: a re-appraisal, organisational change management: a critical review, managing people and organizations in changing contexts, resistance: a constructive tool for change, organizational change, stability and change as simultaneous experiences in organizational life, organizational behavior: science, the real world, and you, related papers.

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Organizational Change: Case Study of GM (General Motor)

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General Motors: Change Management Case Solution & Answer

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In 2009, with the rise of Japanese automakers, General Motors declared bankruptcy after couple of years of having decreased sales and market share in North America. General Motor considered for a large scale of organizational change, as it should bring the changes in the organization in order to avoid the complete closure of the company. Prior to its bankruptcy, General Motors, appointed Fritz Henderson to serve the company as its CEO.

After boarding, Henderson, in order to avoid bankruptcy, he communicated with all of his stakeholders and employees about the change that should be introduced in the company to avoid bankruptcy. Henderson was under pressure because he had limited time to communicate his proposed changes to the employees because General Motor was near to its bankruptcy.

The American government kept the company under scrutiny, which kept Henderson under pressure as they expect a quick turnaround.

This thesis serves the answer how Henderson, before and after filing its bankruptcy, communicated the organizational change to the employees of General Motors through his internal communication effort. Through the perspective of change management, the communication efforts will be analyzed since Henderson had to develop the strategy that would drag the General Motors out of the crisis.

Since sales of the General Motors kept on declining after the emergence of Toyota and other Japanese manufacturers, and when financial crisis began, General Motors began to flounder. Toyota surpassed the General Motors in term of sale as world largest automaker in 2007. American and Canadian government provided the loan to General Motors to support the company in its crisis period.

Problem Statement

General Motors achieved tremendous success in the time of Alfred Salon. However, with the emergence of Japan automakers the company operations started to get disturbed, and General Motors’ profit margin started to shrink because Toyota captured a large market share in America.

External forces such as the emergence of Japanesecars, which decreased the market share of General Motors and other external force i.e. financial crisis, which affected the company’scash flow. In addition, internal forces such as high wages of employees as compared to other company led General motors to change its organizational processes.

 General Motors adopted Cost Cutting change where company reduced the wages to a certain level and Cultural Change was introduced to remove the hierarchy of management in order to speed up the day to day decision making.

Case Analysis

Initially from 1940s to 1980s, the company was operating with its four-core brand i.e. “Chevrolet”, “Pontiac”, “Buick”, and “Cadillac” and it maintained leadership over Ford and Chrysler consistently. However, due to the emergence of the Japanese automakers such as “Toyota”, which to a great extentdisturbed the profitability of General Motors, its forced General Motors to cut prices to maintain market share. This all resulted in organizational change.

There are four methods used for applying the change management within the organization; the four methods that are used are as follows,

• Levin’s model
• Kotter’s model
• Action research
• Organizational development

Change Management Process

Following are the forces that effect the General Motors while it implements the change management process.

External Forces

External forces include a highly automobile market. General Motors have the largest market in North America that is followed by the China. In 2008, Toyota made sales of $2.2 billions, which is close to the sales figure of General Motors, which made a sale of $2.9 billions. The market share of General Motors eroding continuously from 30% in 1999 to 22% in 2008 while General Motors remained the leading automobile manufacturer in America.

During 2000, the main production line of General Motors i.e. SUV and trucks, were affected when the global oil prices were pushed upwards, declining the sales of General Motors. Whereas, Toyota manufactured vehicles with more fuel-efficient technology.

Another major problem for the General Motors was ongoing financial crisis, which hadseverelyaffected General Motors’cash flow. By analyzing the situation, General Motors predicted that they would declare bankruptcy without the help of government aid or merger by the end of 2009.

Internal Forces

The biggest internal issue of General Motors was that General Motors was under the agreement with the trade union. Under the agreement, General Motors had to pay the entire worker the rate of $74 per hour as compared to Toyota, which paid $44 per hour. Whereas, General Motors had to run the manufacturing plant with at least 80% capacity of workforce whether it required or not. Thus General Motors was hampered when it came to cost-cutting measures.

The huge salaries paid to employees of the General Motors are one of the factors, which played a key role in the bankruptcy of the company…………………..

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Introduction

Implementing organizational change, recommendations for future organizational changes.

We all know that for one to thrive in the business world, change is paramount. Management has to develop new initiatives and catch up with the rapid technological and socio-economic advancements in order to stay ahead of the competition.

There are various theories and models recommended to corporate managers on how they can handle organizational change. However, in implementing organizational change in practice, especially where a large-scale organization is involved, can be challenging and complex and if not handled properly, it can be disastrous to the whole organization.

This paper discusses practical implementation of organizational change in a large-scale business. General Motors Corporation will be analyzed by looking into the various changes it has undergone through and problems resolved as well as recommendations on new changes that could be carried out to enable it retain its competitive advantage in the industry. The GM adopted the overall structure organizational change model in implementing its changes.

General Motors Corporation Organizational Changes

The GM recently changed its traditional organizational model from being decentralized to a more centralized and unified one. The traditional model was characterized by a hierarchical structure of management and leadership. Jobs are arranged into independent functional departments. “GM was divided into different independent automakers…each independent automaker was operated differently and competing with each other,” (Kenly85 2009).

The new model, however, does not have independent departments but rather consists of a team and individual employees all focusing on a common organizational goal. This model was adopted to respond to problems such as harmonization of workers. The staff required to develop a central set of skills by learning from each other’s designs of work as well as improve communication amongst themselves so as to work as a team rather than as autonomous individuals.

The management revised its management to respond to the declined demand for medium and high-priced cars which had been created by the depression. A new management staff was put in place at the five-car division with the operational committee being dissolved and the executive committee eliminated.

“In order to cut costs, the divisions had to share frames, chassis and other parts. This meant that productions and designing cars would entail cooperation and coordination among the four divisions,” (Spector, 2010). This resulted into reduced operation costs and streamlined management system.

Further, it was deemed necessary to reorganize the general office. The office was now empowered to oversee the operational and overall financial decisions. The top executive basically made all the major financial decisions in the organization. This is because financial decisions are very important to the future success of an entity through prospective policies and procedures.

This made it a requirement to include general executives with special knowledge in prospective policies in decision making concerning financial matters. Operational policies were therefore left to the administrative committee.

Later, the financial policy committee was created which was meant to authorize all financial decision matters. An operating committee was also formed and was mandated to oversee strategic planning and policies. The division managers no longer had legal authority. Its only role was to recommend policies for the operating policy committee to adopt. The president and chairman formed the CEO and had overall authority over the financial committee.

Division managers were later included in administrative committees but this did not relegate their power of having overall control over policy. Policy groups made up of general office men now formulated policies. The proposed policies were then handed over to the administration committee which were required to debate and ratify or modify the policies. The divisions only had power to revise or amend such policies.

Support systems were also formed to ensure organizational changes were effectively implemented. An Automotive Strategy Board together with a management committee were formed to keep the CEO updated on the happenings of the corporation. There were also monthly meetings whose attendance was compulsory globally.

The meetings were used by operation heads to monitor the progress of the organization so as to inform the CEO. It also ensured that the organization staff worked as a team towards the achievement of the organizational goal.

A Culture Transformation Team as well as an Operating Model Team were established. The Automotive Product Board and also Automotive Strategy Board were eliminated and replaced with one committee consisted of eight individuals. This was done to fasten the decision making process.

The committee reported to the CEO twice a week when they met to discuss product matters. The operation team, however, was composed of ten executives representing the various divisions in the globe. This increased bureaucracy even more and the decision-making was made even slower.

The government has also contributed to the GM change. The U.S. government eliminated certain vehicle brands such as Pontiac and Hummer and slashed headcount. It also reduced its debts and the obligated benefits and shuttered dealerships. The government now has a 60% shareholding in the company; therefore, we can say that the ownership and control of the organization has shifted to the government.

However, most of the government intervention in GM has been helpful to its growth as well as its changes. For example the New Deal Legislation in the past which was aimed at avoiding future depressions through relief, recovery and reform. It has somehow helped and the GM to recover from its bankruptcy through government funding and subsidies. The GM had to implement its organizational changes according to the Chapter 11 of the Bankruptcy act.

The government also funded the GM to the tune of $14 billion through the Emergency Economic Stabilization Act. The Troubled Asset relief Program (TARP) supported the funding. It was aimed at saving the free-market system that GM represented.

Effects of the organizational changes

There were both positive and negative effects of the transition. Positively, the organizational change was able to muster teamwork amongst its workers. Streamlining of production and general operations cut down operational costs. By cutting costs, the organization was able to operate efficiently and maintain its solvency.

Further, a good communication system was established from the teamwork. Good communication increases the motivation of workers through recognition and the ability to voice their grievances. It also helps in reducing resistance to change by engaging employees in the change program.

This ensures that everyone knows what is going to be achieved and they are all willing to contribute towards the same. It will also give management an opportunity to clarify on the need for change and the intended results to ease out employee’s uncertainty and fear of the unknown on the outcomes of the change process such as retrenchments and layoffs.

Much as these changes were meant to add to the development of the corporation, this was not the case. Instead, this transition affected the two most important stakeholders i.e. the customers and the surrounding community. Due to the discontinuation with some of the brands, it became hard for customers of some models to service or upgrade their vehicles. Consequently, GM did not only lose its customer base but also its reputation was affected.

During the transition, however, GM had to close some of its factories aimed at streamlining production. Consequently, other entities “such as restaurants, gas stations, the real-estate market and the grocery stores suffered financially,” (Kenly852009). Therefore, the community’s financial well-being was disturbed.

Of course, this had an impact on the money circulation chain in the market creating unemployment, downsizing in some public departments and generally lower standards of living. “Due to downsizing, people tend to move out of the town resulting to start of the cycle all over again,” (Dawson, 2003).

The transformation of management system also had great effects on the workforce. This is because they were required to learn a new set of skills and also learn central software being used in all the organizations’ offices in the globe. This in turn impaired the communication system. Training and development of staff also became a major problem. This occurred because with the traditional model, the independent departments existing were using different softwares each.

The organization needs to adopt a new organizational culture which, according to Fitz Henderson, should consist of accountability, focus more on the customer and the product as the main subjects and also one that was ready to take risks. Also, it should be faster in decision making process.

In the past, the organization was restructured where the Human Resource was given the responsibility of supporting culture change rather than drive it. Leaders came up with a new performance management standard and conducted an informative education system to communicate the new organizational culture and it’s values to all the workers.

Those cultures were aimed at incorporating a culture into the organization’s highly bureaucratic system to ensure that its independent departments, regions as well as brands became self-governing and competitive within the organization.

In order to retain its competitive advantage in the industry therefore, GM requires to make new changes to its organizational structure. For instance, it needs to come up with new organizational culture. There should be a way of making the executive body accountable for its performance standards.

Employees should be exposed on how other organizations and, in general, other industries operate. The various staff should be promoted based on their performance as opposed to how much they have invested in the organization or how many years they have been on the job.

