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Carnago L, Knisely MR, Malek J. Ethical considerations and decision making in opioid prescribing for chronic pain: A case study in rheumatology practice. J Am Assoc Nurse Pract 2024; 36:300-306. [PMID: 38330235 DOI: 10.1097/jxx.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
ABSTRACT Dilemmas regarding opioid prescribing for chronic pain frequently occur within health care settings. The ethical principles of autonomy, beneficence, nonmaleficence, and justice, as well as the principles of care ethics, can assist in addressing these opioid-related dilemmas. The purpose of this clinical case study is to provide a case study highlighting an opioid prescribing dilemma and then identify opioid-related transition considerations; address ethical questions that nurse practitioners (NPs) may encounter in clinical practice when providing care for individuals living with chronic pain who may need or use a prescribed opioid medication; and draw on the ethical principles and care ethics to provide guidance for NPs who face these challenging issues.
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Affiliation(s)
- Lisa Carnago
- Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke University School of Nursing, Durham, North Carolina
| | | | - Janet Malek
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
- Duke Initiative for Science and Society, Duke University, Durham, North Carolina
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Sharif L, Gunaseelan V, Lagisetty P, Bicket M, Waljee J, Englesbe M, Brummett CM. High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids. Ann Surg 2023; 278:1060-1067. [PMID: 37335197 DOI: 10.1097/sla.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance. BACKGROUND Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance. METHODS In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber. RESULTS Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402). CONCLUSIONS Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.
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Affiliation(s)
- Limi Sharif
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
| | - Mark Bicket
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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3
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Ke JXC, de Vos M, Kojic K, Hwang M, Park J, Stuart H, Osborn J, Flexman A, Blake L, McIsaac DI. Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review. Br J Anaesth 2023; 131:925-936. [PMID: 37716887 DOI: 10.1016/j.bja.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home. METHODS Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis. RESULTS There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies). CONCLUSIONS This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes. SCOPING REVIEW PROTOCOL Open Science Framework (https://osf.io/cq5m6/).
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Affiliation(s)
- Janny X C Ke
- Department of Anesthesia, Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Maya de Vos
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Katarina Kojic
- Department of Anesthesia, Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark Hwang
- Undergraduate Medical Education Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jason Park
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Heather Stuart
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jill Osborn
- Department of Anesthesia, Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alana Flexman
- Department of Anesthesia, Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay Blake
- University of Arkansas for Medical Sciences Library, Little Rock, AK, USA
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
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Hinds S, Miller J, Maccani M, Patino S, Kaushal S, Rieck H, Walker M, Brummett CM, Bicket MC, Waljee JF. Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives. Reg Anesth Pain Med 2022; 47:475-483. [PMID: 35697386 PMCID: PMC9240329 DOI: 10.1136/rapm-2021-103304] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 05/12/2022] [Indexed: 11/10/2022]
Abstract
Introduction In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown. Methods We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos. Results Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening. Discussion These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.
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Affiliation(s)
- Shelby Hinds
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jacquelyn Miller
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Merissa Maccani
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Patino
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Shivani Kaushal
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Heidi Rieck
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica Walker
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Bicket
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
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Ljungvall H, Öster C, Katila L, Åsenlöf P. "Opioids are opioids" - A phenomenographic analyses of physicians' understanding of what makes the initial prescription of opioids become long-term opioid therapy. Scand J Pain 2022; 22:494-505. [PMID: 35172418 DOI: 10.1515/sjpain-2021-0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To explore prescribers' understanding of what makes initial prescription of opioids become long-term opioid therapy (opioids >90 days). METHODS A qualitative research design, phenomenography, was used for this study. Fifteen attending physicians working within primary, secondary and tertiary care in Sweden in the fields of general practice, rehab medicine, orthopedic surgery, neurosurgery, or obstetrics and gynecology were purposively recruited consecutively until categorical saturation was reached. Semi-structured interviews were used for data collection. The transcripts were analyzed and categorized by two researchers. A third researcher checked for consistency between the data and the categories. An outcome space was constructed representing the logical relationship between the categories. RESULTS The analysis identified six categories: The addictive opioid, The deserving patient, The ignorant prescriber, The lost patient, The compassionate prescriber, and The exposed prescriber. The differences in conceptions among the categories were clarified through three main contributors related to opioid therapy: prescriber's characteristics, patient's characteristics, and the healthcare organization. CONCLUSIONS Opioids were understood as being addictive with long-term use promoting a downward spiral of tolerance and withdrawal driving the pain, leading to continued prescription. Long-term opioid therapy could be justified for patients who improved in function, and who were perceived as trustworthy. Inadequate follow-up of patients, poor training in pain management and addiction medicine, personal attitudes and beliefs about opioids, a perceived professional obligation to treat patients with pain, and lack of collegial support, were factors understood to promote clinically unindicated long-term opioid therapy.
