"I Was a Little Surprised": Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain

Equity Using Interventions for Pain and Depression (EQUIPD): A Pilot Randomized Trial

Despite increased calls for improved health equity, Black patients continue to experience worse pain and associated outcomes. Black patients are also offered fewer pain treatment options than White patients and report poorer quality communication with clinicians, including lower participation in shared decision-making. Comorbid depressive symptoms can impede effective pain management and participation in decision-making. The Equity Using Interventions for Pain and Depression (EQUIPD; NCT05695209) pilot study examined feasibility of a one-on-one coaching intervention, paired with a decision aid, to facilitate shared decision-making about evidence-based nonpharmacological pain treatments for Black patients with chronic musculoskeletal pain and symptoms of at least mild depression. We recruited and randomized 30 participants at a rate of 7.5 per month, with 90% retention at 3 months and 87% at 6 months. Intervention participation was high, with 94% of participants completing at least 3 of 4 coaching sessions. Fidelity was also high. Although not powered for effectiveness, most outcomes, including pain interference, depression, anxiety, patient engagement, and shared decision-making, improved, favoring the intervention, with effect sizes ranging from 0.30-0.75 at 3 months. Results indicate that EQUIPD holds promise as an intervention to support autonomy and shared decision-making for Black patients with chronic pain and elevated depressive symptoms. PERSPECTIVE: The EQUIPD intervention, which included one-on-one coaching combined with a decision aid to increase shared decision-making about nonpharmacological pain treatments, was feasible and shows promise in improving pain and related outcomes for Black patients with chronic musculoskeletal pain and depressive symptoms.

Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review

BACKGROUND

Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects.

OBJECTIVE

This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management.

DESIGN

Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature.

DATA SOURCES

Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar.

ELIGIBILITY CRITERIA

All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being).

RESULTS

Ten studies were included; nine were qualitative ( n  = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects.

CONCLUSION

It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.

Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain

Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants' top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. PERSPECTIVE: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.

Shifting the National Consciousness about Pain Treatment: The Critical Need for a National Public Education Campaign

The failure of past practices and policies related to opioid prescribing for chronic pain has led federal agencies and professional organizations to recommend multimodal approaches that prioritize evidence-based nonpharmacological pain treatments (NPTs). These multimodal approaches, which include both traditional and complementary/integrative approaches, hold great promise for reducing the burden of chronic pain and reducing opioid use. Unfortunately, NPT approaches are underutilized due to a daunting array of interrelated barriers including the public's attitudes and beliefs about chronic pain and its treatment. Given the dual crises of chronic pain and opioid use, there is a critical need for a national public health campaign on chronic pain and its treatment to help educate the American public about NPT pain management options, while countering the misleading messages promulgated by the pharmaceutical industry, including but not limited to messages promoting the broad use of prescription opioids and minimizing its risks. Despite these dual crises of chronic pain and opioid use in the U.S., there has never been a concerted effort to broadly educate the American public about these issues and NPT pain management options.

The Impact of Preoperative Distress: A Qualitative analysis of the Perioperative Pain Self-Management Intervention

PURPOSE

Preoperatively distressed patients are at elevated risk for chronic postsurgical pain. Active psychological interventions show promise for mitigating chronic postsurgical pain. This study describes experiences of preoperatively distressed (elevated depressive symptom, anxious symptoms, or pain catastrophizing) and non-distressed participants who participated in the psychologically based Perioperative Pain Self-management (PePS) intervention.

DESIGN

This is a qualitative study designed to capture participants' perspectives and feedback about their experiences during the PePS intervention.

METHODS

Interviews were semi-structured, conducted by telephone, audio-recorded, transcribed, and audited for accuracy. Coded interviews were analyzed using a quote matrix to discern possible qualitative differences in what preoperatively distressed and non-distressed participants found most and least helpful about the intervention.