Further, the organization should change its bureaucratic nature and adopt a more democratic decision making process to include even the employees in the process. This will bring the employees closer to the product, the problem as well as the customer themselves. In return, he will be able to respond quickly to the rapidly changing and divergent needs of customers as well as the highly unpredictable market conditions. Also, a company that is highly bureaucratic takes long in making decisions thus resulting into slow decisions.

The organization should make changes to its production system into a Just-in-Time production system. This reduces costs since production is only done when the products are needed and therefore storage costs are minimized. Also, they should concentrate on producing environmental friendly cars as opposed to the guzzlers.

This will not only ensure a clean environment but will also increase demand since that is what customers are going for nowadays. Further, they should make more connections with suppliers globally to increase their distribution channels. Also, focus on getting low-cost suppliers by using competitive bidding.

By keeping up with the consumer needs and general economic trends, the organization will be able to change as the market changes and produce products that will satisfy the consumers. It will also be able to adapt to current early enough to technological developments to avoid being outdated. In a world where technology is becoming the in thing, failure to adapt to new technology on time will have disastrous results to the whole organization driving it to bankruptcy.

The General Motors has taken various steps to change its organizational design in order to retain its competitive nature in the industry. This organizational change has helped it achieve some of its objectives such as teamwork and cutting operational costs. On the other hand, those changes have brought about several negative effects by affecting the customers, the community as well as the staff themselves. Its bureaucratic system has also contributed negatively to its failures.

But GM’s organizational change has shown that bankruptcy can also be used as an opportunity to take that crucial step to implement major organizational changes that will see a company fly up and start flourishing once again. Therefore, companies should not fear making that big step and making holistic organizational changes.

Dawson, P. (2003). Reshaping Change: A Processual Perspective . Routledge.

Kenly85. (2009). Blog 1: Organizational Change- General Motors (GM) . Web.

Spector, B. (2010). Implementing organizational change: Theory into practice, (2 nd Ed). ND.

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Home » Management Case Studies » Case Study: The Decline and Fall of General Motors

Case Study: The Decline and Fall of General Motors

Failure to innovate is the key reason to the downfall of Old General Motors. Innovation is the process whereby the management team of an organization is charged with the responsibility of introducing something new, which might be a new idea or a methodology or rather, a contrivance to facilitate the operational concerns and production. The Old General Motors failed with innovations in the company. These innovations were needed to ensure that the Old GM able remains competitive, and the company was able to manufacture cars that are in line with the client’s demands. This is related to the Old GM’ field of business to ensure that the organization do continue to produce the respective consumer centered product. The manufacturing industry such as the General Motors, innovation ensure that the output they deliver to the consumer do meet their needs, and expectations in a way that is realistic and makes their product to have a preference by the consumers against other same need satisfying product.

The fall of the Old General motors’ in this context was initially by the lack of personal innovation. The Organizational management was desperate for people who could see things in a different perspective. This would quickly size up the problems and come up with creative solutions to pinch the organization was facing. The failure of the “Old GM” to innovate made the organization less indispensable to consumers of the company products and other key personalities, who preferred the company output. This was both in the organization and outside its walls. The GM did lack the “go to idea personality,” which is essential, to work through intricate challenges and come up with creative solutions such as more performing vehicles. The failure by the Old General Motors to innovate made the company and its technologies obsolete; thus, the company failed to satisfy the needs of evolved human with its obsolete products.

Innovation is essential in an organization for it to be able to thrive in the challenging business world a thing that the Old General Motors did not realize. The company product tends to go through a life cycle. At the initial stage, the product is not well known; and it is costly such as the way General motor’s vehicles were in 1950s hence the sales are restricted. The product does reach growth after some time. At this stage, there is no more growth seen in sales, and at after time, it goes to the decline stage. A better and more satisfying product has replaced the product. It is at this stage that the manufacturer is supposed to come up with realistic ideas towards product development if he has to remain competitive. For example, the Old General Motor’s GMC trucks did reach the declining stage simply because the consumer switched to more efficient ones other than the GMCs that were moving at 50/60kmp speed.

The innovation diffusion is the factor that the organizations tend to take them to be in a better position of running the business. Innovative General Motors is likely to be the first to adopt a new production technology. A company is willing to pay a premium price for the new production processes and unwarranted technology. A later adopter relies on advice from the innovators who are more informed on new techniques. The fall of the “Old GM” seemed to have had been influenced by such factors in that the company never adopted the new technologies not even in the latter stages. Such technologies ensured the organization was able to produce customer more satisfying product, such as the luxurious and comfortable seats that other competitors fitted in personalized cars.

The product life cycle shows very well where innovation is critical for a manufacturing company especially the General motors’ limited. When the “Old GM,” company product did go through the life cycle as shown the company, ran out of ideas, opted out, and watched when other company products replaced its offer to the market, which decreased sales hence making it bankrupt in 2008. At the latter product life cycle stages, the company is supposed to at least make a modification of its marketing strategy a factor on which the Old General Motors failed. For example, when Toyota, was facing an inundated market for its “old face me sedan” based on its conventional usage, the company did opt for innovation to have the private Sedan replace the old one. This innovation did as well come with the fuel efficiency on top of high performance. They extended this to the production of five-seat family cars, which were a relief to the public old Sedans.

It was essential for Old Gm to come up with new products for its consumers, because that is what can make them have a bigger realization of sales. Either these new products can be new to the market in that, no any other manufacturer had made such a product before just like the Chrysler invented the minivan, or the product can be new to the company in that it was an invention done by another organization and the organization is coming up with its own version. For example, The Mercedes Benz Company was not the original manufacturers of the personal cars, but they came in after the market depicted a high potential with very satisfying products. This is innovation at its best, which the old General Motors failed to adopt. A product can be innovated to be new to a certain market segment. For instance, the Mercedes Benz sedans were first aimed at the price insensitive segments, but the manufacturers did in latter stages decide to target the price sensitive segment. This was innovation.

Innovation adoption over time is a critical thing that each of the organizations has to consider enabling it able to thrive in the market. Innovation starts with the innovators who account for about 2.5% of all innovations, then about 13.5% of early adopters and at least 34% of the early majority to take in the innovations. Afterwards, a 34% of the later majorities in innovation adoption do come in then the laggards are at 13.5% as far as innovation adoption and implementation is concerned. The “Old GM” failure could have been caused by his choice of being a laggard in the innovation adoption.

The old General Motors Company limited allowed the force of innovation to work against them. The managers did fear the risk associated with innovation and its adoptions that can either be financially bent or rather socially indented. The Old General Motors did as well fear the chance of trying edging ideas towards product development and growth for the organization to be able to remain in business. The organization might as well have resistance towards erudition on how to use the new technologies and innovation towards consumer satisfying products fabrication and pricing as well as positioning.

The required innovations for an organization to remain in business are adopted and implemented in varying degrees. The innovations might be continuous in that it includes the trivial improvements in due course. For example, the year to another change in vehicle, yet they are driven the same way they were in 1940s. Dynamic continuous innovation is essential in that technology is varied even though the product usage is similar to the older one. As an example, the jet technology came in to replace the propeller aircraft yet they are used for the same purpose. Discontinuous innovation is as well practical in an organization in that it creates a product that completely varies the way things are done. For instance, the introduction of the private and personal family cars did vary the transport sector.

Innovation is hard to embrace; however, in due time, the results are significant, and a failure to innovate in an organization does result to fatal implications. The “Old GM” for instance did not embrace innovation and the organization opted to operate with obsolete technologies a factor that could not let them stay in business. This failure to be creative brought down the organization’s profitability and sustainability in the manufacturing sector. This resulted to General Motors being regarded as a failure with little to offer to the market that was updated.

The Old GM did lack the modernity-desired innovation, and its adoption in that its extent to new production technologies reception was below par, and tainted with fear, and frustrations, which are the practical, proves of failed leadership. Additionally, General Motors might have been devoid of creative leadership ; the management did not value opinion leaders. The chances that the Old General motors’ management never did appreciate the opinion of others did bar innovation in the organization a factor that resulted to no innovation at all. Such a factor coupled by the resistance to change, production techniques, and fear of trying new ideas are some of the factors that resulted to Old General Motors as a manufacturing organization becoming a mere general venture and losing big in its market and standards.

Innovation does create a desirable environment for product positioning; for instance, the efficiency desired by consumers is critical to ensure that a company is able to satisfy the customers’ needs effectively. The resistance and lack of innovation are reasonable and justified factors to conclude that the fall of the Old GM resulted from the company’s lack of innovative ideas. Additionally, the company failed to adopt new technologies when the organization was desperate for innovations.

Innovation is paramount in any organization. The competitive environment is challenging and turbulent. Thus, companies need to be innovative in the achievement of the organizational goals and objectives, and development of products. This is what the old GM failed to realize, and they never embraced innovations when their competitors such as the Chrysler were top at innovations, hence resulting to the company failure and 2008 bankruptcy.

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Alternative Lay Language for Medical Terms for use in Informed Consent Documents

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ABDOMEN/ABDOMINAL body cavity below diaphragm that contains stomach, intestines, liver and other organs ABSORB take up fluids, take in ACIDOSIS condition when blood contains more acid than normal ACUITY clearness, keenness, esp. of vision and airways ACUTE new, recent, sudden, urgent ADENOPATHY swollen lymph nodes (glands) ADJUVANT helpful, assisting, aiding, supportive ADJUVANT TREATMENT added treatment (usually to a standard treatment) ANTIBIOTIC drug that kills bacteria and other germs ANTIMICROBIAL drug that kills bacteria and other germs ANTIRETROVIRAL drug that works against the growth of certain viruses ADVERSE EFFECT side effect, bad reaction, unwanted response ALLERGIC REACTION rash, hives, swelling, trouble breathing AMBULATE/AMBULATION/AMBULATORY walk, able to walk ANAPHYLAXIS serious, potentially life-threatening allergic reaction ANEMIA decreased red blood cells; low red cell blood count ANESTHETIC a drug or agent used to decrease the feeling of pain, or eliminate the feeling of pain by putting you to sleep ANGINA pain resulting from not enough blood flowing to the heart ANGINA PECTORIS pain resulting from not enough blood flowing to the heart ANOREXIA disorder in which person will not eat; lack of appetite ANTECUBITAL related to the inner side of the forearm ANTIBODY protein made in the body in response to foreign substance ANTICONVULSANT drug used to prevent seizures ANTILIPEMIC a drug that lowers fat levels in the blood ANTITUSSIVE a drug used to relieve coughing ARRHYTHMIA abnormal heartbeat; any change from the normal heartbeat ASPIRATION fluid entering the lungs, such as after vomiting ASSAY lab test ASSESS to learn about, measure, evaluate, look at ASTHMA lung disease associated with tightening of air passages, making breathing difficult ASYMPTOMATIC without symptoms AXILLA armpit

BENIGN not malignant, without serious consequences BID twice a day BINDING/BOUND carried by, to make stick together, transported BIOAVAILABILITY the extent to which a drug or other substance becomes available to the body BLOOD PROFILE series of blood tests BOLUS a large amount given all at once BONE MASS the amount of calcium and other minerals in a given amount of bone BRADYARRHYTHMIAS slow, irregular heartbeats BRADYCARDIA slow heartbeat BRONCHOSPASM breathing distress caused by narrowing of the airways

