Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care

Scoping Review: A Hybrid Delivery Model of Pain Management

OBJECTIVES

This scoping review explores hybrid healthcare models combining telehealth and in-person visits for pain management. It examines their components, effectiveness compared to traditional care, advantages, and disadvantages of telehealth, and the influence of future technologies.

DESIGN

The review followed the JBI scoping review methodology and used the PRISMA-ScR checklist. Studies on hybrid pain management models involving adult patients and clinicians were included.

DATA SOURCES

Searches were conducted in PubMed, CINAHL, and Google Scholar, along with gray literature from healthcare organizations.

REVIEW/ANALYSIS METHODS

Studies were screened based on Population, Concept, and Context (PCC) criteria. Data extraction followed a modified JBI tool, with thematic analysis and descriptive statistical summaries of study findings.

RESULTS

Hybrid care models combining telehealth and in-person visits improve access to pain management, particularly in rural areas, and reduce costs. Telehealth provides convenience but faces barriers such as privacy concerns, technological disparities, and patient preference for in-person visits. In-person care remains crucial for diagnostics and patient-provider trust. Future technologies like machine learning show promise for enhancing these models.

CONCLUSIONS

Hybrid models offer a flexible, cost-effective approach to chronic pain management. While telehealth expands access, challenges include privacy issues and digital inequities. Future technologies will likely improve these models' personalization and efficiency.

NURSING PRACTICE IMPLICATIONS

Nurses should be trained in telehealth technologies to facilitate the implementation of hybrid models while continuing to provide essential in-person care to engage patients and build trust.

Opioid-related Transitions for Chronic Pain Management: A Concept Analysis

BACKGROUND

People who are prescribed opioids for pain management may undergo transitions of care. However, little is known about transitions of care that involve a prescribed opioid, which may have significant consequences for people with chronic pain. The purpose of this concept analysis was to define opioid-related transitions (OrTs) and characterize their attributes, antecedents, and consequences.

METHODS

Rodger's evolutionary method for concept analysis was used to identify key attributes, antecedents, and consequences of OrTs. A comprehensive literature search was conducted in September 2024, resulting in the inclusion of 61 articles.

RESULTS

As defined, OrTs occur when opioids are prescribed for chronic pain management and involve an opioid medication transition and/or transition in care settings and/or practitioners. These transitions encompass patient-clinician and clinician-clinician interactions that ideally incorporate opioid-specific information, clear communication, shared decision-making, collective responsibility, weighing the risks and benefits, and knowledge exchange during the processes of opioid prescribing, management, and monitoring. During OrTs, patients and clinicians identified a need for support with care coordination. Notably, team-based involvement in OrTs is present, but guidance for operationalizing patient and clinician support efforts is needed.

CONCLUSIONS

This concept analysis contributes to the conceptual clarity of OrTs by identifying core attributes, antecedents, and consequences. By defining and examining OrTs broadly and including chronic pain, both patient experiences and clinician approaches to managing pain during transitions of care are highlighted. Research is needed on patient and clinician experiences related to managing chronic pain with opioids and the role of nurse-led interventions during OrTs.

Patient and provider experiences with opioid use disorder care delivered via telehealth: A systematic mixed-studies review

INTRODUCTION

Since the onset of the COVID-19 pandemic and loosening of some opioid use disorder (OUD) treatment regulations in the U.S. and Canada, there has been a rapid rise in the use of telehealth for buprenorphine induction, maintenance, and counseling (tele-bupe). Previous reviews highlight that tele-bupe can expand access to OUD care and improve treatment retention, but none to date have synthesized patient and clinician experiences with and perceptions of this care.

OBJECTIVE

This review synthesized findings from quantitative, qualitative, and mixed-methods studies that examined patient and provider experiences with tele-bupe. We assessed the perceived effectiveness and acceptability of this treatment modality.

METHODS

Our systematic review followed PRISMA 2020 guidelines. In July 2023, we searched six databases using keywords 'telehealth AND opioid use disorder' (and related terms) for papers published in English. Papers were eligible for inclusion if they reported findings about patient or provider experiences. Two reviewers screened studies for inclusion; 40 studies were included. We used a data-based convergent synthesis design to extract and synthesize findings, and the Mixed-Methods Appraisal Tool to appraise studies.