RESULTS

Twenty-one participants completed interviews, 7 of whom were classified as distressed. Distressed participants identified learning how to reframe their pain as the most helpful part of the intervention. Non-distressed participants focused on the benefit of relaxation skill-building to manage post-surgical pain. Distressed and non-distressed participants both emphasized the importance of the social support aspects of PePS and- identified goal-setting as challenging.

CONCLUSIONS

Distressed and non-distressed participants emphasized different preferences for pain management strategies offered by PePS. Most participants emphasized the importance of social support that PePS provided.

CLINICAL IMPLICATIONS

Our results indicate that post-operative patients may benefit from interpersonal interaction with a trained interventionist. Our findings also suggest that distressed and non-distressed patients may benefit from varied intervention approaches. How to build flexibility into a manualized intervention or whether these subsets of patients would benefit more from different interventions is a direction for future research.

Implementation of a pharmacist care manager model to expand availability of medications for opioid use disorder

Purpose

The rise in opioid prescribing, often for chronic pain management, resulted in an increased prevalence of opioid use disorder (OUD) throughout the United States, including within the Veterans Affairs (VA) healthcare system. The veteran population has been especially vulnerable to opioid-related harms, but rates of prescribing medications for OUD have been low. Use of care manager models for OUD have increased access to treatment. In this article we provide an overview of a clinical pharmacist care manager (CPCM) model for medications for OUD treatment implemented within the Minneapolis Veterans Affairs Health Care System.

Summary

A CPCM model for medications for OUD was identified as a care model that would address patient and facility barriers to effective OUD treatment. Pharmacists were integral in program development and implementation and served as the main care providers. An interim evaluation of the program established that the proportion of patients with OUD receiving medications for opioid use disorder (MOUD) had increased, with use of the program resulting in treatment of 109 unique patients during 625 visits. Key program implementation facilitators included the facility leadership establishing increased use of MOUD as a priority area, identification of a physician champion, and a history of successful expansion of clinical pharmacy specialist practice within the VA system. Implementation barriers included factors related to provider engagement, patient identification, and program support. The CPCM model of provision of MOUD expanded the pharmacist role in buprenorphine management.

Conclusion

The need to increase the number of patients receiving MOUD led to the implementation of a CPCM model. The program was effectively implemented into practice and expanded the availability of MOUD, which allowed patients to access treatment in multiple care settings.

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.

The evaluating prescription opioid changes in veterans (EPOCH) study: Design, survey response, and baseline characteristics

In the United States (US), long-term opioid therapy has been commonly prescribed for chronic pain. Since recognition of the opioid overdose epidemic, clinical practice guidelines have recommended tapering long-term opioids to reduced doses or discontinuation. The Effects of Prescription Opioid Changes for veterans (EPOCH) study is a national population-based prospective observational study of US Veterans Health Administration primary care patients designed to assess effects of evolving opioid prescribing practice on patients treated with long-term opioids for chronic pain. A stratified random sampling design was used to identify a survey sample from the target population of patients treated with opioid analgesics for ≥ 6 months. Demographic, diagnostic, visit, and pharmacy dispensing data were extracted from existing datasets. A 2016 mixed-mode mail and telephone survey collected patient-reported data, including the main patient-reported outcomes of pain-related function (Brief Pain Inventory interference; BPI-I scores 0–10, higher scores = worse) and health-related quality of life. Data on survey participants and non-participants were analyzed to assess potential nonresponse bias. Weights were used to account for design. Linear regression models were used to assess cross-sectional associations of opioid treatment with patient-reported measures. Of 14,160 patients contacted, 9253 (65.4%) completed the survey. Participants were older than non-participants (63.9 ± 10.6 vs. 59.6 ± 13.0 years). The mean number of bothersome pain locations was 6.8 (SE 0.04). Effectiveness of pain treatment and quality of pain care were rated fair or poor by 56.1% and 45.3%, respectively. The opioid daily dosage range was 1.6 to 1038.2 mg, with mean = 50.6 mg (SE 1.1) and median = 30.9 mg (IQR 40.7). Among the 73.2% of patients who did not receive long-acting opioids, the mean daily dosage was 30.4 mg (SE 0.6) and mean BPI-I was 6.4 (SE 00.4). Among patients who received long-acting opioids, the mean daily dosage was 106.2 mg (SE 2.8) and mean BPI-I was 6.8 (SE 0.07). Higher daily dosage was associated with worse pain-related function and quality of life among patients without long-acting opioids, but not among patients with long-acting opioids. Future analyses will use follow-up data to examine effects of opioid dose reduction and discontinuation on patient outcomes.