CARCINOGENIC cancer-causing CARCINOMA type of cancer CARDIAC related to the heart CARDIOVERSION return to normal heartbeat by electric shock CATHETER a tube for withdrawing or giving fluids CATHETER a tube placed near the spinal cord and used for anesthesia (indwelling epidural) during surgery CENTRAL NERVOUS SYSTEM (CNS) brain and spinal cord CEREBRAL TRAUMA damage to the brain CESSATION stopping CHD coronary heart disease CHEMOTHERAPY treatment of disease, usually cancer, by chemical agents CHRONIC continuing for a long time, ongoing CLINICAL pertaining to medical care CLINICAL TRIAL an experiment involving human subjects COMA unconscious state COMPLETE RESPONSE total disappearance of disease CONGENITAL present before birth CONJUNCTIVITIS redness and irritation of the thin membrane that covers the eye CONSOLIDATION PHASE treatment phase intended to make a remission permanent (follows induction phase) CONTROLLED TRIAL research study in which the experimental treatment or procedure is compared to a standard (control) treatment or procedure COOPERATIVE GROUP association of multiple institutions to perform clinical trials CORONARY related to the blood vessels that supply the heart, or to the heart itself CT SCAN (CAT) computerized series of x-rays (computerized tomography) CULTURE test for infection, or for organisms that could cause infection CUMULATIVE added together from the beginning CUTANEOUS relating to the skin CVA stroke (cerebrovascular accident)

DERMATOLOGIC pertaining to the skin DIASTOLIC lower number in a blood pressure reading DISTAL toward the end, away from the center of the body DIURETIC "water pill" or drug that causes increase in urination DOPPLER device using sound waves to diagnose or test DOUBLE BLIND study in which neither investigators nor subjects know what drug or treatment the subject is receiving DYSFUNCTION state of improper function DYSPLASIA abnormal cells

ECHOCARDIOGRAM sound wave test of the heart EDEMA excess fluid collecting in tissue EEG electric brain wave tracing (electroencephalogram) EFFICACY effectiveness ELECTROCARDIOGRAM electrical tracing of the heartbeat (ECG or EKG) ELECTROLYTE IMBALANCE an imbalance of minerals in the blood EMESIS vomiting EMPIRIC based on experience ENDOSCOPIC EXAMINATION viewing an  internal part of the body with a lighted tube  ENTERAL by way of the intestines EPIDURAL outside the spinal cord ERADICATE get rid of (such as disease) Page 2 of 7 EVALUATED, ASSESSED examined for a medical condition EXPEDITED REVIEW rapid review of a protocol by the IRB Chair without full committee approval, permitted with certain low-risk research studies EXTERNAL outside the body EXTRAVASATE to leak outside of a planned area, such as out of a blood vessel

FDA U.S. Food and Drug Administration, the branch of federal government that approves new drugs FIBROUS having many fibers, such as scar tissue FIBRILLATION irregular beat of the heart or other muscle

GENERAL ANESTHESIA pain prevention by giving drugs to cause loss of consciousness, as during surgery GESTATIONAL pertaining to pregnancy

HEMATOCRIT amount of red blood cells in the blood HEMATOMA a bruise, a black and blue mark HEMODYNAMIC MEASURING blood flow HEMOLYSIS breakdown in red blood cells HEPARIN LOCK needle placed in the arm with blood thinner to keep the blood from clotting HEPATOMA cancer or tumor of the liver HERITABLE DISEASE can be transmitted to one’s offspring, resulting in damage to future children HISTOPATHOLOGIC pertaining to the disease status of body tissues or cells HOLTER MONITOR a portable machine for recording heart beats HYPERCALCEMIA high blood calcium level HYPERKALEMIA high blood potassium level HYPERNATREMIA high blood sodium level HYPERTENSION high blood pressure HYPOCALCEMIA low blood calcium level HYPOKALEMIA low blood potassium level HYPONATREMIA low blood sodium level HYPOTENSION low blood pressure HYPOXEMIA a decrease of oxygen in the blood HYPOXIA a decrease of oxygen reaching body tissues HYSTERECTOMY surgical removal of the uterus, ovaries (female sex glands), or both uterus and ovaries

IATROGENIC caused by a physician or by treatment IDE investigational device exemption, the license to test an unapproved new medical device IDIOPATHIC of unknown cause IMMUNITY defense against, protection from IMMUNOGLOBIN a protein that makes antibodies IMMUNOSUPPRESSIVE drug which works against the body's immune (protective) response, often used in transplantation and diseases caused by immune system malfunction IMMUNOTHERAPY giving of drugs to help the body's immune (protective) system; usually used to destroy cancer cells IMPAIRED FUNCTION abnormal function IMPLANTED placed in the body IND investigational new drug, the license to test an unapproved new drug INDUCTION PHASE beginning phase or stage of a treatment INDURATION hardening INDWELLING remaining in a given location, such as a catheter INFARCT death of tissue due to lack of blood supply INFECTIOUS DISEASE transmitted from one person to the next INFLAMMATION swelling that is generally painful, red, and warm INFUSION slow injection of a substance into the body, usually into the blood by means of a catheter INGESTION eating; taking by mouth INTERFERON drug which acts against viruses; antiviral agent INTERMITTENT occurring (regularly or irregularly) between two time points; repeatedly stopping, then starting again INTERNAL within the body INTERIOR inside of the body INTRAMUSCULAR into the muscle; within the muscle INTRAPERITONEAL into the abdominal cavity INTRATHECAL into the spinal fluid INTRAVENOUS (IV) through the vein INTRAVESICAL in the bladder INTUBATE the placement of a tube into the airway INVASIVE PROCEDURE puncturing, opening, or cutting the skin INVESTIGATIONAL NEW DRUG (IND) a new drug that has not been approved by the FDA INVESTIGATIONAL METHOD a treatment method which has not been proven to be beneficial or has not been accepted as standard care ISCHEMIA decreased oxygen in a tissue (usually because of decreased blood flow)

LAPAROTOMY surgical procedure in which an incision is made in the abdominal wall to enable a doctor to look at the organs inside LESION wound or injury; a diseased patch of skin LETHARGY sleepiness, tiredness LEUKOPENIA low white blood cell count LIPID fat LIPID CONTENT fat content in the blood LIPID PROFILE (PANEL) fat and cholesterol levels in the blood LOCAL ANESTHESIA creation of insensitivity to pain in a small, local area of the body, usually by injection of numbing drugs LOCALIZED restricted to one area, limited to one area LUMEN the cavity of an organ or tube (e.g., blood vessel) LYMPHANGIOGRAPHY an x-ray of the lymph nodes or tissues after injecting dye into lymph vessels (e.g., in feet) LYMPHOCYTE a type of white blood cell important in immunity (protection) against infection LYMPHOMA a cancer of the lymph nodes (or tissues)

MALAISE a vague feeling of bodily discomfort, feeling badly MALFUNCTION condition in which something is not functioning properly MALIGNANCY cancer or other progressively enlarging and spreading tumor, usually fatal if not successfully treated MEDULLABLASTOMA a type of brain tumor MEGALOBLASTOSIS change in red blood cells METABOLIZE process of breaking down substances in the cells to obtain energy METASTASIS spread of cancer cells from one part of the body to another METRONIDAZOLE drug used to treat infections caused by parasites (invading organisms that take up living in the body) or other causes of anaerobic infection (not requiring oxygen to survive) MI myocardial infarction, heart attack MINIMAL slight MINIMIZE reduce as much as possible Page 4 of 7 MONITOR check on; keep track of; watch carefully MOBILITY ease of movement MORBIDITY undesired result or complication MORTALITY death MOTILITY the ability to move MRI magnetic resonance imaging, diagnostic pictures of the inside of the body, created using magnetic rather than x-ray energy MUCOSA, MUCOUS MEMBRANE moist lining of digestive, respiratory, reproductive, and urinary tracts MYALGIA muscle aches MYOCARDIAL pertaining to the heart muscle MYOCARDIAL INFARCTION heart attack

NASOGASTRIC TUBE placed in the nose, reaching to the stomach NCI the National Cancer Institute NECROSIS death of tissue NEOPLASIA/NEOPLASM tumor, may be benign or malignant NEUROBLASTOMA a cancer of nerve tissue NEUROLOGICAL pertaining to the nervous system NEUTROPENIA decrease in the main part of the white blood cells NIH the National Institutes of Health NONINVASIVE not breaking, cutting, or entering the skin NOSOCOMIAL acquired in the hospital

OCCLUSION closing; blockage; obstruction ONCOLOGY the study of tumors or cancer OPHTHALMIC pertaining to the eye OPTIMAL best, most favorable or desirable ORAL ADMINISTRATION by mouth ORTHOPEDIC pertaining to the bones OSTEOPETROSIS rare bone disorder characterized by dense bone OSTEOPOROSIS softening of the bones OVARIES female sex glands

PARENTERAL given by injection PATENCY condition of being open PATHOGENESIS development of a disease or unhealthy condition PERCUTANEOUS through the skin PERIPHERAL not central PER OS (PO) by mouth PHARMACOKINETICS the study of the way the body absorbs, distributes, and gets rid of a drug PHASE I first phase of study of a new drug in humans to determine action, safety, and proper dosing PHASE II second phase of study of a new drug in humans, intended to gather information about safety and effectiveness of the drug for certain uses PHASE III large-scale studies to confirm and expand information on safety and effectiveness of new drug for certain uses, and to study common side effects PHASE IV studies done after the drug is approved by the FDA, especially to compare it to standard care or to try it for new uses PHLEBITIS irritation or inflammation of the vein PLACEBO an inactive substance; a pill/liquid that contains no medicine PLACEBO EFFECT improvement seen with giving subjects a placebo, though it contains no active drug/treatment PLATELETS small particles in the blood that help with clotting POTENTIAL possible POTENTIATE increase or multiply the effect of a drug or toxin (poison) by giving another drug or toxin at the same time (sometimes an unintentional result) POTENTIATOR an agent that helps another agent work better PRENATAL before birth PROPHYLAXIS a drug given to prevent disease or infection PER OS (PO) by mouth PRN as needed PROGNOSIS outlook, probable outcomes PRONE lying on the stomach PROSPECTIVE STUDY following patients forward in time PROSTHESIS artificial part, most often limbs, such as arms or legs PROTOCOL plan of study PROXIMAL closer to the center of the body, away from the end PULMONARY pertaining to the lungs

QD every day; daily QID four times a day

RADIATION THERAPY x-ray or cobalt treatment RANDOM by chance (like the flip of a coin) RANDOMIZATION chance selection RBC red blood cell RECOMBINANT formation of new combinations of genes RECONSTITUTION putting back together the original parts or elements RECUR happen again REFRACTORY not responding to treatment REGENERATION re-growth of a structure or of lost tissue REGIMEN pattern of giving treatment RELAPSE the return of a disease REMISSION disappearance of evidence of cancer or other disease RENAL pertaining to the kidneys REPLICABLE possible to duplicate RESECT remove or cut out surgically RETROSPECTIVE STUDY looking back over past experience

