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Tseng TY, Mitchell MM, Chander G, Latkin C, Kennedy C, Knowlton AR. Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV. AIDS Behav 2024; 28:429-438. [PMID: 38060111 DOI: 10.1007/s10461-023-04235-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.
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Affiliation(s)
- Tuo-Yen Tseng
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bailey J, Gill S, Poole R. Long-term, high-dose opioid prescription for chronic non-cancer pain in primary care: an observational study. BJGP Open 2022; 6:BJGPO.2021.0217. [PMID: 35728819 PMCID: PMC9904796 DOI: 10.3399/bjgpo.2021.0217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/23/2022] [Accepted: 06/16/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Opioid prescriptions for chronic pain have risen sharply over the last 25 years; harms associated with these drugs are related to dose and length of use. AIM The main aim of this study was to identify patients prescribed long-term, high-dose (LTHD) opioids in the community and to assess the prevalence of such use. DESIGN & SETTING An observational study of opioid prescribing in two demographically dissimilar GP practices in North Wales, UK. METHOD Details of opioid prescriptions were collected for 22 841 patients, of whom 1488 (6.5%) were being prescribed opioids on the census date. Exhaustive examination of the data identified all patients who were prescribed oral morphine equivalent doses of ≥120 mg/day for ≥1 year. RESULTS All these patients were being prescribed ≥120 mg/day, as a single drug, morphine, oxycodone, fentanyl, or buprenorphine, irrespective of opioid polypharmacy. Across both practices, 1.71/1000 patients were identified as LTHD users of opioid medication for chronic non-cancer pain (CNCP). Prevalence was similar in the two practices. Repetition of the process until January 2021 showed no change in the pattern. CONCLUSION This study offers confirmation that a significant group of patients are prescribed long-term opioid medication for chronic pain at doses that are unlikely to be effective in reducing pain, but are likely to have harmful consequences. The findings offer a simple, reliable, and practical method of data extraction to identify these patients individually from routinely collected prescribing data, which will help in monitoring and treating individuals and establishing the problem prevalence.
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Affiliation(s)
- John Bailey
- Centre for Mental Health and Society, Bangor University Wrexham Academic Unit, Technology Park Wrexham, Wrexham, UK
| | - Simon Gill
- Betsi Cadwaladr University Health Board, North Wales, UK
| | - Rob Poole
- Centre for Mental Health and Society, Bangor University, Bangor, UK
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A qualitative interview study of GPs' experiences of prescribing opioid medication for chronic pain. BJGP Open 2022; 6:BJGPO.2022.0085. [PMID: 36216370 PMCID: PMC9904793 DOI: 10.3399/bjgpo.2022.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses. AIM To explore GPs' experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice. DESIGN & SETTING Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales. METHOD Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach. RESULTS Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions. CONCLUSION Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely.
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Kosakowski S, Benintendi A, Lagisetty P, Larochelle MR, Bohnert ASB, Bazzi AR. Patient Perspectives on Improving Patient-Provider Relationships and Provider Communication During Opioid Tapering. J Gen Intern Med 2022; 37:1722-1728. [PMID: 34993861 PMCID: PMC9130417 DOI: 10.1007/s11606-021-07210-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/08/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND Efforts to reduce opioid overdose fatalities have resulted in tapering (i.e., reducing or discontinuing) opioid prescriptions despite a limited understanding of patients' experiences. OBJECTIVE To explore patients' perspectives on opioid taper experiences to ultimately improve taper processes and outcomes. DESIGN Qualitative study. PARTICIPANTS Patients on long-term opioid therapy for chronic pain who had undergone a reduction of opioid daily prescribed dosage of ≥50% in the past 2 years in two distinct medical systems and regions. APPROACH From 2019 to 2020, we conducted semi-structured interviews that were audio-recorded, transcribed, systematically coded, and analyzed to summarize the content and identify key themes regarding taper experiences overall and with particular attention to patient-provider relationships and provider communication during tapers. KEY RESULTS Participants (n=41) had lived with chronic pain for an average of 17.4 years (range, 3-36 years) and described generally adverse experiences with opioid tapers, the initiation of which was not always adequately justified or explained to them. Consequences of tapers ranged from minor to substantial and included withdrawal, mobility issues, emotional distress, exacerbated mental health symptoms, and feelings of social stigmatization for which adequate supports were typically unavailable. Narratives highlighted the consequential role of patient-provider relationships throughout taper experiences, with most participants describing significant interpersonal challenges including poor provider communication and limited patient engagement in decision making. A few participants identified qualities of providers, relationships, and communication that fostered more positive taper experiences and outcomes. CONCLUSIONS From patients' perspectives, opioid tapers can produce significant physical, emotional, and social consequences, sometimes reducing trust and engagement in healthcare. Patient-provider relationships and communication influence patients' perceptions of the quality and outcomes of opioid tapers. To improve patients' experiences of opioid tapers, tapering plans should be based on individualized risk-benefit assessments and involve patient-centered approaches and improved provider communication.
