Conversations about analgesics in the emergency department: A qualitative study

Patient Perspectives on Seeking Emergency Care for Acute Low Back Pain and Access to Physical Therapy in the Emergency Department

STUDY OBJECTIVE

Low back pain is a common reason for visiting the emergency department (ED), yet little is known about patient motivations for seeking emergency care. The purpose of this study was to explore patient perspectives on visiting the ED for low back pain to inform a more patient-centered approach to emergency care.

METHODS

We conducted focus group discussions and individual interviews among patients visiting an urban academic ED for acute low back pain. We recruited participants from an ongoing prospective study of 101 patients receiving either ED-initiated physical therapy or usual care. We conducted discussions, and interviews using an a priori developed discussion guide. We audio recorded, transcribed, and iteratively content analyzed the data using a consensual qualitative approach until thematic saturation was reached.

RESULTS

We conducted 4 focus group discussions among 18 participants (median age 46.5 years, 66.7% women, 61.1% Black) and individual interviews with 27 participants (median age 45 years, 55.6% women, 44.4% White). No new themes emerged during the fourth and final focus group. We identified 5 summary themes: (1) the decision to seek emergency care for low back pain is motivated by severe pain, resulting disability, and fears about a catastrophic diagnosis, (2) participants sought various goals from their ED visit but emphasized the primacy of pain control, (3) participants were reluctant to use pain medications but also acknowledged their benefit, (4) participants perceived a number of benefits from direct access to an ED physical therapist in the ED, and (5) participation in physical therapy ultimately facilitated recovery, but the pain was a barrier to performing exercises.

CONCLUSIONS

These patient perspectives and resulting themes may be used to inform a more patient-centered emergency care experience and contextualize quantitative research findings on ED care for low back pain.

Emergency department opioid discharge instructions: a multidisciplinary national Delphi study

OBJECTIVES

Currently, there are no Canadian guidelines for discharge instruction to be given to patients receiving an opioid prescription in the ED. This likely contributes to inadequate discharge instructions for these potentially dangerous medications. The principal goal of this study was to develop an interdisciplinary Canadian consensus regarding important concepts to be included in written opioid discharge instructions within the ED setting.

METHODS

We conducted a modified Delphi study between May and August 2021. The national multidisciplinary panel consisted of 23 healthcare professionals and one patient partner. The survey consisted of 19 initial concepts developed after a review of the literature and a meeting with local experts. The panel added four new concepts after the first survey round. Three rounds of online surveys were distributed in total. Panel consensus was defined a priori as a disagreement index score less than 1, in accordance with the RAND/UCLA Appropriateness Method.

RESULTS

We achieved a 100% response rate in round one and a 96% response rate in rounds two and three of our Delphi study. There was group consensus (disagreement index = 0.66, median importance = 9) that all patients receiving opioid prescriptions from the ED should receive written discharge instructions. The interdisciplinary panel arrived at a consensus on 21/23 concepts for ED opioid discharge instructions. The concepts with the highest level of agreement were related to minimizing the use of the prescribed opioid medication and opioid use safety (mixing with drugs/alcohol, storage, and impairment).

CONCLUSION

This Delphi study with a national, multidisciplinary panel achieved consensus on 21 concepts that should be included in written discharge instructions to patients receiving an opioid prescription upon discharge from the ED.

Patient Perceptions About Opioid Risk Communications Within the Context of a Randomized Clinical Trial

IMPORTANCE

Opioid overdose rates continue to increase, and extant literature suggests that many individuals who use heroin were first introduced to opioids through a medical prescription.

OBJECTIVE

To explore patient experiences related to decisions regarding analgesia after an emergency department visit within the context of a randomized clinical trial aimed to test the efficacy of risk communication interventions on treatment preference, risk recall, and use of opioids.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study of 36 patients making decisions regarding analgesia included qualitative interviews with participants in 2 risk intervention groups. Interviews were audio recorded, transcribed, and edited to remove identifying information to protect the confidentiality of participants. Interviews were conducted from June 4, 2019, to August 6, 2019. We conducted thematic analysis from August to December 2019 using a mixed inductive and deductive approach. Participants received $20 in compensation. The study was conducted in 4 geographically diverse emergency departments in the United States. Participants were adults presenting to the emergency department with either musculoskeletal back or neck pain or kidney stone-related pain. Eligibility criteria included being aged 18 to 70 years, capable of providing informed consent, English speaking or having English comprehension, eligible for emergency department discharge within 24 hours of enrollment, and able to access email or a smartphone.

