Primary care providers' views on chronic pain management among high-risk patients in safety net settings

Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Psychosocial Outcomes of Pain and Pain Management in Adults with Osteogenesis Imperfecta: A Qualitative Study

Osteogenesis imperfecta (OI) is a genetic disorder characterized by bone fragility and fractures, short stature, dental abnormalities, hearing loss, scoliosis, and chronic pain. Despite a growing literature on the functional outcomes of OI, limited research has explicitly examined the psychosocial outcomes of pain within OI. Adults with OI (N = 15) were interviewed to understand pain-related experiences through a thematic analysis of semi-structured interview data. Research team members, genetic research experts, and OI clinicians developed an interview guide focused on topics related to pain and mental health challenges. Participants' transcripts were coded by two independent coders; codes were then merged across coders and quotation outputs were subsequently abstracted (paraphrased then thematically classified) to identify common themes. Themes related to pain management variability regarding pain type, pain risk management and accessibility, pain outcomes (e.g., behavior, cognitive, affective), and pain exacerbating factors (e.g., individual, contextual) were identified. Participants reported chronic and acute pain, and despite the inaccessibility and stigmatization of pain medications (e.g., opioids), pharmacological treatments were the most common pain management approach. Participants reported negative pain outcomes, such as limited daily functioning and activity participation, fear, anger, anxiety, depression, and difficulty concentrating. Lastly, participants suggested that lack of physician and community knowledge on chronic pain in OI indirectly exacerbates both subjective pain intensity and outcomes. Although limited by a small, nondiverse sample, the current study provides valuable exploration of the unique pain experiences of adults with OI that may have implications for proactive management, treatment development, and clinician training.

Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use

INTRODUCTION

A better understanding of pain treatment satisfaction in patients with chronic noncancer pain (CNCP) and substance use is needed, especially as opioid prescribing policies are changing. We sought to identify factors associated with pain treatment satisfaction in individuals with CNCP on recent opioid therapy and prior or active substance use.

METHODS

An exploratory cross-sectional analysis using baseline data from a cohort study of 300 adults with CNCP receiving >20 morphine milligram equivalents of opioids for ≥3 of the preceding 12 months and prior or active substance use. Participants completed interviews, clinical assessments, urine drug screening, and medical chart review.

RESULTS

Participants were predominantly middle-aged (mean age 57.5 years), Black (44%), and cisgender men (60%). One-third (33%) had high, 28% moderate, and 39% low pain treatment satisfaction. Post-traumatic stress disorder (PTSD), tobacco use, past-year opioid discontinuation, and higher average pain scores were associated with lower satisfaction. HIV and prescription cannabis use were associated with higher satisfaction.

CONCLUSIONS

The relationship between PTSD and tobacco use with lower satisfaction should be explored to augment pain outcomes. Higher satisfaction among individuals with HIV and prescription cannabis use presents potential research areas to guide CNCP management and reduce reliance on opioid therapies.

Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial

BACKGROUND

Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines.

METHODS

This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences.

RESULTS

At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69).

CONCLUSIONS

TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.

Experiences of Military Primary Care Providers during Chronic Pain Visits: A Qualitative Descriptive Study

OBJECTIVE

Chronic pain complaints are the second most common reason for outpatient primary care visits, yet a comprehensive assessment of the processes and experiences of providers during a chronic pain visit is still lacking. This qualitative descriptive study aimed to conceptualize the processes and experiences that military primary care providers go through while they assess and manage chronic pain.

SETTING

Single US Army medical center.

METHODS

Semi-structured interviews with 12 military primary care providers. Interviews were audio-recorded, transcribed, and coded using qualitative software. Transcripts were analyzed using thematic analysis to identify emergent themes.

RESULTS

Three broad themes with associated sub-themes captured the processes and providers' experiences: 1) comprehending the pain story - asking the right questions regarding pain impact, navigating through complexities of the pain story, and conveying understanding of pain story back to the patient; 2) optimizing the pain story - perception of provider-patient disconnect on pain management goals, re-setting realistic goals, creating optimal individualized treatment plan, and evaluating treatment effectiveness; and 3) empathetic and therapeutic engagement with patients - trusting patients and fostering patient-provider relationship. A thematic map illustrates these provider experiences.