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Affiliation(s)
- Sarah Kosakowski
- Clinical Addiction Research and Evaluation Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Allyn Benintendi
- Clinical Addiction Research and Evaluation Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Pooja Lagisetty
- Michigan Medicine, Department of Internal Medicine, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Marc R Larochelle
- Clinical Addiction Research and Evaluation Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Michigan Medicine, Department of Anesthesiology, Ann Arbor, MI, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, La Jolla, CA, USA.
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:279-283. [DOI: 10.1093/ijpp/riac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 03/14/2022] [Indexed: 11/14/2022]
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Thakur T, Frey M, Chewning B. Communication between patients and health care professionals about opioid medications. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 2:100030. [PMID: 35481112 PMCID: PMC9030717 DOI: 10.1016/j.rcsop.2021.100030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/26/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022] Open
Abstract
Prescription opioids contribute to 40% of opioid overdose deaths in the United States. Healthcare professionals (HCPs) play an important role in mitigating the prescription opioid epidemic by appropriate opioid prescribing and patient education. Yet, little empirical literature addresses pharmacist (and other HCP) communication with patients related to risks of opioid use associated with dependence, misuse, and overdose. Nor is there much research on the barriers and facilitators which affect whether and how much opioid-related information is discussed. This commentary, based on an extensive literature search, seeks to inform future communication, education, and research agendas by describing (1) topics commonly discussed or excluded from opioid medication counseling, (2) patient and HCP perceptions regarding opioid medication communication, and (3) barriers and facilitators to opioid risk communication. Based on this literature, recommendations are provided for opioid counseling practices, pharmacist education, and research agendas.
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Affiliation(s)
- Tanvee Thakur
- Social and Administrative Sciences in Pharmacy Division, University of Wisconsin-Madison School of Pharmacy, United States
- Corresponding author at: 777 Highland Avenue, Madison, WI 53705, United States.
| | - Meredith Frey
- PGY2 Pharmacy Resident – Ambulatory Care Setting, University of Iowa Hospitals and Clinics, United States
| | - Betty Chewning
- Social and Administrative Sciences in Pharmacy Division, University of Wisconsin-Madison School of Pharmacy, United States
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Roper KL, Jones J, Rowland C, Thomas-Eapen N, Cardarelli R. Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment. PATIENT EDUCATION AND COUNSELING 2021; 104:585-594. [PMID: 32958306 PMCID: PMC7921200 DOI: 10.1016/j.pec.2020.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/21/2020] [Accepted: 08/26/2020] [Indexed: 05/29/2023]
Abstract
OBJECTIVE A mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care. METHODS Two focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks. RESULTS CP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive. CONCLUSION Patients' understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies. PRACTICE IMPLICATIONS These findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.
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Affiliation(s)
- Karen L Roper
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA.
| | - Jarred Jones
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Courtney Rowland
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Neena Thomas-Eapen
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
| | - Roberto Cardarelli
- Department of Family and Community Medicine, University of Kentucky College of Medicine. Lexington, Kentucky, USA
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Thakur T, Frey M, Chewning B. Student pharmacist opioid consultations with standardized limited English proficiency patients: A pre-post educational intervention study. CURRENTS IN PHARMACY TEACHING & LEARNING 2021; 13:146-151. [PMID: 33454071 DOI: 10.1016/j.cptl.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/15/2020] [Accepted: 09/21/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND PURPOSE This study explored the effect of a structured educational intervention for student pharmacists to counsel limited English proficiency (LEP) patients on risks and safety of opioid medications for chronic pain. Specific aims were to compare 2018 pre-intervention versus 2019 post-intervention groups regarding: (1) dose and side effects discussed, (2) opioid risks and safety measures covered, and (3) LEP specific communication practices. EDUCATIONAL ACTIVITY AND SETTING Third-year student pharmacists (P3s) in a required communications course consulted LEP standardized patients (SPs) on opioid medications in 2018 and 2019. An educational intervention for the 2019 P3s consisted of a 50-min lecture, pre-lab instructions about techniques for communication about opioid risks and safety, and for LEP specific communication stressing teach-back. All consultations in the pre- and post-intervention phases were video recorded and quantitatively coded for verbal and non-verbal communication skills. Descriptive statistics and Fisher's exact tests were conducted on data. FINDINGS Twenty-three consultations were recorded in 2018 for the pre-intervention phase and 49 consultations were recorded in 2019 for the post-intervention phase. Only 17% of students in the pre- intervention phase called the medication an "opioid" or "narcotic" in the consultation as compared to 84% in the post-intervention phase. While 100% of students in the post-intervention phase used teach-back, only 61% did so in the pre-intervention group. Significant differences between the two groups were observed for minimizing dependency and overdose, offering naloxone, teach-back, integrating a patient handout into the consultation, and discussing use of alternate pain medications.
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Affiliation(s)
- Tanvee Thakur
- Social and Administrative Sciences in Pharmacy Division, University of Wisconsin-Madison School of Pharmacy, United States.
| | - Meredith Frey
- PGY2 Pharmacy Resident - Ambulatory Care Setting, University of Iowa Hospitals and Clinics, United States.
| | - Betty Chewning
- Social and Administrative Sciences in Pharmacy, University of Wisconsin-Madison School of Pharmacy, United States.