INTERVENTIONS

Participants enrolled from the main randomized clinical trial received 1 of 2 risk interventions: a probabilistic opioid risk tool or a narrative-enhanced probabilistic risk tool (ie, participants viewed eight 1- to 3-minute short videos of patients discussing their experiences with pain treatment and positive and negative experiences with opioid use).

MAIN OUTCOMES AND MEASURES

Factors reported by participants to have influenced their decision-making regarding acute pain and treatment.

RESULTS

Thirty-six participants were interviewed, 18 in the group who received the probabilistic risk tool alone and 18 in the group who received the additional narrative-enhanced probabilistic risk tool intervention. The median age was 38 years (range, 21-67 years), 22 individuals were female (61%), 14 were Black or African American (39%), and 14 were White (39%). Five themes emerged from the analysis in the following domains: the factors associated with the risk interventions; clinician paternalism; analgesia attributes and previous experiences; individual self-identity, attitudes, and values; and perceptions of clinician bias.

CONCLUSIONS AND RELEVANCE

Most participants commented on the powerful lessons they learned from the risk interventions. More research is needed to understand how patients incorporate risk information into their decision-making process.

A Multicentered Randomized Controlled Trial Comparing the Effectiveness of Pain Treatment Communication Tools in Emergency Department Patients With Back or Kidney Stone Pain

Objectives. To compare the effectiveness of 3 approaches for communicating opioid risk during an emergency department visit for a common painful condition. Methods. This parallel, multicenter randomized controlled trial was conducted at 6 geographically disparate emergency department sites in the United States. Participants included adult patients between 18 and 70 years of age presenting with kidney stone or musculoskeletal back pain. Participants were randomly assigned to 1 of 3 risk communication strategies: (1) a personalized probabilistic risk visual aid, (2) a visual aid and a video narrative, or 3) general risk information. The primary outcomes were accuracy of risk recall, reported opioid use, and treatment preference at time of discharge. Results. A total of 1301 participants were enrolled between June 2017 and August 2019. There was no difference in risk recall at 14 days between the narrative and probabilistic groups (43.7% vs 38.8%; absolute risk reduction = 4.9%; 95% confidence interval [CI] = -2.98, 12.75). The narrative group had lower rates of preference for opioids at discharge than the general risk information group (25.9% vs 33.0%; difference = 7.1%; 95% CI = 0.64, 0.97). There were no differences in reported opioid use at 14 days between the narrative, probabilistic, and general risk groups (10.5%, 10.3%, and 13.3%, respectively; P = .44). Conclusions. An emergency medicine communication tool incorporating probabilistic risk and patient narratives was more effective than general information in mitigating preferences for opioids in the treatment of pain but was not more effective with respect to opioid use or risk recall. Trial Registration. Clinical Trials.gov identifier: NCT03134092. (Am J Public Health. 2022;112(S1):S45-S55. https://doi.org/10.2105/AJPH.2021.306511).

Handout use to facilitate opioid risk and safety communication in community pharmacies

BACKGROUND

A number of opioid handouts exist for pharmacists to use for patient education. However, there is limited evidence about what pharmacists most want them to cover and how useful pharmacists perceive them to be.

OBJECTIVES

This study sought to (1) refine and revise an opioid safety handout to facilitate opioid risks and safety communication in community pharmacies and (2) assess the feasibility and acceptability of this tool using a statewide survey of community pharmacists.

METHODS

In phase 1, 8 community pharmacists were interviewed to refine and evaluate the opioid safety handout. In phase 2, a statewide sample of 700 pharmacists were surveyed to identify acceptability and feasibility of using the revised handout. Survey data were analyzed using descriptive statistics and multiple regression analysis.