CONCLUSIONS

During chronic pain visits, the provider-patient disconnect on goals of chronic pain treatment presents a considerable challenge. Further in-depth studies on addressing provider-patient disconnect are warranted to identify solutions, which would help providers communicate realistic chronic pain management expectations to patients. The themes and sub-themes described in this study could serve as a guide for directing strategies to improve chronic pain visits in primary care.

Differences in functional improvement based on history of substance abuse and pain severity following spinal cord injury

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η² = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64-10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings

BACKGROUND

More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited.

OBJECTIVE

The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients.

RESEARCH DESIGN

National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations.

PARTICIPANTS

A total of 5766 homeless-experienced veterans.

MEASURES

Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities.

RESULTS

H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001).

CONCLUSIONS

Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Multidisciplinary Approach for Managing Complex Pain and Addiction in Primary Care: A Qualitative Study

PURPOSE

Primary care providers (PCPs) may feel ill-equipped to effectively and safely manage patients with chronic pain, an addiction, or both. This study evaluated a multidisciplinary approach of supporting PCPs in their management of this psychosocially complex patient population, to inform subsequent strategies clinics can use to support PCPs.

METHODS

Four years ago, at our academic community health safety-net system, we created a multidisciplinary consultation service to support PCPs in caring for complex patients with pain and addiction. We collected and thematically analyzed 66 referral questions to understand PCPs' initially expressed needs, interviewed 14 referring PCPs to understand their actual needs that became apparent during the consultation, and identified discrepancies between these sets of needs.

RESULTS

Many of the PCPs' expressed needs aligned with their actual needs, including needing expertise in the areas of addiction, safe prescribing of opioids, nonopioid treatment options, and communication strategies for difficult conversations, a comprehensive review of the case, and a biopsychosocial approach to management. But several PCP needs emerged after the initial consultation that they did not initially anticipate, including confirming their medical decision-making process, emotional validation, feeling more control, having an outside entity take the burden off the PCP for management decisions, boundary setting, and reframing the visit to focus on the patient's function, values, and goals.

CONCLUSIONS

A multidisciplinary consultation service can act as a mechanism to meet the needs of PCPs caring for psychosocially complex patients with pain and addiction, including unanticipated needs. Future research should explore the most effective ways to meet PCP needs across populations and health systems.

"Chasing the pain relief, not the high": Experiences managing pain after opioid reductions among patients with HIV and a history of substance use

BACKGROUND

Opioid overdose mortality continues to increase in the United States despite significant investments to reverse the epidemic. The national response to-date has focused primarily on reducing opioid prescribing, yet reductions in prescribing have been associated with patients reporting uncontrolled pain, psychological distress, and transition to illicit substances. The aim of this study is to qualitatively explore chronic pain management experiences among PLWH with a history of illicit substance use after long-term opioid therapy reductions or discontinuations.

METHODS

We analyzed 18 interviews, stopping upon reaching thematic saturation, with HIV-positive participants with a history of substance use who were enrolled in a longitudinal cohort study to assess the impact of prescribing changes among patients with chronic pain. Participants in this nested qualitative study had been reduced/discontinued from opioid pain relievers (OPRs) within the 12 months prior to interview. Interviews were audio-recorded and transcribed verbatim. Two analysts coded all interviews, interrater reliability was measured, and coding discrepancies discussed. The study took place in San Francisco, California in 2018.

RESULTS

Eleven participants were male with a mean age of 55; 8 were African American and 8 were White. All participants were HIV-positive, actively engaged in primary care, and had a lifetime history of illicit substance use. Twelve reported using illicit substances within the past year, including non-prescription opioids/heroin (10), and stimulant use (10). After being reduced/discontinued from their long-term opioid therapy, patients reported developing complex multimodal pain management systems that often included both nonpharmacological approaches and illicit substance use. Participants encountered a range of barriers to nonpharmacological therapies including issues related to accessibility and availability. Participants often reported attempts to replicate their prior OPR prescription by seeking out the same medication and dose from illicit sources and reported transitioning to heroin after exhausting other options.