RESULTS

Patients and providers hold generally positive views of tele-bupe and most support its continued use in some form, citing multiple benefits, including accessibility and convenience. Most studies also identified barriers to tele-bupe, including technological challenges. Patients and providers differed in how they thought telehealth affects the clinical relationship, with providers expressing more concern about rapport-building and patients stating that being in their own environments during visits facilitated comfort and openness. The findings also suggest that providers are conflicted about when and for whom tele-bupe is appropriate.

CONCLUSION

Overall, both patients and providers view tele-bupe favorably; however, providers are conflicted about the patients and situations for which it is appropriate, which may lead to inequities in who is offered this form of care.

The Clinical Evolutions of Surveillance and Violence During Three Contemporary US Crises: Opioid Overdose, COVID-19, and Racial Reckoning

In 2020, three crises coalesced to transform the clinical care landscape of addiction medicine in the United States (US). The opioid overdose crisis (crisis #1), which had been contributing to excess US mortality for over two decades, worsened during the COVID-19 pandemic (crisis #2). The racial reckoning (crisis #3) spurred by the murder of George Floyd at the hands of police impacted clinical care, especially in safety net clinical settings where the majority of people targeted by police violence, and other forms of structural violence, receive healthcare to mend both physical and psychological wounds. Collectively, the three crises changed how providers and patients viewed their experiences of clinical surveillance and altered their relationships to the violence of US healthcare. Drawing from two different research studies conducted during the years preceding and during the COVID-19 pandemic (2017-2022) with low income, safety net patients at risk for opioid overdose and their care providers, I analyze the relationship between surveillance and violence in light of changes wrought by these three intersecting health and social crises. I suggest that shifting perceptions about surveillance and violence contributed to clinical care innovations that offer greater patient autonomy and transform critical components of addiction medicine care practice.

Pain Management and Sociology Implications: The Sociomedical Problem of Pain Clinic Staff Harassment Caused by Chronic Pain Patients

Background

Patients with chronic pain often experience psychological issues. They may also exhibit harassing behaviors toward healthcare staff. This complex sociomedical issue necessitates increased attention.

Objectives

This study analyzed incidents of staff harassment caused by chronic pain patients. It examined the characteristics of chronic pain patients who harassed clinic staff, as well as the causative or associated factors. The study also explored the management and outcomes of these harassment incidents.

Methods

This prospective observational study involved 1102 chronic pain patients who received treatment at a pain clinic. Data were prospectively collected on patients' gender, age, ethnicity, occupation, injury insurance claims, and incidents of staff harassment caused by patients.

Results

Pain clinic staff were harassed by 121 patients (11%). Among the harassers, females constituted 70.2% and males 29.8%. Additionally, 50.4% of the harassers were unemployed, with unemployed patients causing more staff harassments (P = 0.001). A significant portion, 86 %, of the harassers had injury insurance claims and were associated with a higher incidence of staff harassments (P = 0.002). Patients making disability insurance claims also caused more staff harassments (P = 0.001). Among the harassers, 50.4 % demanded higher drug doses, and 50% did not have regular primary healthcare providers. The types of harassment included insults (34.7%), threats (19.8%), retaliations (3.3%), and sexual harassment (42.2%). All cases of sexual harassment were addressed; the patients involved were counseled. Most harassment incidents were resolved through tactful communication. Of the harassers, 9.9 % were discharged from the clinic.

Conclusions

Harassment of pain clinic staff by chronic pain patients is significant. This sociomedical issue may be worsening due to factors such as opioid misuse, racism, the pandemic, and socioeconomic challenges. While most chronic pain patients are reasonable, some can be challenging. This study confirmed that the majority of patients who harassed staff were female, unemployed, had made injury insurance claims, and demanded higher drug doses. Abusive patients should receive anxiolytic therapy, behavioral boundaries, counseling, distraction therapy, and empathy. Pain clinics should implement staff training and support programs to protect staff from harassment. Additionally, pain clinicians should establish peer support networks to mitigate the psychological impacts of patient aggression and maintain professional well-being.