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Palis H, Guh D, MacDonald S, Harrison S, Brissette S, Marsh DC, Schechter MT, Oviedo-Joekes E. Longitudinal patterns of cocaine use among patients receiving injectable hydromorphone or diacetylmorphine for the treatment of opioid use disorder: A growth curve modeling approach. Drug Alcohol Depend 2021; 218:108333. [PMID: 33268225 DOI: 10.1016/j.drugalcdep.2020.108333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Cocaine use is prevalent among people receiving injectable opioid agonist treatment. Investigations of cocaine use in this population have been descriptive and the potential heterogeneity existing in patterns of use have not been characterized. As such, among patients receiving injectable opioid agonist treatment, this study aimed to: 1) quantify intra- and inter-individual variation in cocaine use over 24-months and; 2) determine how predictors of interest explained this variation. METHODS Participants were patients receiving injectable opioid agonist treatment for opioid use disorder. Study visits were completed at baseline prior to receiving treatment, and 3,6,9,12,18, and 24 months after baseline. A multi-level regression approach to growth curve modeling was employed to estimate and explain intra- (within-person) and inter-individual (between-person) variation in cocaine use. RESULTS Significant intra and inter-individual variation in cocaine use was identified over 24-months. Treatment engagement was on average associated with reductions in the prior month number of days of cocaine use (range: 0-30)(Estimate (standard error): -0.05(0.02), p = 0.003). On average, men reported less cocaine use compared to women (Estimate (standard error): -5.91(1.57), p=<0.001), and participants reporting ever regularly using cocaine at baseline reported more cocaine use over 24-months compared to participants reporting never regularly using cocaine (Estimate (standard error): 4.72 (1.91), p = 0.013). CONCLUSIONS Significant reductions in cocaine use were observed and significant heterogeneity in patterns of cocaine use was identified. These heterogeneous cocaine use profiles suggest that an individualized approach to care will be critical in responding to patients' cocaine use in injectable opioid agonist treatment.
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Affiliation(s)
- Heather Palis
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Daphne Guh
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Suzanne Brissette
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 St-Denis, Montréal, QC, H2X 0A9, Canada
| | - David C Marsh
- Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON, P3E 2C6, Canada; Canadian Addiction Treatment Centres, 175 Commerce Valley West, Suite 300, Markham, Ontario, L3T 7P6, Canada; ICES North, 41 Ramsey Lake Rd, Sudbury, ON, P3E 5J1, Canada; Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada
| | - Martin T Schechter
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
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Holtrop JS, Fisher M, Martinez DE, Simpson M, Awadallah NS, Nease DE, Zittleman L, Westfall JM. What Works for Managing Chronic Pain: An Appreciative Inquiry Qualitative Analysis. J Prim Care Community Health 2020; 10:2150132719885286. [PMID: 31747822 PMCID: PMC6873267 DOI: 10.1177/2150132719885286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Chronic pain is a prevalent and dynamic condition for
both patients and providers. Learning how patients with chronic pain
successfully manage their pain may prove helpful in guiding health care
providers in their treatment of other patients with chronic pain. This research
sought to identify successful strategies for managing chronic pain from
interviews with individuals experiencing chronic pain who were able to do “most
of what they want on most days.” Methods: Qualitative, descriptive
study. Patients were from metro Denver, Colorado, USA and were recruited from
community and health care settings. Appreciative inquiry (AI) was used as an
approach to elicit stories of successful pain management. We conducted
one-on-one, in person interviews using a semistructured interview guide.
Analysis was completed using a grounded hermeneutic editing approach.
Results: Twenty-four interviews were completed representing a
range of adult ages, genders, race/ethnicities, and underlying reasons for
chronic pain. Consistent themes were found in that all patients had developed
multiple strategies for ongoing pain management and prevention, as well as a
mental approach embedded with elements of positive beliefs and determination.
Friends, family, support group members, and health care providers were key in
support and ongoing management. Although 10 patients regularly used opioid pain
medications, none were dependent, and all stated an active desire to avoid these
medications. Conclusions: Successful chronic pain management seems
possible as displayed from the patient narratives but requires persistence
through individual trial and error. Recommendations for health care provider
teams are made to apply these findings to assist patients with chronic pain.
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Affiliation(s)
| | - Mary Fisher
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | | | - Matthew Simpson
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Nida S Awadallah
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Donald E Nease
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Linda Zittleman
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - John M Westfall
- University of Colorado Denver School of Medicine, Aurora, CO, USA
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Finley EP, Schneegans S, Curtis ME, Bebarta VS, Maddry JK, Penney L, McGeary D, Potter JS. Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts. PLoS One 2020; 15:e0234425. [PMID: 32542028 PMCID: PMC7295233 DOI: 10.1371/journal.pone.0234425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 05/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors. OBJECTIVE We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S. DESIGN We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems. PARTICIPANTS Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated. APPROACH Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation. KEY RESULTS Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery. CONCLUSIONS Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.