SARCOMA a type of cancer SEDATIVE a drug to calm or make less anxious SEMINOMA a type of testicular cancer (found in the male sex glands) SEQUENTIALLY in a row, in order SOMNOLENCE sleepiness SPIROMETER an instrument to measure the amount of air taken into and exhaled from the lungs STAGING an evaluation of the extent of the disease STANDARD OF CARE a treatment plan that the majority of the medical community would accept as appropriate STENOSIS narrowing of a duct, tube, or one of the blood vessels in the heart STOMATITIS mouth sores, inflammation of the mouth STRATIFY arrange in groups for analysis of results (e.g., stratify by age, sex, etc.) STUPOR stunned state in which it is difficult to get a response or the attention of the subject SUBCLAVIAN under the collarbone SUBCUTANEOUS under the skin SUPINE lying on the back SUPPORTIVE CARE general medical care aimed at symptoms, not intended to improve or cure underlying disease SYMPTOMATIC having symptoms SYNDROME a condition characterized by a set of symptoms SYSTOLIC top number in blood pressure; pressure during active contraction of the heart

TERATOGENIC capable of causing malformations in a fetus (developing baby still inside the mother’s body) TESTES/TESTICLES male sex glands THROMBOSIS clotting THROMBUS blood clot TID three times a day TITRATION a method for deciding on the strength of a drug or solution; gradually increasing the dose T-LYMPHOCYTES type of white blood cells TOPICAL on the surface TOPICAL ANESTHETIC applied to a certain area of the skin and reducing pain only in the area to which applied TOXICITY side effects or undesirable effects of a drug or treatment TRANSDERMAL through the skin TRANSIENTLY temporarily TRAUMA injury; wound TREADMILL walking machine used to test heart function

UPTAKE absorbing and taking in of a substance by living tissue

VALVULOPLASTY plastic repair of a valve, especially a heart valve VARICES enlarged veins VASOSPASM narrowing of the blood vessels VECTOR a carrier that can transmit disease-causing microorganisms (germs and viruses) VENIPUNCTURE needle stick, blood draw, entering the skin with a needle VERTICAL TRANSMISSION spread of disease

WBC white blood cell

• Open access
• Published: 03 July 2024

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour

• HHK Wilson 1 , 2 , 5 ,
• B. Harris Roxas 2 ,
• N. Lintzeris 1 , 3 , 4 , 5 &
• MF Harris 5  

BMC Primary Care volume  25 , Article number:  236 ( 2024 ) Cite this article

Metrics details

Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs’ experiences diagnosing and managing pOUD in their chronic pain patients.

This qualitative research used semi-structured interviews and a case study to investigate GPs’ experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual’s perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed.

Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions.

Conclusions

Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Peer Review reports

‘Fear is the cheapest room in the house. I’d like to see you in better living conditions’ Hafiz, Persian mystic and poet.

A leading cause of disability worldwide [ 1 ], chronic pain is defined as persistent pain continuing for longer than 3–6 months and occurring on most days [ 2 ]. It is a complex condition, ‘an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience’ [ 3 ]. It has been estimated that 20% of Australians over age 45 experience chronic pain [ 2 ]. Nearly one fifth of patients seen by their general practitioner (GP) are suffering chronic pain [ 4 ]. Rates of opioid prescribing by Australian GPs for chronic pain are high [ 2 ]. One or more opioid prescriptions, mostly oxycodone, were provided to 3.1 million (13%) of the Australian population in 2016-17 with 1.5% (46,500 people) taking them on a daily basis [ 5 ].

Long term opioid use, that is, daily use on most days for more than 3 months [ 6 , 7 ], is associated with increasing evidence of significant harms and limited effectiveness for chronic pain [ 8 , 9 , 10 , 11 ]. Risky opioid use or non-medical use of opioids in people prescribed opioids is common [ 12 ]. Opioid risk increases with dose and length of use [ 13 , 14 ]. Each day, in Australia, three people die and 150 are hospitalised due to pharmaceutical opioid overdose [ 5 ]. Other significant health risks include hyperalgesia (increased pain sensitivity), endocrine abnormalities, falls, fractures, motor vehicle accidents, aberrant medication behaviours and medication on-selling or sharing [ 8 , 15 , 16 , 17 ]. Nearly one in 10 people prescribed opioids for chronic pain in Australia meet criteria for Opioid Use Disorder (OUD) [ 14 ]. OUD is categorised by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM-5-TR) as a pattern of opioid use with clinically significant impacts [ 18 ]. Opioid Agonist Treatment (OAT), is an evidence-based treatment for OUD and prescription OUD (pOUD) and includes two opioid medications, methadone and buprenorphine [ 19 , 20 ]. In Australia, state based OAT programs allow GPs to diagnose and prescribe methadone and buprenorphine for OUD [ 21 ]. This treatment, like many other chronic conditions, can be appropriately managed for many patients in general practice [ 22 ].

In the UK, 50% of GPs prescribed OAT in 2005 [ 23 ]. While in Ireland, 54% of GPs trained in the management of OUD in 2018 [ 24 , 25 ]. In 2022, in contrast, 2,352 private prescribers (mostly GPs) provided OAT Australia wide [ 26 ]. With 31,926 GPs working in Australia in 2022 [ 27 ], this suggests low engagement, with only 7% of Australian GPs providing OAT. This is supported by research that suggests Australian GP assessment of pOUD, management with OAT and referrals for OUD to specialist Alcohol and Other Drugs services are low [ 28 , 29 , 30 ]. Australian and international literature suggests that issues of stigma, poor remuneration, low knowledge, confidence, and lack of specialist support adversely affect GP involvement in OAT [ 31 , 32 , 33 , 34 ]. Our recent scoping review found that current published literature described GPs’ concern regarding risk of prescription opioid overdose, addiction and diversion, but screening for pOUD was haphazard [ 35 ]. We could find no literature that explored Australian GPs’ experience of diagnosing and managing pOUD in their chronic pain patients for whom they prescribed opioids [ 35 ].

Research aim

This research aims to gain an in-depth understanding of GPs’ attitudes and experience diagnosing and managing pOUD in their patients’ prescribed opioids for chronic pain in the community general practice setting in the state of New South Wales, Australia.

Study design and setting

This qualitative study used semi-structured interviews to explore GPs’ experience of diagnosing and managing pOUD in patients prescribed opioids for chronic pain. The semi-structured interview method was chosen as it is useful to investigate individuals’ subjective experience [ 36 ]. We used the Theory of Planned Behaviour (TPB) to frame, code and investigate the issues [ 37 ].

TPB assesses an individual’s perception of the issues that surround a decision to undertake a behaviour and elucidates the factors that increase or decrease intention to undertake this behaviour. It describes three subjective factors perceived by individuals: subjective behavioural, normative and control beliefs. Behavioural beliefs are guided by emotions (affect) and thoughts (cognition) and inform positive and negative attitudes. Normative beliefs are guided by perceived social norms; what a person thinks others do themselves and whether others support or oppose the individual undertaking the behaviour. Control beliefs describe barriers or facilitators, both internal, e.g., knowledge, and external e.g., time. The negative or positive strengths of these three factors affect intention to undertake a behaviour, which influences whether the actual behaviour is performed [ 37 , 38 ]. The theory also suggests that subjective control beliefs can directly influence behaviour [ 39 ]. See Fig.  1 .

It is important to note that TPB only addresses individuals’ perceptions. It is not a model for behaviour change nor does it systematically address how systems affect behaviour.

The interview guide asked about participant’s experience with chronic pain and pOUD through the lens of TPB and their awareness of any policies or strategies to support GP opioid prescribing. (See supplemental File 1 – interview guide).

TPB factors and how they affect behaviour

A two-part case study supported the interview guide. Part one, depicted a 42-year-old woman prescribed opioids in hospital after acute pelvic and spinal injury some years previously, who attends her GP practice regularly for opioid prescriptions. Part two describes signs and symptoms that suggest pOUD. (See Table  1 ).

Participant recruitment

GPs in New South Wales (NSW), Australia, were recruited via Primary Healthcare Networks, an Australian GP Facebook page called ‘GPs Down Under’ and via snowballing by email. All interviews were undertaken via a video conferencing platform (Zoom) from May to September 2021 by the lead author (HW). To be eligible, participants needed to be federally registered as medical practitioners, and working in the community primary care setting in NSW. The study was limited to NSW due to variations in opioid and OAT prescribing legislation and accreditation in each state/territory in Australia.

Data collection

The interviews were audio recorded, transcribed verbatim and de-identified. Data were stored on a secure server. A reflective journal helped support the audit trail.

Data analysis

The data were analysed deductively using the mid-level theoretical framework of TPB [ 37 ] and inductively with open coding, including thematic analysis [ 40 ]. Top-level codes were grouped under the ‘a priori’ conceptual categories of subjective behavioural beliefs, subjective normative beliefs and subjective control beliefs while open coding allowed the analysis of other aspects that were seen to be important [ 41 ]. Higher-order concepts were interpreted through testing of codes, reiterative reflection, and extensive rereading of transcripts. The data was managed via QSR N-Vivo software. Authors HW and BHR reviewed the transcripts to support data accuracy and integrity.

COREQ checklist for qualitative reporting [ 42 ] are included in supplemental file 2 .

Researcher positionality

We used an interpretive description approach. This emphasised analysis of in-depth contextual description, drawing on interpretation, clinical and research experience in order to understand practice-based issues [ 43 , 44 ]. The lead researcher (HW) is a GP, addiction specialist and PhD student with extensive clinical experience managing chronic pain, prescribing opioids and OAT. The senior researchers include a GP (MH), a primary care researcher (BHR) and an addiction specialist (NL).

Ethics approval

Ethics approval was obtained from the Human Research Ethics Committee of the South Eastern Sydney Local Health District (HREC 18/018 (LNR/18/POWH/156) and University of NSW HREC18/018. All methods were carried out in accordance with relevant guidelines and regulations and informed consent was obtained from all participants involved in this study.

Twenty-four GPs took part in the study. They all saw patients with chronic pain and 23 reported currently prescribing opioids for this indication. Fifteen were female. There was a wide range of ages and practice experience. Participants worked across metropolitan, regional and rural NSW [ 45 ]. Five prescribed OAT currently (one was a GP and a Fellow of the Chapter of Addiction Medicine) and 2 GPs reported prescribing OAT in the past but not currently. (See Table  2 ).

This study used the three factors in TPB (see Fig.  1 ) to analyse the interviews, however there was an overarching universal theme of holistic and complex care.

Holistic complex care in the general practice setting

Participants gave extensive responses to the case study patient’s presentation and her social, vocational, family, mental and physical co-morbidities. This universal approach may be linked to each participant’s identity as a GP and appeared integral to their professional approach to patients.

 ‘….how does the pain limit what she can do? how’s it affecting her relationships? What else is going on for her husband and her teenage kids?   Endometriosis (a disorder of abnormal spread of the womb lining) … the psoriasis (a chronic skin condition) … mental health issues… she’s probably perimenopausal (the period of time around menopause) … she hasn’t even managed to get back to work…’ (GP18, female, metro, established GP).