CONCLUSION

After being reduced/discontinued from OPRs, HIV-positive patients with a history of substance use reported experimenting with a range of pain management modalities including nonpharmacological therapies and illicit substance use to manage symptoms of opioid withdrawal and pain. Providers should consider that any change to a patients' long-term opioid therapy may result in experimentation with pain management outside of the medical setting and may want to employ patient-centered, holistic approaches when managing patients' opioid prescriptions and chronic pain.

Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation

Objective

Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA).

Design

Qualitative process evaluation using semistructured interviews.

Setting

Seven VA health care systems in the Sierra Pacific region.

Subjects

Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20).

Methods

Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research.

Results

Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources.

Conclusions

Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

Provider confidence in opioid prescribing and chronic pain management: results of the Opioid Therapy Provider Survey

Introduction

Many providers report lack of confidence in managing patients with chronic pain. Thus, the primary aim of this study was to investigate the associations of provider confidence in managing chronic pain with their practice behaviors and demographics.

Materials and methods

The primary outcome measure was the results of the Opioid Therapy Provider Survey, which was administered to clinicians attending a pain-focused continuing medical education conference. Nonparametric correlations were assessed using Spearman’s rho.

Results

Of the respondents, 55.0% were women, 92.8% were white, and 56.5% were physicians. Primary care providers accounted for 56.5% of the total respondents. The majority of respondents (60.8%) did not feel confident managing patients with chronic pain. Provider confidence in managing chronic pain was positively correlated with 1) following an opioid therapy protocol (P=0.001), 2) the perceived ability to identify patients at risk for opioid misuse (P=0.006), and 3) using a consistent practice-based approach to improve their comfort level with prescribing opioids (P<0.001). Provider confidence was negatively correlated with the perception that treating pain patients was a “problem in my practice” (P=0.005).

Conclusion

In this study, the majority of providers did not feel confident managing chronic pain. However, provider confidence was associated with a protocolized and consistent practice-based approach toward managing opioids and the perceived ability to identify patients at risk for opioid misuse. Future studies should investigate whether provider confidence is associated with measurable competence in managing chronic pain and explore approaches to enhance appropriate levels of confidence in caring for patients with chronic pain.

What do providers want to know about opioid prescribing? A qualitative analysis of their questions

BACKGROUND

In 2012, the US Food and Drug Administration (FDA) responded to the opioid crisis with a Risk Evaluation and Mitigation Strategy, requiring manufacturers of extended-release/long-acting opioids to fund continuing medical education based on the "FDA Blueprint for Prescriber Education." Topics in the Blueprint are "Assessing Patients for Treatment," "Initiating Therapy, Modifying Dosing, and Discontinuing Use," "Managing Therapy," "Counseling Patients and Caregivers about Safe Use," "General Drug Information," and "Specific Drug Information." Based on the FDA Blueprint, Boston University School of Medicine's "Safe and Competent Opioid Prescribing Education" (SCOPE of Pain) offers live trainings for physicians and other prescribers. During trainings, participants submit written questions about the curriculum and/or their clinical experiences.

METHODS

The objective was to compare themes that arose from questions asked by SCOPE of Pain participants with content of the FDA Blueprint in order to evaluate how well the Blueprint answers prescribers' concerns. The authors conducted qualitative analyses of all 1309 questions submitted by participants in 29 trainings across 16 states from May 2013 to May 2015, using conventional content analysis to code the questions. Themes that emerged from participants' questions were then compared with the Blueprint.

RESULTS

Most themes fell into the topic categories of the Blueprint. Five main themes diverged: Participants sought information on (1) safe alternatives to opioids, (2) overcoming barriers to safe opioid prescribing, (3) government regulations of opioid prescribing, (4) the role of marijuana in opioid prescribing, and (5) maintaining a positive provider-patient relationship while prescribing opioids.

CONCLUSIONS

In addition to learning the mechanics of safe opioid prescribing, providers want to understand government regulations and effective patient communication skills. Aware of the limitations of opioids in managing chronic pain, providers seek advice on alternatives therapies. Future updates to the FDA Blueprint and other educational guidelines on opioid prescribing should address providers' additional questions.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain.

PERSPECTIVE

In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.

Managing chronic pain in primary care

At least 100 million adults in the United States are afflicted with chronic pain. Nurse practitioners and other providers are often challenged by the complexity of chronic pain management. This article discusses systematic strategies to facilitate safe, efficient, satisfactory, and quality care of patients with chronic pain in primary care.