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Affiliation(s)
- Erin P. Finley
- UT Health San Antonio, San Antonio, Texas, United States of America
- South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Suyen Schneegans
- UT Health San Antonio, San Antonio, Texas, United States of America
| | - Megan E. Curtis
- UT Health San Antonio, San Antonio, Texas, United States of America
| | - Vikhyat S. Bebarta
- University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Joseph K. Maddry
- Emergency Department, Brooke Army Medical Center, San Antonio, Texas, United States of America
- 59th Medical Wing Science and Technology Cell, San Antonio, Texas, United States of America
- San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, United States of America
| | - Lauren Penney
- UT Health San Antonio, San Antonio, Texas, United States of America
- South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Don McGeary
- UT Health San Antonio, San Antonio, Texas, United States of America
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Thakur T, Barnet JH, LeCaire T, Bersch A, Peppard P, Malecki K, Moberg DP. Prescribed Opioid Use in Wisconsin 2008-2016: Findings From the Survey of the Health of Wisconsin. WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2020; 119:102-109. [PMID: 32659062 PMCID: PMC7492104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND The opioid epidemic is a national crisis. The objectives of this report were to describe prescription opioid use in Wisconsin from 2008 through 2016 using unique populationrepresentative data and to assess which demographic, health, and behavioral health characteristics were related to past 30-day prescribed opioid use. METHODS Data were obtained from the Survey of the Health of Wisconsin (SHOW), a statewide representative sample of 4,487 adults. Prescription medication use was ascertained via in-person interviews that included an inventory of all prescription medications used by the respondent in the past 30 days. The data were weighted to represent the adult population of Wisconsin, aged 21 to 74. Chi-square, logistic regression, and descriptive statistics were used to analyze data. RESULTS From 2008 to 2016, 6.4% (95% CI, 5.5-7.3) of adults age 21 years or older reported using a prescribed opioid in the past 30 days. Hydrocodone was the most prescribed opioid class followed by oxycodone. People 50 years of age and older, self-identified black or Hispanic, urban dwellers, those with a high school education or less, and those having incomes below 200% of the federal poverty level (FPL) reported significantly higher rates of prescribed opioid use relative to others. Participants reporting physician-diagnosed drug or alcohol abuse, current smokers, and those currently suffering from depression also reported significantly higher use. CONCLUSION These data from 2008-2016 demonstrate concerning levels of prescription opioid use and provide data on which population groups may be most vulnerable. While policies and clinical practice have changed since 2016, ongoing evaluation of prescribing practices, including consideration of behavioral health issues when prescribing opioids, is called for.
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Affiliation(s)
- Tanvee Thakur
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin
| | - Jodi H Barnet
- Survey of the Health of Wisconsin, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Tamara LeCaire
- Survey of the Health of Wisconsin, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrew Bersch
- Survey of the Health of Wisconsin, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Paul Peppard
- Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kristen Malecki
- Survey of the Health of Wisconsin, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - D Paul Moberg
- Population Health Institute, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,
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13
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Taylor JL, Drazich BF, Roberts L, Okoye S, Rivers E, Wenzel J, Wright R, Beach MC, Szanton SL. Pain in low-income older women with disabilities: a qualitative descriptive study. J Women Aging 2020; 32:402-423. [PMID: 32475259 DOI: 10.1080/08952841.2020.1763895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The purpose of this qualitative study was to identify how low-income older women with disabilities perceive pain, pain management, and communication with healthcare providers. We interviewed 26 low-income women (average age 75 years; SD 7.0), eliciting the following overarching themes: "Invisibility of Pain: Unnoticed or Undetected," "Escalating Pain Leads to Help Seeking," "Communication with Healthcare Providers and Outcomes," "Pain Management Facilitates Function and Accomplishment," and "The Intersection of Pain, Disability, and Depressive Symptoms." Study findings support the ways in which behavior changes from pain can impede pain management.
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Affiliation(s)
- Janiece L Taylor
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | | | - Laken Roberts
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Safiyyah Okoye
- Bloomberg School of Public Health, Johns Hopkins University , Baltimore, Maryland, USA
| | - Emerald Rivers
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Jennifer Wenzel
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Rebecca Wright
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA.,Bloomberg School of Public Health, Johns Hopkins University , Baltimore, Maryland, USA
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14
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Torres PJ, Henry SG, Ramanathan V. Let's talk about pain and opioids: Low pitch and creak in medical consultations. DISCOURSE STUDIES 2020; 22:174-204. [PMID: 32256188 PMCID: PMC7111341 DOI: 10.1177/1461445619893796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
In recent years, the opioid crisis in the United States has sparked significant discussion on doctor-patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources when describing chronic pain, narrating symptoms, and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions.