Participants were aware of the complexities of managing chronic pain and suggested that chronic pain rarely presented alone, and this was difficult to adequately address.

‘No one ever comes in just for their chronic pain. And it’s a 15 minute consultation, usually that they’ve booked. And there’s a lot of other things going on….a lot of them are either too disorganized, too much going on with their life socially or within other medical conditions…’ (GP4, female, regional, new fellow).

Sitting underneath the theme of ‘holistic complex care in the general practice setting’ were the three factors of TPB.

Subjective behavioural beliefs diagnosing and managing pOUD

Many participants sighed or paused for long periods when answering questions related to diagnosis and management of pOUD in chronic pain patients prescribed opioids.

Positive salient affective/cognitive (thoughts/feelings) beliefs

Some participants described positive thoughts and feelings about diagnosing and managing pOUD. This included being a good doctor, doing the right thing, achieving something difficult and appropriate treatment leading to better patient outcomes.

‘because when you have the right diagnosis…. you have the right treatment…’ (GP1, male, rural, new fellow). ‘…it would benefit several of my patients in real life, and it would certainly benefit Judy’ (case study patient). (GP3, female, rural, registrar)

Negative salient affective/cognitive (thoughts/feelings) beliefs

Drawing on past experience, most participants expressed high levels of negative thoughts and feelings when considering pOUD in chronic pain patients. They described the case study as ‘really difficult’ and a ‘heart sink patient’ , like patients they had seen in the past. Patients, whom, they had found to be time-consuming and someone they didn’t want to see or knew they would continue to think and worry about after the consultation.

‘a demanding patient… one of those patients, … oh, I have to see her today or you’d go home, and think, oh, why did I say that, or do that. So it’s one of those patients, that you kind of dwell on before and after the consult…’ (GP10, male, rural, established GP).

Most participants described the difficulty and futility of trying to talk to chronic pain patients about changing their opioid treatment.

‘You raised it a hundred times previously and like a broken record, you raise it again and at some point, you think, what’s the point? Like, I raised it a hundred times and it gets nowhere so why should I bother?’ (GP9, male, regional, established GP).

Many expressed a sense of nihilism, that there was not much they could do beyond prescribing opioids.

‘…you feel like there’s nothing I can do, apart from giving them this medication…’ (GP9, male, regional, established GP).

Participants were worried that diagnosing and managing pOUD would fracture the GP-patient therapeutic alliance.

‘… feeling like the rapport is broken, that they won’t come back and see you and you have no idea what happens to them …’ (GP16, female, metro, new fellow).

Some participants expressed regret prescribing opioids and described feeling guilty and complicit. They felt a personal responsibility for opioid harms experienced by patients.

‘…you have to come to terms with the fact that you have done something, which actually is not good health care. You know that’s a pretty sobering thing to realize that you’ve actually been complicit…’ (GP14, female, regional, established GP). ‘I feel quite guilty when people come in and they’re like this, because we’ve started (opioids)…. and now this person is in a whole heap of trouble, and mess. ’ (GP9, female, metro, established GP).

The risks of prescription opioid overdose and withdrawal were recognised by all participants. This led to feeling overwhelmed by the situation for some participants.

‘…if you do give them the medication you’re worried about them overdosing, if you don’t give them the medication you worry about them getting withdrawal symptoms…’ (GP17, male, metro, established GP).

Many participants described the onerous responsibility of managing pOUD long term if they diagnosed it, as they believed management was going to be difficult.

‘I don’t want to be the one to do it, because I don’t want to be the one that’s taking responsibility, I know this sounds horrible, but I really don’t want to be the one that’s taking responsibility for the ongoing care with this because I know that it’s gonna be really difficult…’ (GP20, female, new fellow, metro).

Some suggested that with all the competing demands placed on GPs, addressing pOUD was low on their priorities. They suggested that this was a group of people who appeared stable and didn’t complain about their medication. As a result, some participants suggested they found it easier to continue prescribing opioids for the management of chronic pain. The participants found considering the issue of pOUD immediately made the happy patient unhappy and took time, was complex and impossible to manage.

‘…these people generally are stable, they’re often not complaining too much, they just pitch up every four weeks, and we, we forget actually, it becomes very low on that list of priorities, if I’m honest, I think it just sort of gets sucked up in doing everything every day, and you have to actually make that conscious decision, are you going to address this problem?’ (GP4, female, metro, established GP).

Many participants expressed a guilty relief when patients with complex chronic pain presentations stopped seeing them. They expressed concern about the risk of burnout.

‘….you never want to be sacked by a patient, but I wasn’t disappointed….she was quite a demanding patient saturating my energy and my time…’ (GP11, male, rural, established GP). ‘…they’re long hard consults… you risk burning out really…I don’t want to burn out by loading up my days with dealing with this…’ (GP10, male, rural, established GP).

Most participants described feeling uncomfortable and avoiding difficult conversations about pOUD with chronic pain patients. As health professionals they wanted to help and found it difficult to frame the conversation in a way that would assist the patient to reconsider their treatment.

‘…how do I really explain that well to the patient, because a lot of them will just think, you’re not helping me, or you’re taking away something that I need. And I think that’s the hardest thing as a GP….is that you want to help. And so, if you’ve got someone saying well this is helping me and you’re taking it away, how you explain, frame that for them, I still find really difficult…’ (GP4, female, regional, established GP).

The difficulty of the conversation seemed to lead to therapeutic inertia for the participants.

‘…and especially if I’m running late, or busy or if I’m tired, there’s a temptation to just, you know, tie them over. Yeah, not have that difficult conversation.’ (GP9, male, outer metro, established GP).

The participants with training in the management of OUD expressed similar negative experiences and attitudes.

‘I find these patients really, really difficult. With what I feel is a reasonable amount of experience and knowledge about how to treat…I still feel uncomfortable…’ (GP3, male, metro, established GP).

Most participants noted that while the patient in the case study seemed to have some insight into their situation, this was uncommon. In their experience, patients had little insight or desire to change their medication and could not perceive doing anything differently. The discussion felt like a battle where the GP tries to discuss changing treatment and the patient defends their position.

‘…it’s ‘why are you even asking me this question, it’s not a problem, …it’s never been a problem before?’ … they know that they have to put up a fight to get the script, because there’s a general sort of culture of ‘no I don’t want to give this medication to you’ every time. You know, every time I ask, I have to fight for it.’ (GP2, female, rural, established GP).

Prescribing opioids for chronic pain was seen as part of a GP’s role but many did not consider managing pOUD as ‘usual business’.

‘…prescribing opiates, even large doses of opiates…the vibe is it’s a normal part of general practice, while the vibe is, I think, perhaps treating substance use disorders, and maybe particularly with opiate use disorders is not….’ (GP15, male, metro, established GP).

Some participants described the need to actively work to change their mindset, to stop and consider that the treatment they were providing could be causing harm.

‘I remember having to stop and just go, hang on, I am giving this medication that is causing her more harm, and it was such a different mindset for me to have to just go, this is not working and it was a medication I was prescribing for her.’ (GP13, female, metro, established GP).

Subjective normative beliefs diagnosing and managing pOUD

Diagnosing/managing poud supported by others.

Many participants perceived that specialist pain and addiction services were happy for them to diagnose and manage pOUD as this would relieve pressure on their services. One participant suggested that some of their GP colleagues were supportive, but only because this meant they would not have to do this themselves. This was seen as a perverse disincentive to diagnose and manage pOUD.

‘…it would be; ‘I’m (The GP colleague) really glad that you’re (the participant) doing this so I don’t have to do it, and then everyone would refer…rather than taking it on themselves…’ (GP2, female, rural, established GP).

Diagnosing/managing pOUD NOT supported by others

Some participants suggested that while they might be happy to undertake diagnosing and managing pOUD, they had to consider their colleagues who may be concerned about risks and how this would affect practice amenity and other patients’ safety. Some participants suggested that staff would not approve of people with pOUD and did not want ‘these patients’ in the practice.

‘Changing the stigma of my (senior) colleague…it’s not going to be easy to change his mind about things, change his views, his perception, and he would feel like, ‘what are you turning this clinic into?’’ (GP6, male, metro, new fellow).

Most participants perceived that patients themselves did not want a pOUD diagnosis, they did not want their management to change or become part of a stigmatised patient group, they did not want referral to drug and alcohol services and did not see themselves as possibly needing a change in treatment plan, such as deprescribing or OAT.

‘…this poor girl literally sat in my room crying, being like, “I don’t want to be labelled a druggie”….’ (GP19, female, metro, new fellow). ‘…they don’t see themselves as someone who should be on methadone or suboxone. And there’s a lot of shame and stigma around that …’ (GP2, female, rural, established GP).

Some participants recognised the complexity of dual diagnosis of chronic pain and pOUD and described a regulatory system that had a dichotomous view of the patients, they were either pain patients or had pOUD who had to be treated with OAT. For the participants, this meant that pOUD diagnosis inexorably led to OAT, something that no patient wanted. To avoid this, they avoided the diagnosis of pOUD.

Administrative staff responding to demanding patients at reception added to a sense for some participants that they were powerless and this increased the chance that an opioid prescription would be written and decreased their ability to drive change.

‘…they’re (patients) putting pressure on reception staff to make sure they’ve got the script. And so, I guess there’s that pressure to do what they wanted…and in the time they wanted it to be done. And I can feel that kind of balance of power on the doctor patient relationship. Switching more to them being in control, being more and more demanding and telling me what I was going to do, rather than me guiding them on optimal treatment and actually being able to help them make a change’ (GP18, female, metro, established GP).

Participants who currently prescribed OAT were less affected by the social norms of colleagues but were equally concerned about the patient’s desire not to be diagnosed.

Diagnosing/managing pOUD undertaken by others

GP colleagues who undertook OAT prescribing were seen as addiction colleagues not as mainstream GPs by non-OAT prescribing GPs.

‘….she (GP Colleague) is the addiction specialist…’ (GP24, male, rural, established GP).

This suggests that treating pOUD was not normative for GPs. Participants had little experience of other GPs prescribing OAT. Those who did prescribe saw this as a professional responsibility rather than something they wanted to do.

‘I’m not really interested in taking (more of) these (OAT) patients on …that’s just being honest.’ (GP10, male, rural, established GP). ‘It’s not my forte in general practice and I must admit, this isn’t something I seek out.’ (GP22, female, metro, new fellow).

Subjective behavioural controls diagnosing and managing pOUD

Internal behavioural controls.

Many participants described lack of knowledge, skills and low confidence with diagnosis and management of pOUD in chronic pain patients. Many participants without addiction training did not know the criteria for the diagnosis of OUD.

‘…it is something that I don’t know a lot about, I don’t see a lot of, I’m not doing it all day long…’ (GP 11, female, metro, established GP).

Younger participants suggested they would be happy to prescribe but did not have the knowledge and skills needed to do this.

‘.it’s a knowledge and management thing rather than an I don’t want to do it. I just feel like I’m not sure how.’ (GP7, female, rural, registrar).