Experiences of people taking opioid medication for chronic non-malignant pain: a qualitative evidence synthesis using meta-ethnography

OBJECTIVE

To review qualitative studies on the experience of taking opioid medication for chronic non-malignant pain (CNMP) or coming off them.

DESIGN

This is a qualitative evidence synthesis using a seven-step approach from the methods of meta-ethnography.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched selected databases-Medline, Embase, AMED, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and Scopus (Science Citation Index and Social Science Citation Index)-for qualitative studies which provide patients' views of taking opioid medication for CNMP or of coming off them (June 2017, updated September 2018).

DATA EXTRACTION AND SYNTHESIS

Papers were quality appraised using the Critical Appraisal Skills Programme tool, and the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation working group - Confidence in Evidence from Reviews of Qualitative research) guidelines were applied. We identified concepts and iteratively abstracted these concepts into a line of argument.

RESULTS

We screened 2994 unique citations and checked 153 full texts, and 31 met our review criteria. We identified five themes: (1) reluctant users with little choice; (2) understanding opioids: the good and the bad; (3) a therapeutic alliance: not always on the same page; (4) stigma: feeling scared and secretive but needing support; and (5) the challenge of tapering or withdrawal. A new overarching theme of 'constantly balancing' emerged from the data.

CONCLUSIONS

People taking opioids were constantly balancing tensions, not always wanting to take opioids, and weighing the pros and cons of opioids but feeling they had no choice because of the pain. They frequently felt stigmatised, were not always 'on the same page' as their healthcare professional and felt changes in opioid use were often challenging.

TRIAL REGISTRATION NUMBER

49470934; Pre-results.

Apparent Effects of Opioid Use on Neural Responses to Reward in Chronic Pain

Neural responses to incentives are altered in chronic pain and by opioid use. To understand how opioid use modulates the neural response to reward/value in chronic pain, we compared brain functional magnetic resonance imaging (fMRI) responses to a monetary incentive delay (MID) task in patients with fibromyalgia taking opioids (N = 17), patients with fibromyalgia not taking opioids (N = 17), and healthy controls (N = 15). Both groups of patients with fibromyalgia taking and not taking opioids had similar levels of pain, psychological measures, and clinical symptoms. Neural responses in the nucleus accumbens to anticipated reward and non-loss outcomes did not differ from healthy controls in either fibromyalgia group. However, neural responses in the medial prefrontal cortex differed, such that patients with fibromyalgia not taking opioids demonstrated significantly altered responses to anticipated rewards and non-loss outcomes compared to healthy controls, but patients with fibromyalgia taking opioids did not. Despite limitations including the use of additional non-opioid medications by fibromyalgia patients taking opioids, these preliminary findings suggest relatively "normalized" neural responses to monetary incentives in chronic pain patients who take opioids versus those who do not.