Opioids for chronic pain: a knowledge assessment of nonpain specialty providers

Introduction

Although the majority of opioids in the US are prescribed by nonpain specialists, these providers often report inadequate training in chronic pain management and opioid prescribing. The extent of health care providers’ knowledge of opioid prescribing for chronic pain has not been well established. The purpose of this study was to assess knowledge about the use of opioids for chronic pain among health care providers seeking pain-focused continuing medical education.

Materials and methods

The study participants (n=131) were recruited at a pain-focused continuing medical education conference for nonpain specialists. Upon commencement of the conference, the KnowPain-50 survey was completed. The survey comprised 50 questions, and 18 questions were related to opioid management. The focus of each opioid question was further categorized as either medicolegal (n=7) or clinical (n=11).

Results

The majority of study participants were male physicians with a mean age of 51.8 years. The proportion of correct responses to the 50-item survey was 72%. The proportion of correct responses to the 32 nonopioid questions was 74%, and the proportion of correct responses to the 18 opioid questions was 69% (P<0.001). Similarly, the proportion of correct responses to the seven medicolegal opioid questions was 74%, and the proportion of correct responses to the eleven clinical opioid questions was 67% (P<0.001).

Conclusion

Health care providers demonstrated gaps in knowledge about the use of opioids for chronic pain. Lower scores on clinically based opioid questions may indicate an opportunity to provide focused educational content about this area of practice. This information could be helpful in designing future educational modules for nonpain providers.

Exploring the experience of chronic pain among female Survival Sex Workers: a qualitative study

BACKGROUND

The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people. Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This study aimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtown eastside (DTES).

METHODS

This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members of PACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experience known to PACE support workers were invited to participate. Interviews were conducted, audio recorded and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed.

RESULTS

Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival Sex Workers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribed and illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the downtown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to a pain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of a sense of community and survival.

CONCLUSIONS

Our study emphasizes the complex nature of chronic pain and addictions among a uniquely marginalized population. The study is unique in that it contributes the perspectives of a traditionally "hard-to-reach" population and demonstrates that Sex Workers should not only participate in but should lead development and implementation of research and programs for managing chronic pain in the setting of addiction.

Future implications of eHealth interventions for chronic pain management in underserved populations

SUMMARY 

Many underserved communities, especially those in rural settings, face unique challenges that make high quality healthcare less accessible. The implementation of eHealth technologies has become a potentially valuable option to disseminate interventions. The authors’ work in rural Alabama Federally Qualified Health Centers provide insights into the access to technology as well as the likelihood of utilizing eHealth technology in underserved communities. This paper will review current challenges related to digital dissemination of behavioral health interventions for chronic pain. Two major concerns are the lack of technological resources and the lack of appropriate materials for patients who may have low levels of reading, health and/or digital literacy. We will propose some recommendations to address common barriers faced by those providing care.

Risks and responsibilities in prescribing opioids for chronic noncancer pain, part 2: best practices

Opioids are increasingly prescribed to provide effective therapy for chronic noncancer pain, but increased use also means an increased risk of abuse. Primary care physicians treating patients with chronic noncancer pain are concerned about adverse events and risk of abuse and dependence associated with opioids, yet many prescribers do not follow established guidelines for the use of these agents, either through unawareness or in the mistaken belief that urine toxicology testing is all that is needed to monitor compliance and thwart abuse. Although there is no foolproof way to identify an abuser and prevent abuse, the best way to minimize the risk of abuse is to follow established guidelines for the use of opioids. These guidelines entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors: history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. By following these guidelines, physicians can prescribe opioids to provide effective analgesia while reducing the likelihood of abuse.

It made my life a little easier: primary care providers' beliefs and attitudes about using opioid treatment agreements

OBJECTIVE

To understand primary care providers (PCPs)' experiences, beliefs, and attitudes about using opioid treatment agreements (OTAs) for patients with chronic pain.

DESIGN

Qualitative research study.

PARTICIPANTS

Twenty-eight internists and family medicine physicians at two health centers.