Many participants indicated that they felt unprepared to be involved in the management of pOUD. They suggested that patients with aberrant behaviours such as injecting and diverting medication needed addiction services and that they would not be able to manage these issues. For this group of GPs, patients exhibiting aberrant behaviour were negatively compared to chronic pain patients with dependence on pain medications.

‘…if I’m suspecting substance abuse behaviours rather than dependence on the medication someone with chronic pain can have, then it changes things, I need to involve more of an addiction specialist, or addiction services rather than to continue prescribing myself…’ (GP 12, female, rural, established GP).

Referral to specialist services was considered by most participants. They suggested that they would tend to refer patients like the case study to pain specialists and would be reluctant to refer to drug and alcohol services.

‘I haven’t done it (referred to drug and alcohol) for a long, long while, though…I probably haven’t had a lot of experience with it…’ (GP18, female, metro, established GP).

Concern and fear of perceived risks associated with prescribing OAT for pOUD in their chronic pain patients was a feature of many participants’ responses. They were concerned that prescribing OAT would lead to an influx of patients requesting this treatment and worried about being overwhelmed by this demand.

‘I don’t necessarily want to open the floodgates to all of the people who might be interested or need my help in that zone because there’s so much of it around here, and I don’t think that I can treat or see them all and I’m scared that if I open up that door that it will be never ending.’ (GP2, female, regional, established GP).

External behavioural controls

Lack of time, money and support, were universal to the participants’ experience. They described how limited consultation time and poor remuneration stopped them from engaging in what they saw as difficult, time-consuming conversations. The lack of adequate remuneration suggested for them that GPs’ time and effort was not valued.

‘…they’re long hard consults…not paid, as well as what you deserve to be remunerated for, you know how much effort you’re putting in and how much reward you’re getting financially is not great…at the end of the day …you want to feel valued…’ (GP10, male, rural, established GP).

Conversations with patients about their pain and opioid use were made easier with more consultation time for many participants.

‘I think, framing things correctly, is more difficult when you don’t have time. Just having plenty of time available and having just that sense of calm. It just makes your difficult conversation much easier.’ (GP 9, male, outer metro, established GP).

Treatment affordability was described by many participants as an important barrier preventing many patients from accessing alternatives to opioids.

‘…a lot of the alternative things that I can use though, are very restricted financially depending on your patient…’ (GP8, female, metro, established GP).

Participants working in private billing practices (government funded with additional patient co-payment) suggested a different experience compared to working in bulkbilling (wholly government funded) practices. These participants suggested their patients, who had higher levels of education, health literacy and better financial status, showed higher engagement with advised treatment options and greater ability to pay for more costly alternative treatments.

‘a lot of our patients are very much about prevention and trying to get off medication…because we’re private clinic,…that changes the dynamic and… I would say probably (the) overwhelming majority of my patients have…. university degrees and they’re pretty well educated and…have high health literacy.’ (GP16, female, metro new fellow).

Low levels of specialist support were seen as a barrier to assisting patients with chronic pain and pOUD by most participants.

‘I just don’t have necessarily have access to a chronic pain team or that kind of help…’ (GP7, female, rural registrar). ‘…the couple of times I’ve tried to work with drug and alcohol. The doctor I’ve spoken to hasn’t been that helpful and so that’s made me more reluctant to talk with them, because it’s kind of feels like well wherever I turn my patients are getting knocked back. And so, it’s hard to access this specialist support for my patients.’ (GP18, female, metro, established GP).

One GP who expressed interest in providing OAT described how he was inundated by patients from the public addiction service and had to stop accepting referrals. This was compounded by the lack of promised support from the specialist service.

‘I just got pummelled and eventually ended up saying, no. Sorry, I just don’t have the capacity to take on large numbers of patients, but also because the promise the system, the reality was always substantially less than the expectation, in terms of that support availability.’ (GP24, male, rural, established GP).

The role of specialist patient centred shared care and support was seen as a great advantage by many participants and one that could lead to better outcomes.

‘I think it can be fantastic, obviously, to have a shared care arrangement where, especially with complex comorbidity, then the more people on the team and the more eyes on the situation, the better the outcome is for the patients, 100% having expert advice that’s accessible and patient centred is terrific.’ (GP11, female, metro, established GP).

Some suggested that they had good understanding of their patient within their context and knew what local services were available. They suggested the value of good professional relationships with their local pharmacists.

‘I can ring my community pharmacist and go, Hey, what do you think about this person and their dosing? Do you think that there’s any issues or like, how do you think that they should go? …and I feel like I can trust them, I know them because they’re around the corner.’ (GP2, female, rural, established GP).

Many participants were worried that patients might experience stigma with other health professionals. This led to avoidance of using the term pOUD, with patients, in the medical record or letters to other services. They suggested that this may lead to inferior treatment by other health professionals.

‘I don’t love labels…if I’m referring a patient to hospital,…I don’t want them to be discriminated against any way…’ (GP12, female, rural, established GP).

The three TPB factors investigated in this study are summarised in Fig.  2 below.

Theory of Planned Behaviour factors

This study, based on GP self-report, explored the subjective behavioural, normative and control beliefs that impact pOUD diagnosis and management in patients prescribed opioids for chronic pain. Overall, the beliefs expressed by the participants suggest there will be low intention and therefore low levels of actual diagnosis or management of pOUD if this develops in their chronic pain patients on opioids.

All participants responded to the scenario in the case study with a holistic generalist approach considering the impact of multiple biopsychosocial issues. They gave considered, thoughtful responses regarding their difficulties and their failings in their approach to working with patients prescribed opioids for chronic pain.

Participants expressed feelings of conflict and futility in the face of diagnosing and managing pOUD in their chronic pain patients. They described negative emotional experiences, discomfort and fear, and feelings of being complicit in causing harms to their patients. They suggested that diagnosing and managing pOUD was important, but this was outweighed by their past experiences of difficult conversations, difficult patients, fragile therapeutic alliances, a lack of sense of control and a sense of futility and powerlessness that they could positively influence their patients’ use of opioids. This led to avoidance of these conversations. Difficult conversations with patients experiencing chronic pain have been previously described in the literature [ 46 ], but to our knowledge, the difficulty of conversations around diagnosing and managing pOUD in patients prescribed opioids for chronic pain has not been studied.

Diagnosing and managing pOUD was not the norm for participants and impacted by lack of support from colleagues, practice staff and specialist services [ 32 , 47 ]. The idea that staff did not want “these patients” in the practice belies the fact that patients with pOUD were already in the practice, just not yet diagnosed. Participants described positive support from some of their medical colleagues, but only because this enabled those colleagues to avoid diagnosing and managing pOUD themselves. Paramount was the lack of positive patient social norms. Participants believed that patients didn’t want to have these conversations, they didn’t want the diagnosis, or change in management. Participants believed that their patients saw themselves as pain sufferers, that they needed their opioids and did not want to consider management that would make them part of a stigmatised group of people with OUD.

Participants had few role models to provide them with a basis to undertake this behaviour. They expected to be left unsupported and unable to provide the level of care required for this chronic condition. Prescribing for pOUD was not seen as ‘normal’ work for many participants, but rather as specialist work, outside the responsibility of general practice. No one wanted this diagnosis, not the patient, not the participant and not the participant’s GP practice. The risk of ‘inundation’ that participants felt is compounded by a long standing lack of ODT prescribers [ 28 ] and the resulting unmet treatment need in Australia [ 48 , 49 ].

Participants described low levels of knowledge, skill, and confidence as well as barriers including limited time, remuneration, little specialist support and difficult regulatory requirements. Internal and external behavioural controls to prescribing OAT; lack of skill, knowledge, confidence, time, remuneration and specialist support have been described in previous studies [ 31 , 32 , 33 , 34 ]. External controls also speak to systemic and structural issues, particularly time constraints that are integral to the ‘fee for service’ structure in Australian general practice [ 50 ].

Participants were highly aware of the risks associated with long term prescribed opioids [ 51 , 52 ]. However, their knowledge of pOUD, the variety of treatments available and regulatory requirements was often incomplete. The task of re-considering treatment options required participants to re-orient their approach deliberately and consciously. This did not come easily. Putting limits and boundaries on patient opioid requests was conflictual. Negotiating a person-centred approach that did not give in to patient demand was perceived to be difficult. Participants considered the role of reducing opioid dose, changing treatment plan but avoided the diagnosis of pOUD as they felt they had to choose between continuing the status quo, or diagnosing pOUD, a diagnosis that they felt must inexorably lead to a difficult change in management and force them to move the patient to treatment with methadone or buprenorphine under the NSW OAT program [ 53 ], despite the fact that this is not mandatory. This decreased participants’ intent to diagnose and manage pOUD and dovetailed into the participants’ fear that they would be overwhelmed by demand.

Stigma is often cited as a reason GPs avoid treating addiction [ 54 ]. Experience of stigma and discrimination prevents people seeking or staying in care, leading to poorer treatment effectiveness and adverse patient outcomes [ 55 ]. Stigma and bias were important factors driving participant beliefs and intentions in this study. This was not simple and had two important aspects; participants’ lived experience of difficult conversations with patients at risk of pOUD and their concern about the risk of patient stigma and discrimination by colleagues and other health services. Past experience led to a tendency to believe that all future conversations would be conflictual, that all patients would be complex [ 56 ], when in fact there are a wide range of patient presentations and levels of stability [ 57 ]. Both past experience and concern about stigma from other services led to inertia and avoidance of the conversation and the diagnosis. Medicolegal concerns about the implications of diagnosis were important, however participants were also aware of the risk of not diagnosing pOUD, including medicolegal risk [ 58 , 59 ]. On balance, the difficult emotional work, lack of social norms and adverse internal and external behavioural controls pushed them towards inaction, despite the risks.

Strengths and limitations

This study examined the lived experience of GPs working in rural, regional and metro NSW. The participants spoke frankly about their difficulties. A qualitative method with a mid-range theory supported the study’s ability to do this as did the insider status of the GP interviewer.

Our participants included female GPs who tend to see more patients with complex and psychological issues [ 60 ] and younger GPs who may be more open to addressing addiction [ 61 ]. As a result, this group may be more open to the issue of pOUD in chronic pain and reluctance to diagnose and manage pOUD may be even stronger among other Australian GPs.

The study relied on participant’s self-report. Memory may have been selective, misattributed or exaggerated. Participants may have wished to appear more confident and comfortable than they really were. Social desirability bias may have led them to report what they felt they should do rather than what they actually do in practice. This may have been mitigated by the use of an experienced ‘insider’ interviewer; a GP who has experienced the issues and as a result was able to put participants at ease using a curious questioning style that encouraged frank discussion.

Australian State and Territory regulatory requirements limit access to OAT. In NSW, GPs can prescribe for up to 30 people without training and for 200 after training [ 62 ]. This is more liberal than other Australian jurisdictions, which have a varied range of prescriber restrictions. Given the complex barriers experienced by GPs in NSW, it is likely that less liberal rules in other jurisdictions will further negatively impact GPs’ willingness to prescribe OAT.TPB describes a framework for individual intention, and it is important to address systems issues that impact on behaviour, including societal stigma, fear and loathing of people with substance use disorders and lack of legitimacy for these as a chronic medical condition. Constraints including time, remuneration and regulatory requirements are both perceived and actual, they are structural and systemic. TPB cannot address this and is limited to individual intentions.