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Affiliation(s)
| | - Stephen Gresham Henry
- Division of General Medicine, Geriatrics, and Bioethics, University of California Davis, Sacramento, CA, USA
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15
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Thakur T, Frey M, Chewning B. Pharmacy Student Opioid Consultations with Standardized Limited English Proficiency Patients. CURRENTS IN PHARMACY TEACHING & LEARNING 2020; 12:418-422. [PMID: 32334757 DOI: 10.1016/j.cptl.2019.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 09/27/2019] [Accepted: 12/07/2019] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Limited healthcare studies have analyzed communication practices with limited English proficiency (LEP) patients. Empirical literature lacks evidence about LEP patient-pharmacist communication about opioid risks. This study aimed to (1) explore topics discussed in opioid medication consults, (2) assess if students inform patients about dependency and overdose risks associated with opioid use and the manner in which those risks were introduced and discussed, and (3) assess LEP specific communication practices. METHODS Third-year pharmacy students in a required communications course consulted LEP standardized patients (SPs) who spoke 30% English and 70% non-English language. The SP followed a script simulating an encounter between a pharmacist and patient picking up a new, month long prescription of oxycodone. All consultations were video recorded and quantitatively coded for verbal and non-verbal communication skills. RESULTS Twenty-three pharmacy students conducted consultations with LEP SPs. The majority of students discussed common side effects, but only a few discussed severe side effects. Four of 23 students named the medication as an "opioid" or "narcotic" and described dependency, overdose, or other opioid specific risks. Students used several filler words, long sentences, and a fast pace. A majority of students used teach back methods to identify patient understanding. Students expressed the need for more structured education and training in providing patient counseling for opioids and communicating with LEP patients. CONCLUSIONS Pharmacy students lack confidence and skills in communicating with LEP patients regarding opioid-specific risks, suggesting structured training is needed.
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Affiliation(s)
- Tanvee Thakur
- University of Wisconsin-Madison School of Pharmacy, United States.
| | - Meredith Frey
- University of Iowa Hospitals and Clinics, United States.
| | - Betty Chewning
- University of Wisconsin-Madison School of Pharmacy, United States.
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16
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Gerhart J, Duberstein P, Paull D, O'Mahony S, Burns J, DeNicolo M, Hoerger M. Geopersonality of Preventable Death in the United States: Anger-Prone States and Opioid Deaths. Am J Hosp Palliat Care 2020; 37:624-631. [PMID: 32008364 DOI: 10.1177/1049909120902808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Opioid overdoses have reached epidemic levels in the United States and have clustered in Northeastern and "Rust Belt" states. Five Factor Model (FFM) personality traits also vary at the state level, with anger-prone traits clustered in the Northeast region. This study tested the hypothesis that state-level anger proneness would be associated with a greater increase in rates of opioid overdose death. METHODS This was a secondary analysis of state-level data on FFM traits, opioid overdose deaths, and other classes of preventable death. Robust mixed models tested whether change in rates of opioid overdose death from 2008 to 2016 was moderated by state-level anger proneness. RESULTS State-level anger proneness was significantly associated with greater increases in rates of opioid overdose deaths (B = 1.01, standard error = 0.19, P < .001, 95% confidence interval: 0.63-1.39). The slope of increase in opioid overdose death rates was 380% greater in anger-prone states and held after adjustment for potential confounders such as state-level prevalence of major depressive disorder, number of mental health facilities, and historical patterns of manufacturing decline. A similar pattern was observed between state-level anger proneness and benzodiazepine overdose deaths but was not significant for the latter after adjustment for potential confounders. CONCLUSION These findings suggest that states characterized as more anger prone have experienced greater increases in opioid overdose deaths.
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Affiliation(s)
- James Gerhart
- Department of Psychology, Central Michigan University, MI, USA
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Health, New Brunswick, NJ, USA
| | - Danielle Paull
- Department of Psychology, Central Michigan University, MI, USA
| | - Sean O'Mahony
- Department of Internal Medicine, Palliative Medicine Service, Rush University Medical Center, Chicago, IL, USA
| | - John Burns
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | | | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, LA, USA
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17
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Gruß I, Firemark A, Mayhew M, McMullen CK, DeBar LL. Taking opioids in times of crisis: Institutional oversight, chronic pain and suffering in an integrated healthcare delivery system in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:62-68. [PMID: 31536957 PMCID: PMC6893145 DOI: 10.1016/j.drugpo.2019.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Opioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews. METHODS We interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12. RESULTS The experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients' relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain. CONCLUSION We highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.
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Affiliation(s)
- Inga Gruß
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Alison Firemark
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Meghan Mayhew
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Carmit K McMullen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466, United States.
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18
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Henry SG, Matthias MS. Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review. PAIN MEDICINE 2019; 19:2154-2165. [PMID: 29401356 DOI: 10.1093/pm/pny003] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research. Methods A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development. Results The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids. Conclusions Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.
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Affiliation(s)
- Stephen G Henry
- Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Department of Communication Studies, Indiana University-Purdue University, Indianapolis, Indiana.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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19
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Heirich MS, Sinjary LS, Ziadni MS, Sacks S, Buchanan AS, Mackey SC, Newmark JL. Use of Immersive Learning and Simulation Techniques to Teach and Research Opioid Prescribing Practices. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:456-463. [PMID: 30215778 PMCID: PMC6657568 DOI: 10.1093/pm/pny171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Unsafe opioid prescribing practices to treat acute and chronic pain continue to contribute to the opioid overdose crisis in the United States, a growing public health emergency that harms patients and their communities. Poor opioid prescribing practices stem in part from a lack of education and skills training surrounding pain and opioid management. METHODS As part of the Clinical Pain Medicine Fellowship at Stanford University, physicians were given the opportunity to participate in a pilot program to practice opioid management in a live, simulated interaction. Twenty-seven physician trainees participated in the simulation with a live, standardized patient actor. Before beginning the simulation, participants were given a detailed patient history that included the patient's risk for opioid abuse. They were also provided with relevant risk evaluation and mitigation (REM) tools. All simulation interactions were video-recorded and coded by two independent reviewers. A detailed coding scheme was developed before video analysis, and an inter-rater reliability score showed substantial agreement between reviewers. RESULTS Contrary to expectations, many of the observed performances by trainees contained aspects of unsafe opioid prescribing, given the patient history. Many trainees did not discuss their patient's aberrant behaviors related to opioids or the patient's risk for opioid abuse. Marked disparities were also observed between the trainees' active patient interactions and their written progress notes. DISCUSSION This simulation addresses a pressing need to further educate, train, and provide point-of-care tools for providers prescribing opioids. We present our experience and preliminary findings.