APPROACH

Semistructured telephone interviews, informed by the Integrative Model of Behavioral Prediction. Themes were analyzed using a Grounded Theory approach, and similarities and differences in themes were examined among OTA adopters, nonadopters, and selective adopters.

RESULTS

Participants were 64 percent female and 68 percent white, and practiced for a mean of 9.5 years. Adoption of OTAs varied: seven were adopters, five were nonadopters, and 16 were selective adopters. OTA adoption reflected PCPs' beliefs and attitudes in the following three thematic categories: 1) perceived effect of OTA use on the therapeutic alliance, 2) beliefs about the utility of OTAs for patients or providers, and 3) perception of patients' risk for opioid misuse. PCPs commonly believed that OTAs were useful for physician self-protection, but few believed that they prevent opioid misuse. Selective adopters expressed ambivalent beliefs and made decisions about OTA use for individual patients based on both observed data and a subjective sense of each patient's risk for misuse.

CONCLUSIONS

Substantial variability in PCP use of OTAs reflects differences in PCP beliefs and attitudes. Research to understand the impact of OTA use on providers, patients, and the therapeutic alliance is urgently needed to guide best practices.

Using electronic health records data to identify patients with chronic pain in a primary care setting

OBJECTIVE

To develop and validate an accurate method to identify patients with chronic pain using electronic health records (EHR) data at a multisite community health center.

MATERIALS AND METHODS

We identified patients with chronic pain in our EHR system using readily available data elements pertaining to pain: diagnostic codes (International Classification of Disease, revision 9; ICD-9), patient-reported pain scores, and opioid prescription medications. Medical chart reviews were used to evaluate the accuracy of these data elements in all of their combinations. We developed an algorithm to identify chronic pain patients more accurately based on these evaluations. The algorithm's results were validated for accuracy by comparing them with the documentation of chronic pain by the patient's treating clinician in 381 random patient charts.

RESULTS

The new algorithm, which combines pain scores, prescription medications, and ICD-9 codes, has a sensitivity and specificity of 84.8% and 97.7%, respectively. The algorithm was more accurate (95.0%) than pain scores (88.7%) or ICD-9 codes (93.2%) alone. The receiver operating characteristic was 0.981.

DISCUSSION

A straightforward method for identifying chronic pain patients solely using structured electronic data does not exist because individual data elements, such as pain scores or ICD-9 codes, are not sufficiently accurate. We developed and validated an algorithm that uses a combination of elements to identify chronic pain patients accurately.

CONCLUSIONS

We derived a useful method that combines readily available elements from an EHR to identify chronic pain with high accuracy. This method should prove useful to those interested in identifying chronic pain patients in large datasets for research, evaluation or quality improvement purposes.

Contrasting tensions between patients and PCPs in chronic pain management: a qualitative study

OBJECTIVE

With greater scrutiny on primary care providers' (PCPs) approaches to chronic pain management, more research is needed to clarify how concerns and uncertainties about opioid therapy affect the ways both patients with chronic pain and PCPs experience primary care interactions. The goal of this qualitative study was to develop a better understanding of the respective experiences, perceptions, and challenges that patients with chronic pain and PCPs face communicating with each other about pain management.

DESIGN

Purposive and snowball sampling techniques were used to identify 14 PCPs. Patients who received ≥6 opioid prescriptions during the prior year were selected at random from the panels of participating physicians. Face-to-face in-depth interviews were conducted individually with patients and PCPs.

SETTING

VISN 11 Roudebush VA Medical Center (RVAMC) in Indianapolis, Indiana.

SUBJECTS

Fourteen PCPs and 26 patients with chronic pain participated.

METHODS

An inductive thematic analysis was conducted separately with patient and PCP interview data, after which the emergent themes for both groups were compared and contrasted.

RESULTS

Three notable tensions between patients and PCPs were discovered: 1) the role of discussing pain versus other primary care concerns, 2) acknowledgment of pain and the search for objective evidence, and 3) recognition of patient individuality and consideration of relationship history.

CONCLUSIONS

Competing demands of primary care practice, differing beliefs about pain, and uncertainties about the appropriate place of opioid therapy in chronic pain management likely contributed to the identified tensions. Several clinical communication strategies to help PCPs mitigate and manage pain-related tensions are discussed.