RESULTS

A total of 140 surveys were returned from community pharmacists. Over 60% of pharmacists reported that the handout would be useful in counseling patients on opioid risks and safety and would be a good opioid education tool for patients. Pharmacists who had practiced for many years (P = 0.002) and pharmacists who discussed safe opioid disposal and storage regularly (P = 0.002) reported a higher likelihood of using the handout. Pharmacists were much more likely to counsel patients on opioid risks and safety using this handout for a long-term opioid prescription than for a short-term opioid prescription.

CONCLUSION

A participatory research design successfully refined a handout for opioid risks and safety counseling, which the majority of pharmacists evaluated as feasible and useful for community pharmacists.

Communication between patients and health care professionals about opioid medications

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.

A patient decision aid for prescribing pain medication: Results from a pilot test in two emergency departments

OBJECTIVE

This study piloted a patient education and decision aid tool about prescription pain relievers to determine potential impact on: comfort receiving an opioid prescription; knowledge about opioids; decisional conflict about whether to take an opioid; and shared decision making with the prescribing physician.

METHODS

Patients with acute pain were recruited from two emergency departments (ED), and randomized to complete the tool (N = 65) or a time-matched control (N = 59) on a tablet. Data collection involved: a baseline survey; a post-test immediately following the assigned program; a discharge survey after seeing the physician; and a 6-week follow-up survey.

RESULTS

Knowledge increased and comfort receiving an opioid decreased as hypothesized, but did not reach statistical significance. Despite the lack of knowledge differences, the tool had significant positive impact on patients feeling more informed and experiencing less decisional conflict. Shared decision making with the prescribing physician was not impacted.

CONCLUSION

A patient decision aid can help ED patients feel more informed and less conflicted about prescription pain relievers but did not impact shared decision-making.

PRACTICE IMPLICATIONS

Patient education programs implemented in the ED should consider engaging physicians in the program to help to promote patient-centered approaches in the treatment of acute pain.

Perceptions of Signs of Addiction Among Opioid Naive Patients Prescribed Opioids in the Emergency Department

OBJECTIVES

Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction.

METHODS

This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes.

RESULTS

There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use.

CONCLUSIONS

Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.

Stories to Communicate Individual Risk for Opioid Prescriptions for Back and Kidney Stone Pain: Protocol for the Life STORRIED Multicenter Randomized Clinical Trial

Background

Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative–enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain.

Objective

Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain.

Methods

This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative–enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge.

Results

A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms.

Conclusions

This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations.

Trial Registration

ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092

International Registered Report Identifier (IRRID)

DERR1-10.2196/19496

A Multifaceted Intervention to Improve Patient Knowledge and Safe Use of Opioids: Results of the ED EMC2 Randomized Controlled Trial

OBJECTIVES

Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC² ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids.

METHODS

This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC² intervention, or 3) EMC²  + short message service (SMS) text messaging. The ED EMC² intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC²  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment.

RESULTS

Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC² group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC²  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC²  + SMS group (β = 0.57, 95% CI = 0.09 to 1.06) than usual care.

CONCLUSIONS

The study found that the EMC² tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.

Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review

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.

The development and feasibility of a pharmacy-delivered opioid intervention in the emergency department

OBJECTIVES

To develop a brief intervention and to assess the feasibility of pharmacy-delivered education on opioid safety and overdose prevention in the emergency department.

METHODS

A convenience sample of patients (n = 102) approached between May and June 2016 at a single community-based suburban emergency department located in the Midwest.

RESULTS

The intervention included scripted counseling to be delivered in person and 2 educational brochures. The counseling took approximately 5 minutes, and only 2 patients refused the counseling. All the patients were satisfied with the intervention, and 97.4% of them reported that the counseling improved their knowledge of opioid side effects. The majority of patients thought that their own risk of addiction was significantly less than the general public's risk of addiction when taking opioids.

CONCLUSION

This study provides preliminary evidence that student pharmacists or pharmacists are able to deliver opioid safety and overdose education in the emergency department.