This research is limited to the experience of GPs and does not investigate the perspectives from other stakeholders such as patients, carers and policy makers.

Our analysis suggests that there were major perceived barriers to diagnosing and managing pOUD in patients prescribed opioids for chronic pain by GPs in general practice in NSW, Australia. Negative attitudes, negative social norms and negative perceived behavioural controls lead to low intention to diagnose and manage pOUD, and therefore low chance that this will occur, a decision which is associated with potential significant harms. Without adequately addressing these barriers, we cannot hope to change this.

Implications

Understanding GPs’ past negative experience and the influence of this on current behaviours is core to improving the diagnosis and management of pOUD in chronic pain patients prescribed opioids. It is essential to address not only the perceived behavioural controls such as time, remuneration and skills, but also to reduce the negative beliefs and strengthen appropriate social norms for GPs. These may be addressed by giving GPs opportunities to reflect on their patients with chronic pain through audit and education that includes building skills to manage difficult clinical interactions [ 63 ]. Repeated and early exposure to these complexities for doctors in training may assist. Ensuring people with lived experience of pOUD are involved in leading this training would be helpful as may building role models and champions [ 64 ] in primary health networks and GP colleges.

Additional support from specialist services to GPs (both in managing chronic pain and pOUD), training other team members in the practice on pOUD, including reception staff/practice managers, nurses, and allied health staff will ensure they have better understanding of the complexities of patients’ issues and skills to manage these. Providing a signal that this care is supported and valued through changes to funding mechanisms, i.e., creating specific Medicare item numbers for this treatment may also positively impact social norms.

Better understanding of the treatment options for people who develop pOUD for GPs with comorbidity (chronic pain and pOUD) treatment guidelines could improve knowledge and better nuanced regulatory approaches may support this.

There have been several policy changes in Australia including OUD prescribing guidelines, regulatory changes, and the introduction of real time prescription monitoring. It is unclear if these changes will be sufficient to change the frequency that pOUD is diagnosed and managed in general practice. Further investigation through the lens of TPB will help government, policy makers and service managers to assess the positive impact of these changes on this complex clinical presentation and GPs intention to diagnose and manage pOUD.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the sensitive, confidential, and potentially re-identifiable nature of the semi structured interviews undertaken. Additionally, our ethics approvals does not allow disclosure of these data. More details are available from the corresponding author on reasonable request.

Abbreviations

General Practitioner

Prescription Opioid Use Disorder

Opioid Agonist Treatment

Alcohol and Other Drugs

Theory of Planned Behaviour

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Wilson, H., Roxas, B.H., Lintzeris, N. et al. Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour. BMC Prim. Care 25 , 236 (2024). https://doi.org/10.1186/s12875-024-02474-6

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Industrial metaverse: a comprehensive review, environmental impact, and challenges.

1. Introduction

1.1. motivation, 1.2. our contributions.

• Considering the IM architecture, we examined the IM concept and the numerous enabling technologies used to build and experience the IM.
• We explored new and upcoming prevalent use cases of the IM and deployments.
• We explored the impact of the technologies underpinning the IM such as data centers and network infrastructure on the environment.
• We address novel privacy and security risks, as well as outline open research challenges while considering that the IM is based on a strong data fabric.

1.3. Paper Organization

2. methodological approach, 3. industrial metaverse’s architecture, roadmap, and core technologies overview, 3.1. industrial internet of things, 3.2. artificial intelligence.

• Security: The Metaverse presents a number of security risks, including fraud, identity theft, and cyberattacks. AI can monitor user behavior and identify any questionable activities, such as identity theft or malevolent actions.
• Personalization: AI systems are capable of analyzing user data to provide each user with a customized experience. An AI system, for instance, can be trained to learn user preferences for virtual apparel, virtual accessories, and virtual activities and then provide tailor-made suggestions.
• Creating and managing digital entities: AI is utilized in the Metaverse to generate and manage diverse digital creatures, including chatbots, virtual assistants, and NPCs. These entities can interact with users, offering tailored experiences according to their tastes and actions.
• Immersion: Since AI makes realistic physics, lighting, and sound effects possible, it can aid in the creation of more immersive virtual environments. AI systems, for instance, can mimic the behavior of fire, water, and other natural elements, adding realism to the virtual world.
• Real-time translation: AI has the potential to facilitate real-time language translation in the Metaverse, facilitating international collaboration and communication. This could result in the ability of AI to translate spoken languages in the Metaverse in real time, facilitating international collaboration and communication. This has the potential for the establishment of an entirely worldwide virtual community.
• Intelligent NPCs: NPCs are virtual characters that can communicate with players in the virtual world and are managed by the AI of the game. AI algorithms can make it possible for NPCs to comprehend common language and respond appropriately, adding realism and interest to interactions [ 20 ].

3.3. Cross, Virtual, Augmented, and Mixed Reality

3.4. cloud computing.

• Growing usage of cloud computing and the Metaverse across a range of industries: The Metaverse has the potential to significantly impact numerous industries ranging from retail, gaming, entertainment, and healthcare to education. In order to provide the infrastructure required to enable these virtual experiences, cloud computing will be crucial. Thus, in the upcoming years, we should anticipate seeing a rise in the use of cloud computing and the Metaverse in these sectors.
• VR/AR technology developments: The Metaverse relies heavily on VR/AR technology, and as this field continues to progress, more lifelike and immersive digital experiences should be possible. As a consequence of these developments, a stable and expandable cloud infrastructure will be necessary to meet the demanding computational needs of VR and AR.
• The expansion of the creative economy: It is possible that the Metaverse will present chances for artists to make money off of their abilities. In order to give content creators the infrastructure they need to produce and market their work globally, cloud computing will be crucial.
• Improved remote collaboration and work: It is anticipated that cloud computing and the Metaverse would enhance distant collaboration and work, making it possible for teams to operate together in virtual settings with ease. This could result in a workforce that is more adaptable and effective, as well as more productive.
• Privacy and ethical issues: Data privacy, ownership, and security are only a few of the ethical and privacy issues brought up by the usage of cloud computing and the Metaverse. It will be crucial to address these issues as the Metaverse and cloud computing develop in order to guarantee that they are used in an ethical and responsible manner.

3.5. Edge-Computing

3.6. blockchain, 3.7. three-dimensional modeling/scanning.

• Faro Technologies: Faro is a leading 3D scanning company. It provides many software tools, laser scanners, and 3D measuring, imaging, and realization technology.
• Artec 3D: Artec 3D, which is well-known for its portable, handheld 3D scanners, offers solutions for businesses in the automotive, aerospace, and entertainment sectors, as well as for independent producers.
• Hexagon: Hexagon provides high-precision 3D scanning and metrology solutions for sectors including automotive, aerospace, and manufacturing, with a strong emphasis on industrial applications.
• Leica Geosystems: Leica, a member of the Hexagon group, is well known for its precise, high-quality 3D scanning solutions for a range of markets, including building, surveying, and mapping sectors. They have cutting-edge laser scanning technology, such as the Leica BLK series, which makes it possible to seamlessly incorporate places and items from the real world into the Metaverse.

3.8. Digital Twins

4. use cases and deployment.

• In product design: Product design is the process of making physical or digital products. The Metaverse enables designers to have the full autonomy to create products that never existed. For instance, fashion companies like Nike and Balenciaga have created items that, even if they were available to consumers, they might not necessarily choose to wear in real life, but which help them create or define their virtual personas on this platform. Given the nearly endless innovation, designers have never-before-seen opportunities to push the limits of design [ 47 ].
• Improve the manufacturing and production process: Metaverse simulations provide the capability to test several factory scenarios and gain insights from scaling up or reducing production. The provision of optimization opportunities within the facilities through these simulations can be obtained without affecting the manufacturing that is already taking place. Practically, in a smart factory, operators can use Microsoft Dynamics 365 Guides for real-time instructions overlaid on equipment, while IoT sensors collect data on machine performance, quality metrics, and inventory levels. This renders it possible for operators to quickly identify and solve problems, optimize production settings, and enhance the general effectiveness and quality of manufacturing.
• Improve quality control: IoT sensors are deployed for the harnessing of data in manufacturing processes. This facilitates the collection of real-time data from the various equipment and machinery. Subsequently, one can examine data from the production procedures to find flaws or problems that require attention [ 48 ]. Manufacturing companies can streamline processes and boost efficiency by using Metaverse technologies and applications such as VR and AR. For example, Dynamics 365 Guides and Remote Assist can be leveraged for 3D drawing in a real-world environment. Moreover, front-line workers wearing a HoloLens can also annotate their physical space with digital ink, creating an interactive and immersive experience. In the automotive manufacturing industry, BMW workers wear headsets that overlay digital information onto real-world objects. This allows them to visually inspect and identify defects in the components in real time, reducing the risk of defective products reaching the assembly line or being shipped to customers.
• Better warehouse and logistics management: AR can be leveraged to streamline logistics and warehousing procedures by utilizing Metaverse technology. A case in point is that of DHL, a global logistics company that is using augmented reality (AR) headsets to provide their workers with real-time information, such as order details, inventory locations, and picking instructions, overlaid onto their field of vision. This allows their workers to work hands-free and efficiently navigate the warehouse, reducing errors and improving order accuracy.

• Biomechanics—the study of how the bones, muscles, tendons, and ligaments interact and affect an operator’s fatigue—will be applied to all the motions recorded. Subsequent software will replicate the biomechanics of an individual operator carrying out prolonged duties. Health problems can be precisely detected through simulation, and the operator can be fit with personalized protective equipment or bespoke exosuits.
• A digital twin can be created from each operator’s 3D model, allowing for the simulation of authentic factories. Given GM’s massive production staff and the amount of robots in the line, it is critical to determine whether the robots are not impeding operator movements. Before starting the production line, General Motors can ensure that the robots and workers are operating in perfect harmony.
• In real time, simulate and monitor the operator tasks: Precautionary steps can be performed before any work-related illness or accident arises by tracking biomechanics in real time. Businesses may protect the well-being and security of their most valuable asset—humans—with the aid of the IM.
• Massive data collection: Renault Group has created a platform for gathering large amounts of data to feed the IM, a special data capture and standardization solution, and levers that enable the production process to be performed in real-time while gathering data from all industrial sites. Massive data collection will benefit from dynamic spectrum technologies works in [ 82 , 83 , 84 ], and this may perhaps will be extended to smart farming [ 85 ] and cultural heritage [ 86 , 87 ].
• Digital twins of processes: The utilization of DTs is enhanced by supplier data, sales forecasts, quality data, and exogenous data like weather and traffic patterns, among other things. Artificial intelligence also makes it possible to create predictive scenarios.
• Connecting the supply chain ecosystem: Supplier data, sales forecasts, quality data, as well as external data like traffic or weather improve the use of digital twins. Artificial intelligence also makes it possible to create predictive scenarios.
• Ensemble of advanced technologies: Advanced technologies (big data, real time, 3D, cloud, etc.) are converging to speed up this digital transition. In light of the technologies’ convergence required to manage the digital twins and their ecosystems in a resilient manner, the Renault Group has created a special platform [ 88 ].