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Affiliation(s)
- Marissa S Heirich
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Lanja S Sinjary
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Maisa S Ziadni
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Sandra Sacks
- Department of Anesthesiology, Ronald Regan UCLA Medical Center, Los Angeles, CA
| | - Alexandra S Buchanan
- Center for Immersive and Simulation-based Learning, Stanford University School of Medicine, Stanford CA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, Stanford, CA
| | - Jordan L Newmark
- Department of Anesthesiology, Pain and Functional Restoration Clinic, Alameda Health System, Oakland, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Addiction, Stanford University School of Medicine, Stanford, CA
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20
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Lor M, Koleck TA, Bakken S. Information visualizations of symptom information for patients and providers: a systematic review. J Am Med Inform Assoc 2019; 26:162-171. [PMID: 30535152 PMCID: PMC6657383 DOI: 10.1093/jamia/ocy152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 12/25/2022] Open
Abstract
Objective To systematically synthesize the literature on information visualizations of symptoms included as National Institute of Nursing Research common data elements and designed for use by patients and/or healthcare providers. Methods We searched CINAHL, Engineering Village, PsycINFO, PubMed, ACM Digital Library, and IEEE Explore Digital Library to identify peer-reviewed studies published between 2007 and 2017. We evaluated the studies using the Mixed Methods Appraisal Tool (MMAT) and a visualization quality score, and organized evaluation findings according to the Health Information Technology Usability Evaluation Model. Results Eighteen studies met inclusion criteria. Ten of these addressed all MMAT items; 13 addressed all visualization quality items. Symptom visualizations focused on pain, fatigue, and sleep and were represented as graphs (n = 14), icons (n = 4), and virtual body maps (n = 2). Studies evaluated perceived ease of use (n = 13), perceived usefulness (n = 12), efficiency (n = 9), effectiveness (n = 5), preference (n = 6), and intent to use (n = 3). Few studies reported race/ethnicity or education level. Conclusion The small number of studies for each type of information visualization limit generalizable conclusions about optimal visualization approaches. User-centered participatory approaches for information visualization design and more sophisticated evaluation designs are needed to assess which visualization elements work best for which populations in which contexts.
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Affiliation(s)
- Maichou Lor
- School of Nursing, Columbia University, New York City, New York USA
| | - Theresa A Koleck
- School of Nursing, Columbia University, New York City, New York USA
| | - Suzanne Bakken
- School of Nursing, Columbia University, New York City, New York USA
- Department of Biomedical Informatics, Columbia University, New York City, New York USA
- Data Science Institute, Columbia University, New York City, New York, USA
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21
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Isenberg SR, Maragh-Bass AC, Ridgeway K, Beach MC, Knowlton AR. A qualitative exploration of chronic pain and opioid treatment among HIV patients with drug use disorders. J Opioid Manag 2018; 13:5-16. [PMID: 28345742 PMCID: PMC5560049 DOI: 10.5055/jom.2017.0363] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The study explored high-risk participants' experiences with pain management regarding clinical access to and use of prescription opioids. DESIGN Qualitative semistructured interviews and focus groups. SETTING Data were collected August 2014 to May 2015 at an urban community-based research facility in Baltimore City, MD. PARTICIPANTS HIV participants with chronic pain and a history of illicit drug use. METHODS Qualitative coding and analysis used an iterative, inductive, and thematic approach and coders achieved inter-coder consistency. RESULTS The authors identified two major themes. First, participants had positive and negative interactions with healthcare providers regarding chronic pain treatment. Participants perceived that providers lacked empathy for their pain and/or were not adequately managing their pain. These interactions resulted in participants seeking new providers or mistrusting the medical system. Further, providers' surveillance of participants' pain treatment regimen contributed to distress surrounding pain management. The second theme centered on participants' pain management experiences with prescribed opioid analgesics. Participants felt they were receiving dosages and classes of analgesics that did not sufficiently address their pain, and consequently modified their dosages or rationed prescription opioids. Other participants were reluctant to take analgesics due to their history of illicit drug use. Some participants relapsed to illicit drug use when they felt their prescription opioids did not adequately address their pain needs. CONCLUSIONS Participant struggles with receiving and managing prescribed opioid analgesics suggest a need for: therapies beyond these medications; guidelines for providers specific to this population; and harm reduction trainings for providers.
