Communication Study
“I’m Not Abusing or Anything”: Patient–physician communication about opioid treatment in chronic pain

https://doi.org/10.1016/j.pec.2013.06.021Get rights and content

Abstract

Objective

To characterize clinical communication about opioids through direct analysis of clinic visits and in-depth interviews with patients.

Methods

This was a pilot study of 30 patients with chronic pain, who were audio-recorded in their primary care visits and interviewed after the visit about their pain care and relationship with their physicians. Emergent thematic analysis guided data interpretation.

Results

Uncertainties about opioid treatment for chronic pain, particularly addiction and misuse, play an important role in communicating about pain treatment. Three patterns of responding to uncertainty emerged in conversations between patients and physicians: reassurance, avoiding opioids, and gathering additional information. Results are interpreted within the framework of Problematic Integration theory.

Conclusion

Although it is well-established that opioid treatment for chronic pain poses numerous uncertainties, little is known about how patients and their physicians navigate these uncertainties. This study illuminates ways in which patients and physicians face uncertainty communicatively and collaboratively.

Practice implications

Acknowledging and confronting the uncertainties inherent in chronic opioid treatment are critical communication skills for patients taking opioids and their physicians. Many of the communication behaviors documented in this study may serve as a model for training patients and physicians to communicate effectively about opioids.

Introduction

Chronic pain affects over 100 million Americans [1] and has been described by patients and physicians as burdensome and challenging [2], [3], [4], [5], [6], [7]. Some patients report being labeled as “hypochondriacs” or “drug seekers,” and having their pain reports disbelieved by providers [2]. A study of Veterans Affairs (VA) primary care providers (PCPs) found that almost three-quarters considered chronic pain care a “major source of frustration” [6]. PCPs have described pain management as “frustrating,” and “overwhelming,”—perceptions rooted in concerns including opioid misuse and potential addiction [5].

Opioid treatment for chronic non-cancer pain has increased dramatically in recent decades, coupled with similar increases in abuse [8], [9], [10]. Although evidence supports opioid use for acute and end-of-life pain, limited data are available for opioid use in chronic pain, and numerous studies call into question long-term benefits of opioids [11], [12], [13], [14], [15]. The lack of long-term data, questions about benefits of opioids, and risks of addiction and misuse create a climate of uncertainty for patients and physicians as they consider opioid treatment and manage ongoing opioid therapy. However, little is known about how these uncertainties are addressed and negotiated communicatively, in clinic visits with physicians and patients.

The many uncertainties related to opioid treatment for chronic pain highlight the need for effective communication. Multiple studies have relied on interview accounts [2], [4], [5], [7], [16], which are dependent on participants’ interpretations and recall [17], [18]. Studies are beginning to directly examine clinical communication about pain. Henry and Eggly [19] analyzed the time spent on pain-related discussions in primary care visits with low-income patients. Eggly and Tzelepis [20] analyzed three clinical interactions purposefully selected because the physicians reported conflict related to patients’ requests for pain medication. Merrill and colleagues [21] examined communication with inpatients with active illicit drug use who were prescribed opioids either for pain or drug withdrawal, finding fear and mistrust in both patients and physicians. However, we are aware of no published studies that have directly examined clinical communication about opioids for chronic pain in primary care outpatient visits, where most chronic pain is managed [22].

The purpose of this study was to understand how physicians and patients with chronic musculoskeletal pain communicated about issues related to opioids, particularly in light of the inherent uncertainties associated with opioid treatment. Toward this end, we audio-recorded primary care clinic visits and conducted in-depth patient interviews immediately after the visits.

Section snippets

Methods

Research was conducted in primary care clinics at a Veterans Affairs (VA) medical center. Participants were VA PCPs and their patients. Procedures were approved by the local institutional review board, and all participants signed an informed consent. Patients signed a HIPAA authorization.

All PCPs in the facility were eligible for participation. Eligible patients (1) had a diagnosis of chronic musculoskeletal pain; (2) had at least moderately severe pain (≥4), assessed by a 0 (no pain) to 10

Participants

Five physicians participated. Three were female. From these PCPs’ panels, 190 patients met eligibility criteria. PCPs requested that we not contact 41 of these patients. Most common reasons were poorly controlled psychiatric comorbidities (e.g., anxiety, paranoia) and terminal cancer. Letters were mailed to the 149 eligible patients, followed by phone calls. Seventy-one patients were successfully contacted; 27 declined to participate. Most common reasons were lack of interest, transportation

Discussion

Opioids for chronic pain are associated with numerous uncertainties, ranging from the risks of addiction, diversion, and side effects, to uncertainties related to the safety and effectiveness of long-term opioids [9], [11], [15]. In spite of these uncertainties, little is known about how (and whether) patients and physicians communicate about these uncertainties in clinical interactions. This study's goal was to gain firsthand understanding about how patients and physicians communicate about

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

The project reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (CDA 10-034) and a Young Investigator Award from the Indiana Institute for Medical Research. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

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