5. Environmental Impact and Sustainable Development

Click here to enlarge figure

• e-Waste: Electronic waste (e-waste) has significantly increased because of the growing need for the latest technology, posing an environmental threat. A case in point is the innovation in cellular phones that has adopted the digital part IM. Innovation is an expensive endeavor that requires much trial and error and produces waste in various forms. The digital part industry can reduce waste, conserve resources, and accelerate innovation cycles by moving the innovation process to the Internet of Medical Things. Faster innovation does, however, result in shorter product lifetimes, which increases waste and obsolescence. Consider the smartphone market, which is expected to sell more than 1.7 billion units by 2021. Since most of these cell phones have replaced older models in this (almost) mature market, there are now over 1.5 billion cell phones worth of e-waste. Innovation is a cause of this replacement as new, eye-catching models were introduced. Innovation must coexist with recycling and reuse because it is essential for business and beneficial to users. The IM, which spans all layers, can play a crucial role in innovation and e-waste management [ 94 ]. This unorganized sector often deprives e-waste of its most advantageous components, exacerbating the real threats posed by e-waste. All electronic waste contains hazardous elements like lead, cadmium, beryllium, mercury, and brominated flame retardants. Incorrect disposal of gadgets and devices increases the risk of these hazardous compounds leaking into water bodies, poisoning the air, and increasing the risk of contamination. Unmanaged e-waste directly affects people’s health and the environment, claims [ 95 ]. As a result of improper e-waste disposal, 45 million kg of polymers containing brominated flame retardants and 58 thousand kg of mercury are currently released into the environment annually. The increasing demand for electronics increases the quantity of outdated and abandoned electronics. Approximately 50 million tonnes of e-waste are produced annually, which is greater than the mass of all commercial aircraft ever manufactured. Rather, considering these factors, it can be inferred that the Metaverse will have a greater negative impact on the environment than a positive one [ 96 ]. However, according to [ 97 ], globally, only 17.4% of electronic waste is recycled, which worsens environmental and health problems, especially in developing nations. An estimated USD 57 billion is lost every year as a result of electronic waste being disposed of, including important raw materials like iron, copper, and gold. By implementing circular models, businesses can reduce their environmental impact and explore new opportunities to address e-waste issues. On the positive, it is important to note that, according to [ 95 ], 52 billion kg of CO 2 -equivalent emissions were avoided and 900 billion kg of ore were not dug during primary mining as a result of the creation of secondary raw material from e-waste recycling.
• Virtual economies and blockchain: The IM’s virtual economies, which are supported by blockchain technologies such as non-fungible tokens (NFTs) and cryptocurrencies, have significant energy needs. Blockchain networks’ energy usage is a major concern [ 98 , 99 ], particularly for those that employ proof-of-work consensus techniques. According to research, mining Bitcoin uses as much energy as small nations, which results in a large carbon footprint approximated to 475 g per kilowatt-hour (gCO 2 /kWh) [ 99 ]. Furthermore, Ref. [ 100 ] estimates that 127 terawatt-hours (TWh) are consumed annually by Bitcoin alone, which is more than several nations combined, including Norway. In the U.S., the cryptocurrency industry emits between 25 and 50 million tons of CO 2 annually, which is comparable to the emissions from U.S. railroads’ diesel fuel usage. It is recommended that GameFi platforms look into eco-friendly options, such as proof-of-stake consensus algorithms, to reduce their carbon footprint and enable the gaming industry to promote sustainable expansion [ 101 ].
• Elimination of pollution-generating activities: Increasingly, with the adoption of the IM, numerous pollution-generating activities are avoided. These activities range from commuting, face-to-face meetings, off-site work events, and transport. Virtual meeting space Gather.Town has over four million users who prefer a virtual space platform that provides a novel approach to organizing online conferences, events, and meetings. Users can engage each other in real time in a 2D environment on the platform virtually as if they were in the same physical space [ 102 , 103 ].
• Reduction in pollution generated by activities: To evaluate the effects of various scenarios on an entity’s energy consumption, such as a city or factory, one can use the Metaverse. To evaluate the effects of various scenarios on energy usage, an entity like a factory can be created using the IM. For instance, the IM’s digital twins can be used to replicate real-world performance conditions cost effectively and safely. Microsoft’s implementation of IM capabilities for Hellenic, one of the biggest Coca-Cola bottlers, is an example. With over 55 locations in Europe, Hellenic services 29 local markets. Ninety thousand Coca-Cola bottles are produced per hour on a single production line in Greece. Microsoft used sensor data to create digital twins that allowed factory workers to immerse themselves in the models. The factory reportedly reduced its energy consumption by more than 9% percent in 12 weeks. Furthermore, physical objects like diesel generators account for CO 2 emissions, amounting to 1,091,618 kg/yr of pollutants [ 104 ], and this is costly to mitigate.
• Reduction in the consumption of physical objects: It is important to think about the possible challenges of virtual consumption and how the environment might be affected. Although virtual environments have the potential to be more environmentally friendly than real ones, it is still unclear how this will impact energy consumption and carbon emissions [ 105 ]. Realizing the possibility of much less materialistic consumption can be facilitated by the IM. It is stated that 21% of consumers expressed their willingness to engage in digital activities in the future, which is expected to reduce the need for physical items [ 106 ].
• Precise assessment of pollution generated and improvement in reward and enforcement: Finding out how much pollution a company produces can help with processes related to rewards and enforcement, as well as encouraging the adoption of eco-friendly practices. While tracking carbon in the real world is difficult, it can be done in the Metaverse by using blockchain technology to create fungible digital assets. Tokenization makes it easier to transfer carbon credits and establishes a market for voluntary carbon credit exchange. The credits might be used to offset emissions that have been reduced as a result of conservation efforts in the forestry industry and participation in carbon sequestration initiatives like improved soil and altered land use planning. This is exemplified by Reseed company’s platform, which utilizes blockchain technology to ensure the validity of carbon stock management, from registration through validation and verification, enabling farmers to receive additional income while providing a potential return to investors [ 107 ]. To be ready for sustainability within the IM, enterprises may consider utilizing renewable energy sources and cloud services, in addition to developing a culture of examining the effects of products on the environment, as well as creating a circular economy.

6. Innovative Security and Privacy Threats

• Data security and cybersecurity risks: With the increased reliance on interconnected systems and data sharing, the IM raises concerns about data security and cybersecurity risks. To this end, more and more devices, as well as platforms are increasingly becoming interconnected. Practically, this increases the risk of cyber threats and data breaches. Safeguarding sensitive data is, thus, imperative to protect enterprises, governments, and individuals.
• Privacy implications and regulatory compliance: The IM also brings to the fore challenges with regulatory compliance and privacy issues. Thus, with companies collecting and analyzing huge amounts of data, there is a need to ensure that the privacy of individuals is respected and protected. Optimizing innovation and privacy is a challenge that needs to be addressed.
• Avatar authentication issue: Increasingly, digital avatars such as faces, videos, and voices are employed in the virtual world, which is a form of Metaverse, where user authentication and verification are common in comparison to the real world. Realistically, attackers can make identical sounds and movies by mimicking the appearance of the real user using sophisticated AR and VR tools and devices coupled with AI bots. Consequently, the security and privacy of avatars remain a major concern.

7. Future Research Challenges

• Security by design: The robust datasets linked to digital twins are useful for both businesses and hackers. Digital twins are vulnerable to manipulation by hackers who could use them to harvest identities, encrypt data, extort businesses, or spy on corporate [ 110 ] secrets. A case in point is the deployment of fake digital twins, which enable hackers to create virtual versions of users or entire environments using compromised data for criminal intents. A deep flake scenario could, as an example, pose as a dishonest executive member of a company in a Metaverse virtual conference room to trick the victim into disclosing sensitive information. Data Poisoning is another aspect where data from the underlying AI and ML learning systems may be altered. This compromises the insights businesses derive from their simulations and, in the worst case scenario, may result in disastrous business decisions based on inaccurate data. Companies run the risk of allocating funds to unproductive channels in the belief that they are acting based on reliable projections from their digital twins if, for instance, demographic data or action profiles of the modeled target groups are fabricated. Consequently, security and user privacy must be foundational design components that should be considered when creating any Metaverse applications rather than being added on later [ 111 ].
• Communications and protocol design: Immersive IM experiences will require high download speeds, low latency, and large capacity to facilitate heterogeneous interconnected devices to communicate with the virtual model at the requisite level. In industrial settings, this will require 5G and possibly also 6G networks [ 109 ]. To this end, a change in paradigm for the communication protocol will be required that is goal-oriented and semantically aware. A seamless instant messaging experience must be taken into account when designing a communication protocol. In the end, a model design will be needed to standardize the IM’s communication protocols, so that it can be accessed from various virtual worlds’ heterogeneous communication systems.
• Energy-efficient and Green IM: The IM market is now projected to be worth between USD 100 and USD 150 billion, with a conservative 2030 forecast of about USD 400 billion, but with a potential of increasing to more than USD 1 trillion [ 48 ]. The IM is creating more opportunities for companies and workers and increasing the adoption of greener practices and renewable energy [ 112 ].
• Limitations of VR and AR technologies: The current limitations in the capabilities and dependability of VR and AR technologies present a significant obstacle to the implementation of the IM in mining. To produce precise and practical digital twins of mines and supply the situational awareness required for increased safety, these technologies may be enhanced.
• High-cost implementation: The newest gear and software for virtual reality and augmented reality is expensive. To decide if these technologies are feasible for their operations, miners must assess the costs and potential benefits.
• Human factors and ergonomics: It is critical to protect the health and safety of employees on the IM. This entails reducing the possibility of accidents, making sure employees are properly trained, and offering help when needed. Furthermore, using the IM for an extended period may harm one’s health.
• Training and adoption: The workforce in the mining sector is diverse, and not every employee may be familiar with the newest technological advancements. Some may oppose the changes engineered by the use of new instruments. Mining businesses must engage in thorough and customized training and change management programs that are especially geared to suit the needs of their employees to ensure the successful adoption and usage of these tools.

8. Conclusions

Author contributions, data availability statement, conflicts of interest.

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Share and Cite

Nleya, S.M.; Velempini, M. Industrial Metaverse: A Comprehensive Review, Environmental Impact, and Challenges. Appl. Sci. 2024 , 14 , 5736. https://doi.org/10.3390/app14135736

Nleya SM, Velempini M. Industrial Metaverse: A Comprehensive Review, Environmental Impact, and Challenges. Applied Sciences . 2024; 14(13):5736. https://doi.org/10.3390/app14135736

Nleya, Sindiso Mpenyu, and Mthulisi Velempini. 2024. "Industrial Metaverse: A Comprehensive Review, Environmental Impact, and Challenges" Applied Sciences 14, no. 13: 5736. https://doi.org/10.3390/app14135736

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