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Affiliation(s)
- Sarina R Isenberg
- Doctoral Candidate, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Allysha C Maragh-Bass
- Doctoral Candidate, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kathleen Ridgeway
- Graduate of the MSPH program, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary C Beach
- Professor of Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amy R Knowlton
- Associate Professor, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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22
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Matthias MS, Johnson NL, Shields CG, Bair MJ, MacKie P, Huffman M, Alexander SC. "I'm Not Gonna Pull the Rug out From Under You": Patient-Provider Communication About Opioid Tapering. THE JOURNAL OF PAIN 2017; 18:1365-1373. [PMID: 28690000 PMCID: PMC6219456 DOI: 10.1016/j.jpain.2017.06.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many health care organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. Because of the importance of effective patient-provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) explaining-patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential, 2) negotiating-patients needed to have input, even if it was simply the rate of tapering, 3) managing difficult conversations-when patients and providers did not reach a shared understanding, difficulties and misunderstandings arose, and 4) nonabandonment-patients needed to know that their providers would not abandon them throughout the tapering process. PERSPECTIVE Although opioid tapering can be challenging, helping patients to understand individualized reasons for tapering, encouraging patients to have input into the process, and assuring patients they would not be abandoned all appear to facilitate optimal communication about tapering.
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Affiliation(s)
- Marianne S Matthias
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana; Department of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana; Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
| | - Nicole L Johnson
- Department of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
| | - Cleveland G Shields
- Department of Human Development & Family Studies, Regenstrief Center for Healthcare Engineering, Purdue Center for Cancer Research, Purdue University, West Lafayette, Indiana
| | - Matthew J Bair
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Inc, Indianapolis, Indiana; Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Palmer MacKie
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Henry SG, Bell RA, Fenton JJ, Kravitz RL. Goals of Chronic Pain Management: Do Patients and Primary Care Physicians Agree and Does it Matter? Clin J Pain 2017; 33:955-961. [PMID: 28244944 PMCID: PMC5572549 DOI: 10.1097/ajp.0000000000000488] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Assess patient-physician agreement on management goals for chronic musculoskeletal pain and its associations with patient and physician visit experiences. MATERIALS AND METHODS Pre-visit and post-visit questionnaires for 87 primary care visits that involved patients taking opioids for chronic musculoskeletal pain and primary care resident physicians. After each visit, patients and physicians independently ranked 5 pain treatment goals from most to least important. RESULTS In total, 48% of patients ranked reducing pain intensity as their top priority, whereas 22% ranked finding a diagnosis as most important. Physicians ranked improving function as the top priority for 41% of patients, and ranked reducing medication side effects as most important for 26%. The greatest difference between patient and physician rankings was for reducing pain intensity. In regression analyses, neither overall agreement on goals (ie, the physician's first or second priority included the patient's top priority) nor difference in patient versus physician ranking of pain intensity was significantly associated with patient-reported visit experience (β for overall agreement, -0.08; 95% confidence interval [CI], -0.45 to 0.30; P=0.69; β for intensity, -0.06; 95% CI, -0.17 to 0.04; P=0.24) or physician-reported visit difficulty (β for overall agreement, 1.92; 95% CI, -2.70 to 6.55; P=0.41; β for intensity, 0.42; 95% CI, -0.87 to 1.71; P=0.53). DISCUSSION Patients and physicians prioritize substantially different goals for chronic pain management, but there is no evidence that agreement predicts patient experience or physician-reported visit difficulty. Primary care physicians may have adapted to new recommendations that emphasize functional goals and avoidance of long-term opioid therapy, whereas patients continue to focus on reducing pain intensity.
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Affiliation(s)
- Stephen G Henry
- Department of Internal Medicine; University of California Davis; 4150 V Street Suite 2400; Sacramento, CA 95817; USA
- University of California Davis Center for Healthcare Policy and Research; 2103 Stockton Boulevard; Sacramento, CA 95817; USA
| | - Robert A Bell
- Departments of Communication and Public Health Sciences; University of California, Davis; 377 Kerr Hall; Davis, CA 95616; USA
| | - Joshua J Fenton
- University of California Davis Center for Healthcare Policy and Research; 2103 Stockton Boulevard; Sacramento, CA 95817; USA
- Department of Family and Community Medicine; University of California, Davis; 4860 Y Street Suite 2300; Sacramento, CA 95817; USA
| | - Richard L Kravitz
- Department of Internal Medicine; University of California Davis; 4150 V Street Suite 2400; Sacramento, CA 95817; USA
- University of California Davis Center for Healthcare Policy and Research; 2103 Stockton Boulevard; Sacramento, CA 95817; USA
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24
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Mitchell MM, Nguyen TQ, Maragh-Bass AC, Isenberg SR, Beach MC, Knowlton AR. Patient-Provider Engagement and Chronic Pain in Drug-Using, Primarily African American Persons Living with HIV/AIDS. AIDS Behav 2017; 21:1768-1774. [PMID: 27787673 DOI: 10.1007/s10461-016-1592-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Among disadvantaged persons living with HIV/AIDS (PLHIV), patient-provider engagement, which has been defined as patient-provider relationships that promote the use of health care services and are characterized by active listening and supportive decision making, has been associated with antiretroviral therapy (ART) maintenance and viral suppression. However, chronic pain, depression, and substance use, all of which are prevalent in this population, can reduce the quality of patient-provider engagement. We hypothesized a model in which chronic pain, depression, and substance use would be associated with poorer patient-provider engagement, which would be positively associated with adherence, with the latter associated positively with viral suppression. We analyzed data from the BEACON study, which included surveys from 383 PLHIV who were primarily African American, on ART, and had histories of drug use. Due to six missing cases on the chronic pain variable, we used data from 377 respondents in a structural equation model. Chronic pain and depressive symptoms were significantly associated with poorer patient-provider engagement, while substance use was associated with better engagement. Patient-provider engagement in turn was associated with better ART adherence, which was associated with higher viral suppression. Results suggest the role of chronic pain in poor patient-physician engagement in this population, which has potential implications for quality of HIV patient care and health outcomes. Findings suggest the need for attention to patient-provider engagement in PLHIV.