Evaluation of a peer coach-led intervention to improve pain symptoms (ECLIPSE): Rationale, study design, methods, and sample characteristics

Chronic pain is prevalent, costly, and a leading cause of disability. Pain self-management (i.e., employing self-management strategies including behavioral modifications) is an effective, evidence-based treatment. However, implementation and delivery of a pain self-management model is challenging because of time and resources. Peer supported pain self-management offers a promising approach to implementing pain self-management programs using fewer clinical resources. Evaluation of a Peer Coach-Led Intervention for the Improvement of Pain Symptoms (ECLIPSE) is a randomized controlled trial testing effectiveness of peer coach-delivered pain self-management intervention versus controls receiving a class on pain and pain self-management. ECLIPSE is a Hybrid Type 1 study testing effectiveness while examining implementation factors. ECLIPSE enrolled 215 veterans randomly assigned to the peer coaching (N = 120) or control (N = 95) arm. The peer coaching intervention lasts 6 months, with patient-peer coach pairs instructed to talk twice per month. Coaches attend initial training, are provided a detailed training manual, and attend monthly booster sessions. Outcomes are assessed at baseline, 6 months, and 9 months. The primary outcome is overall pain (intensity and interference), measured by the Brief Pain Inventory (BPI). Secondary outcomes are self-efficacy, social support, pain catastrophizing, patient activation, health-related quality of life, and health care utilization. To maximize implementation potential of pain self-management, innovative delivery methods are needed that do not require additional resources from healthcare teams. A novel and promising approach is a peer-coaching model, in which patients who are successfully managing their pain offer information, ongoing support, and advice to other patients with pain. Clinical Trials Registration: NCT02380690.

Patient and provider characteristics associated with communication about opioids: An observational study

OBJECTIVE

Our objective is to examine the relationship of patient and provider characteristics and communication with chronic non-cancer pain and opioid management in primary care.

METHOD

We conducted an observational study using audio-recorded primary care appointments (up to 3/patient) and self-reported assessments of primary care providers (PCPs) and patients. We coded visit transcripts for 1) opioid and pain management talk and 2) mental health and opioid safety talk.

RESULTS

Eight PCPs and 30 patients had complete data for 78 clinic visits. PCPs and patients engaged in more opioid and pain management talk when patients reported greater pain catastrophizing and PCPs reported higher psychosocial orientation. PCPs and patients engaged in talk about mental health and opioid safety when patients reported greater anxiety, higher working alliance with their PCP, and when PCPs reported higher burnout. PCPs' negative attitudes about opioids were associated with fewer discussions about mental health and opioid safety.

CONCLUSIONS

Our results should facilitate design of interventions that improve communication and, ultimately, pain outcomes for patients.

PRACTICE IMPLICATIONS

Clinicians can use our results to increase patient engagement in discussions about opioid use and pain management or mental health and safety discussions.

Comparative Responsiveness of the PROMIS Pain Interference Short Forms With Legacy Pain Measures: Results From Three Randomized Clinical Trials

The Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS-PI) scales are reliable and publicly accessible; however, little is known about how responsive they are to detect change in clinical trials and how their responsiveness compares with legacy measures. The study purpose was to evaluate responsiveness for the PROMIS-PI scales and to compare their responsiveness with legacy pain measures. We used data from 3 clinical trials totaling 759 participants. The clinical trials included patients with chronic low back pain (n = 261), chronic back or osteoarthritis pain (n = 240), and a history of stroke (n = 258). At both baseline and follow-up, participants completed PROMIS-PI scales and legacy pain measures (Brief Pain Inventory Interference scale; Pain, Enjoyment, General Activity scale; 36-Item Short Form Survey (SF-36) Bodily Pain scale; and Roland-Morris Disability Questionnaire). We measured global ratings of pain change, both prospectively and retrospectively, as anchors to identify patients as improved, unchanged, or worsened. Responsiveness was assessed with standardized response means, statistical tests comparing change groups, and area under the curve analysis. The PROMIS-PI scales had largely comparable responsiveness with the Brief Pain Inventory Interference and Pain, Enjoyment, General Activity scales. The 4 PROMIS-PI short forms had comparable responsiveness. For all pain questionnaires, responsiveness varied based on the study population and whether pain improved or worsened. PERSPECTIVE: This article presents 1) how responsive the PROMIS-PI scales were to detect change over time in the context of 3 clinical trials and 2) how their responsiveness compared with legacy pain measures. The findings can help researchers and clinicians choose between different patient-reported pain outcome measures.