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Affiliation(s)
- Hanna Ljungvall
- Department of Women's and Children's Health, Uppsala University, Sweden
- Department of Sociology, Centre for Social Work (CESAR), Uppsala University, Sweden
| | - Caisa Öster
- Department of Medical Sciences, Uppsala University, Sweden
| | - Lenka Katila
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Pernilla Åsenlöf
- Department of Women's and Children's Health, Uppsala University, Sweden
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Tran T, Ford J, Hardidge A, Antoine S, Veevers B, Taylor S, Elliott RA. Evaluation of a post-discharge pharmacist opioid review following total knee arthroplasty: a pre- and post-intervention cohort study. Int J Clin Pharm 2022; 44:1269-1276. [PMID: 35829822 PMCID: PMC9277971 DOI: 10.1007/s11096-022-01455-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022]
Abstract
Background More than 70% of patients continue to use opioid medications 3-weeks following total knee arthroplasty. Post-discharge pharmacist reviews improve medication management, however it’s effect on opioid usage is not known. Aim This study aimed to evaluate the impact of post-discharge pharmacist review on opioid use following a total knee arthroplasty. Method A pilot, cohort pre- and post-intervention study was undertaken on patients who had undergone a total knee arthroplasty and were supplied an opioid upon discharge from hospital. During the intervention, patients were contacted via telephone by a pharmacist approximately five days post-discharge to review analgesic usage, provide education and advice and communicate an opioid management plan to their general practitioner. The primary endpoint was the percentage of patients taking opioids 3-weeks post-discharge. Secondary endpoints included: percentage of patients obtaining an opioid refill; patient satisfaction with opioid supply and the pharmacist review. Results Pre- and post-intervention, 63 and 44 patients were included, respectively. The percentage of patients taking opioids 3-weeks post-discharge declined from 74.6 to 29.6% (p < 0.001) and the percentage requiring an opioid refill from their general practitioner declined from 71.4 to 36.4% (p < 0.001). More patients were satisfied with opioid supply during the intervention period (79.5% cf. 47.6%, p = 0.001). Twenty-eight (63.6%) patients could recall the post-discharge pharmacist review, and all were either satisfied or extremely satisfied with the review. Conclusion Pharmacist-delivered post-discharge analgesia review reduced the percentage of patients taking opioids 3-weeks post-discharge following a total knee arthroplasty. This intervention has the potential to provide a smoother transition of care for patients supplied with opioids at the time of hospital discharge.
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Affiliation(s)
- Tim Tran
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia.
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.
| | - James Ford
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
| | - Andrew Hardidge
- Orthopaedic Surgery, Austin Health, Heidelberg, VIC, Australia
| | - Shari Antoine
- Health Independence Program, Austin Health, Heidelberg, VIC, Australia
| | - Beth Veevers
- Health Independence Program, Austin Health, Heidelberg, VIC, Australia
| | - Simone Taylor
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
| | - Rohan A Elliott
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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Tang R, Santosa KB, Vu JV, Lin LA, Lai YL, Englesbe MJ, Brummett CM, Waljee JF. Preoperative Opioid Use and Readmissions Following Surgery. Ann Surg 2022; 275:e99-e106. [PMID: 32187028 PMCID: PMC7935087 DOI: 10.1097/sla.0000000000003827] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the association between preoperative opioid exposure and readmissions following common surgery. SUMMARY BACKGROUND DATA Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown. METHODS We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type. RESULTS Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29). CONCLUSIONS Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.
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Affiliation(s)
- Ruiqi Tang
- Medical Student, University of Michigan Medical School
| | - Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | | | - Lewei A. Lin
- Assistant Professor, Department of Psychiatry, Michigan Medicine Medicine and Research Investigator, VA Ann Arbor Healthcare System
| | - Yen-Ling Lai
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN)
| | - Michael J. Englesbe
- Darling Professor of Surgery, Section of Transplantation, Department of Surgery, Michigan Medicine
| | - Chad M. Brummett
- Associate Professor, Division of Pain Medicine, Department of Anesthesiology, Michigan Medicine
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
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Giannitrapani KF, Silveira MJ, Azarfar A, Glassman PA, Singer SJ, Asch SM, Midboe AM, Zenoni MA, Gamboa RC, Becker WC, Lorenz KA. Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study. J Gen Intern Med 2021; 36:1867-1874. [PMID: 33948790 PMCID: PMC8298631 DOI: 10.1007/s11606-021-06747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN Qualitative research. PARTICIPANTS We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.
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Affiliation(s)
- K F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - M J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, University of Michigan, Ann Arbor, MI, USA.,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - A Azarfar
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,University of Central Florida, Orlando, FL, USA
| | - P A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S J Singer
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - S M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - A M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - M A Zenoni
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - R C Gamboa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - W C Becker
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - K A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Stonington SD. 'Acute-on-chronic': Emergency Affect and the One-way Staircase of Pharmaceutical Escalation. Med Anthropol 2020; 40:228-240. [PMID: 32886015 DOI: 10.1080/01459740.2020.1811704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The opioid epidemic in the United States is often portrayed as leading to a "pendulum swing" from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed "emergency affect," a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this "emergency affect" can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.
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Affiliation(s)
- Scott D Stonington
- Department of Anthropology, University of Michigan, Ann Arbor, Michigan, USA
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