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Affiliation(s)
- Mary M Mitchell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA.
| | - Trang Q Nguyen
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allysha C Maragh-Bass
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry St., 2nd Floor, Baltimore, MD, 21205, USA
| | | | - Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 745, Baltimore, MD, 21205, USA
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25
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Scherrer JF, David Schneider F, Lustman PJ. Opioid analgesics and chronic non-cancer pain: a prescription for research in primary care. Fam Pract 2016; 33:569-571. [PMID: 27496956 DOI: 10.1093/fampra/cmw078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, MO, USA,
| | - F David Schneider
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA and.,John Cochran Division, The Bell Street Clinic, VA St. Louis Health Care System, St Louis, MO, USA
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Ruta NS, Ballas SK. The Opioid Drug Epidemic and Sickle Cell Disease: Guilt by Association. PAIN MEDICINE 2016; 17:1793-1798. [DOI: 10.1093/pm/pnw074] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Henry SG, Chen M, Matthias MS, Bell RA, Kravitz RL. Development of the Chronic Pain Coding System (CPCS) for Characterizing Patient-Clinician Discussions About Chronic Pain and Opioids. PAIN MEDICINE 2016; 17:1892-1905. [PMID: 26936453 DOI: 10.1093/pm/pnw005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To describe the development and initial application of the Chronic Pain Coding System. DESIGN Secondary analysis of data from a randomized clinical trial. SETTING Six primary care clinics in northern California. SUBJECTS Forty-five primary care visits involving 33 clinicians and 45 patients on opioids for chronic noncancer pain. METHODS The authors developed a structured coding system to accurately and objectively characterize discussions about pain and opioids. Two coders applied the final system to visit transcripts. Intercoder agreement for major coding categories was moderate to substantial (kappa = 0.5-0.7). Mixed effects regression was used to test six hypotheses to assess preliminary construct validity. RESULTS Greater baseline pain interference was associated with longer pain discussions (P = 0.007) and more patient requests for clinician action (P = 0.02) but not more frequent negative patient evaluations of pain (P = 0.15). Greater clinician-reported visit difficulty was associated with more frequent disagreements with clinician recommendations (P = 0.003) and longer discussions of opioid risks (P = 0.049) but not more frequent requests for clinician action (P = 0.11). Rates of agreement versus disagreement with patient requests and clinician recommendations were similar for opioid-related and non-opioid-related utterances. CONCLUSIONS This coding system appears to be a reliable and valid tool for characterizing patient-clinician communication about opioids and chronic pain during clinic visits. Objective data on how patients and clinicians discuss chronic pain and opioids are necessary to identify communication patterns and strategies for improving the quality and productivity of discussions about chronic pain that may lead to more effective pain management and reduce inappropriate opioid prescribing.
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Affiliation(s)
- Stephen G Henry
- *Department of Internal Medicine, University of California Davis, Sacramento, California;
| | - Meng Chen
- Department of Communication, University of California Davis, Davis, California
| | - Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Department of Communication Studies, Indiana University-Purdue University, Indianapolis, Indiana.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robert A Bell
- Department of Communication, University of California Davis, Davis, California.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Richard L Kravitz
- *Department of Internal Medicine, University of California Davis, Sacramento, California
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Knowlton AR, Nguyen TQ, Robinson AC, Harrell PT, Mitchell MM. Pain Symptoms Associated with Opioid Use among Vulnerable Persons with HIV: An exploratory study with implications for palliative care and opioid abuse prevention. J Palliat Care 2016; 31:228-33. [PMID: 26856123 DOI: 10.1177/082585971503100404] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current or former injection drug users with human immunodeficiency virus (HIV) are at high risk for pain, which adversely affects their quality of life and may increase their risk for illicit drug use or relapse. We explored associations between pain symptoms and substance use among injection-drug-using study participants with HIV who had histories of heroin use. Using generalized estimating equations and controlling for prior substance use, we found that pain in each six-month period was associated with the use of heroin and prescription opioids, but not the use of nonopioid drugs or alcohol. Routine clinical assessment and improved management of pain symptoms may be needed for persons with HIV and a history of injection drug use, particularly those with chronic pain, for whom there is increased risk for heroin use.
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