Primary Care Clinicians’ Beliefs and Strategies for Managing Chronic Pain in an Era of a National Opioid Epidemic

Militello, Laura G.; Hurley, Robert W.; Cook, Robert L.; Danielson, Elizabeth C.; Diiulio, Julie; Downs, Sarah M.; Anders, Shilo; Harle, Christopher A.

doi:10.1007/s11606-020-06178-2

Cited by 13 publications

(15 citation statements)

References 26 publications

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“…30,31 Improving communication may help patients feel more empowered and in control of their care 11 and may require organizational change so providers have time to establish rapport with patients and discuss opioid use in a more nuanced way. 32 Tools for communication and shared decision-making around LTOT should assess whether patients and providers are aligned regarding LTOT treatment goals and perceived risks and benefits, assess whether deprescribing LTOT is appropriate, identify strategies for eliciting patient feedback and input on decisions, develop scripts for patients to convey LTOT benefits and pain management concerns to providers, and support best practices on how to resolve disagreements between patients and providers.…”

Section: Discussionmentioning

confidence: 99%

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy

et al. 2022

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BACKGROUND: Given efforts to taper patients off longterm opioid therapy (LTOT) because of known harms, it is important to understand if patients and providers align in LTOT treatment goals. OBJECTIVE: To investigate patient and provider perceptions about the harms and benefits of continuing and discontinuing LTOT. DESIGN: Qualitative study PARTICIPANTS: Patients and providers with experiences with LTOT for pain in two Veterans Health Affairs regions. APPROACH: We conducted semi-structured interviews and analyzed data using rapid qualitative analysis to describe patient and provider preferences about LTOT continuation and discontinuation and non-opioid pain treatments. KEY RESULTS: Participants (n=43) included 28/67 patients and 15/17 providers. When discussing continuing LTOT, patients emphasized the benefits outweighed the harms, whereas providers emphasized the harms. Participants agreed on the benefits of continuing LTOT for improved physical functioning. Provider-reported benefits of continuing LTOT included maintaining the status quo for patients without opioid alternatives or who were at risk for illicit drug use. Participants were aligned regarding the harms of negative side-effects (e.g., constipation) from continued LTOT. In contrast, when discussing LTOT tapering and discontinuation, providers underscored how benefits outweighed the harms, citing patients' improved well-being and pain management with tapering or alternatives. Patients did not foresee benefits to potential LTOT tapers or discontinuation and were worried about pain management in the absence of LTOT. When discussing non-opioid pain treatments, participants emphasized that they were adjunctive to opioid therapy rather than a replacement (except for cannabis). Providers described the importance of mental health services to manage pain, which differed from patients who focused on treatments to improve strength and mobility and reduce pain.CONCLUSIONS: Patients emphasized the benefits of continuing LTOT for pain management and well-being, which differed from providers' emphasis on the benefits of discontinuing LTOT. Patient and provider differences are important for informing patient-centered care and decisions around continuing, tapering, or discontinuing LTOT.

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Section: Discussionmentioning

confidence: 99%

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy

et al. 2022

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Section: Methodsmentioning

confidence: 99%

“…38 Prior to this study, we developed a Tx Tracker prototype based on a series of studies that identified primary care clinicians' information needs and decision-making challenges during visits by patients with chronic noncancer pain. 32 35 39 The prototype is an interactive application developed using the Axure prototyping tool ( ). While prior studies have evaluated decision support for opioid prescribing and chronic pain care, 40 41 42 this study is innovative because no prior evaluations focus on a tool to aid clinicians in choosing among many pain treatment options based on a presentation of past, current, and potential future treatments.…”

Section: Background and Significancementioning

confidence: 99%

“…We recruited through our professional network, by approaching clinicians who had participated in a prior interview study about their information needs and decision-making processes for chronic noncancer pain. 39 All 12 interviews consisted of background questions related to EHR utilization, current EHR functions that are useful, prototype exploration, the use of Tx Tracker in a hypothetical use case scenario, and evaluation questions. The moderator's guide, including the evaluation questions, use case scenario, and prototype exploration tasks, can be found in ►Supplementary Appendix (available in the online version).…”

Section: Interviewsmentioning

confidence: 99%

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Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care

et al. 2022

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Objectives The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design. Methods We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts. Results We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality. Conclusion Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.

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“… 10 , 19 But evidence suggests that primary care clinicians express low confidence in their ability to manage pain 10 and may have gaps in knowledge or supports to implement evidence. 20 Previous literature suggests that the prevalence of chronic pain among primary care patients varies by age and sex and often occurs with chronic illness. 18 , 21 Also, chronic pain disproportionately affects disadvantaged populations 22 and these groups are experiencing the largest increases in chronic pain prevalence.…”

Section: Introductionmentioning

confidence: 99%

Are Pain Screening and Functional Assessment Results Associated with New Diagnoses and Treatment for Pain in Primary Care? An Observational Study

Scholle¹,

Nguyen-Louie²,

Bifulco³

et al. 2022

JPR

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Purpose To determine if pain screening and functional assessment results are associated with new diagnoses and treatment for pain in primary care. Patients and Methods Observational study at 13 primary care sites of a statewide federally qualified health center that implemented routine screening and functional assessment for all adults in primary care. The study group included 10,091 adults aged 18+ who had an in-person visit between July 2, 2018, and June 1, 2019, where they screened positive for chronic pain and completed a 3-question functional assessment with the PEG (Pain, Enjoyment of Life, General Activity). Multivariate logistic regressions quantified associations between pain frequency, diagnosis and treatment, sociodemographics, comorbidities, and self-reported severe pain impairment with pain diagnoses and treatment documented after screening. Results Patients were mostly women (60.3%), Latinx (41.1%), English-speaking (80.1%), and Medicaid-insured (62.0%); they averaged 49.1 years old (SD = 13.7 years). Patients with severe pain impairment or who were Latinx were more likely to get a newly documented pain diagnosis (absolute risk difference [ARD]: 13.2% and 8.6%, ps < 0.0001), while patients with mental health/substance use or medical comorbidities were less likely (ARDs: −20.0% to −6.2%, ps < 0.001). Factors most consistently associated with treatment were prior treatment of the same modality (4 of 7 treatments, ARDs = 27.3% to 44.1%, ps <0.0001), new pain diagnosis (5 of 7, ARDs = 3.2% to 27.4%, ps <0.001), and severe impairment (4 of 7, ARDs = 2.6% to 6.5%, ps < 0.0001). A new diagnosis had the strongest association with non-opioid pain analgesics and physical medicine (ARD = 27.0% and 27.4%, p < 0.0001). Latinx patients were less likely to receive opioid analgesics and mental health/substance use medications and counseling (ARDs = −3.3% to 7.5%, ps <0.0001). Conclusion Screening and assessment with patient-reported tools may influence pain care. Care for Latinx patients differed from non-Latinx white patients.

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Primary Care Clinicians’ Beliefs and Strategies for Managing Chronic Pain in an Era of a National Opioid Epidemic

Cited by 13 publications

References 26 publications

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy

Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care

Are Pain Screening and Functional Assessment Results Associated with New Diagnoses and Treatment for Pain in Primary Care? An Observational Study

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