“It Sometimes Doesn’t Even Work”: Patient Opioid Assessments as Clues to Therapeutic Flexibility in Primary Care

Stephen G. Henry, Melissa M. Gosdin, Anne E.C. White, Richard L. Kravitz

Research output: Contribution to journalArticle

2 Scopus citations

Abstract

Background: Physicians’ fear of difficult patient interactions is an important barrier to discontinuing long-term opioid therapy. Objective: To identify patient statements about opioids that indicate potential openness to tapering opioids or trying non-opioid pain treatments Design: This is an observational study of regularly scheduled primary care visits involving discussion of chronic pain management. A coding system to characterize patient assessments about opioids, physician responses to assessments, and patient-endorsed opioid side effects was developed and applied to transcripts of video-recorded visits. All visits were independently coded by 2 authors. Participants: Eighty-six established adult patients taking opioids for chronic pain; 49 physicians in 2 academic primary care clinics Main Measures: Frequency and topic of patients’ opioid assessments; proportion of opioid assessments classified as clues (assessments indicating potential willingness to consider non-opioid pain treatments or lower opioid doses); physician responses to patient clues; frequency and type of patient-endorsed side effects Key Results: Patients made a mean of 3.2 opioid assessments (median 2) per visit. The most common assessment topics were pain relief (51%), effect on function (21%), and opioid safety (14%). Forty-seven percent of opioid assessments (mean 1.5 per visit) were classified as clues. Fifty-three percent of visits included ≥ 1 clue; 21% of visits contained ≥ 3 clues. Physicians responded to patient clues with no/minimal response 43% of the time, sympathetic/empathetic statements 14% of the time, and further explored clues 43% of the time. Fifty-eight percent of patients endorsed ≥ 1 opioid-related side effect; 10% endorsed ≥ 3 side effects. The most commonly endorsed side effects were constipation (15% of patients), sedation (15%), withdrawal symptoms (13%), and nausea (12%). Conclusions: Patient statements suggesting openness to non-opioid pain treatments or lower opioid doses are common during routine primary care visits. Listening for and exploring these clues may be a patient-centered strategy for broaching difficult topics with patients on long-term opioid therapy.

Original languageEnglish (US)
JournalJournal of general internal medicine
DOIs
StateAccepted/In press - Jan 1 2019

Keywords

  • chronic pain
  • doctor-patient relations
  • health communication
  • opioid analgesics
  • patient-centered care
  • primary care
  • tapering

ASJC Scopus subject areas

  • Internal Medicine

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