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Knight KR. The Clinical Evolutions of Surveillance and Violence During Three Contemporary US Crises: Opioid Overdose, COVID-19, and Racial Reckoning. Cult Med Psychiatry 2024; 48:470-487. [PMID: 38227118 PMCID: PMC11362391 DOI: 10.1007/s11013-023-09842-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
In 2020, three crises coalesced to transform the clinical care landscape of addiction medicine in the United States (US). The opioid overdose crisis (crisis #1), which had been contributing to excess US mortality for over two decades, worsened during the COVID-19 pandemic (crisis #2). The racial reckoning (crisis #3) spurred by the murder of George Floyd at the hands of police impacted clinical care, especially in safety net clinical settings where the majority of people targeted by police violence, and other forms of structural violence, receive healthcare to mend both physical and psychological wounds. Collectively, the three crises changed how providers and patients viewed their experiences of clinical surveillance and altered their relationships to the violence of US healthcare. Drawing from two different research studies conducted during the years preceding and during the COVID-19 pandemic (2017-2022) with low income, safety net patients at risk for opioid overdose and their care providers, I analyze the relationship between surveillance and violence in light of changes wrought by these three intersecting health and social crises. I suggest that shifting perceptions about surveillance and violence contributed to clinical care innovations that offer greater patient autonomy and transform critical components of addiction medicine care practice.
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Affiliation(s)
- Kelly Ray Knight
- Dept. of Humanities and Social Sciences, School of Medicine, University of California, San Francisco, USA.
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2
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Carlin L, Zhao QJ, Bhatia D, Taenzer P, Flannery J, Furlan AD. "Keep trying": a qualitative investigation into what patients with chronic pain gain from Project ECHO. SAGE Open Med 2024; 12:20503121241254941. [PMID: 38826827 PMCID: PMC11143813 DOI: 10.1177/20503121241254941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/29/2024] [Indexed: 06/04/2024] Open
Abstract
Objective The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain. Introduction Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation. Methods Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them. Results Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation. Conclusions Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain.
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Affiliation(s)
- Leslie Carlin
- Temerty Faculty of Medicine, Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Q Jane Zhao
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | | | | | | - Andrea D Furlan
- University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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3
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Joniak-Grant E, Blackburn NA, Dasgupta N, Nocera M, Dorris SW, Chelminski PR, Carey TS, Ranapurwala SI. "Cookbook medicine": Exploring the impact of opioid prescribing limits legislation on clinical practice and patient experiences. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 3:10.1016/j.ssmqr.2023.100273. [PMID: 38798786 PMCID: PMC11120475 DOI: 10.1016/j.ssmqr.2023.100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Opioid dependence and overdose are serious public health concerns. States have responded by enacting legislation regulating opioid-prescribing practices. Through in-depth interviews with clinicians, state officials, and organizational stakeholders, this paper examines opioid prescribing limits legislation (PLL) in North Carolina and how it impacts clinical practice. Since the advent of PLL, clinicians report being more mindful when prescribing opioids and as expected, writing for shorter durations for both acute and postoperative pain. But clinicians also report prescribing opioids less frequently for acute pain, refusing to write second opioid prescriptions, foisting responsibility for patient pain care onto other clinicians, and no longer writing opioid prescriptions for chronic pain patients. They directly credit PLL for these changes, including institutional policies enacted in response to PLL, and, to a lesser degree, notions of "do no harm." However, we argue that misapplication of and ambiguities in PLL along with defensive medicine practices whereby clinicians and their institutions center their legal interests over patient care, amplify these restrictive changes in clinical practice. Clinicians' narratives reveal downstream consequences for patients including undertreated pain, being viewed as drug-seeking when questioning opioid-prescribing decisions, and having to overuse the medical system to achieve pain relief.
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Affiliation(s)
- Elizabeth Joniak-Grant
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Natalie A. Blackburn
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7440, USA
| | - Nabarun Dasgupta
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Office of Research, Innovations, and Global Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7415, USA
| | - Maryalice Nocera
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Samantha Wooten Dorris
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Paul R. Chelminski
- Departments of Allied Health Sciences and Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Timothy S. Carey
- Department of Medicine, School of Medicine, Cecil G. Sheps Health Center for Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Shabbar I. Ranapurwala
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7435, USA
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4
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Burraway J, Helbert B, Schexnayder J, Knick T, Dillingham R, Scherz C. Reliving it All Over Again: Uncanny Temporalities of Injection Drug Use and Hepatitis C Diagnosis in Southwest Virginia, USA. Med Anthropol 2023; 42:21-34. [PMID: 35944242 PMCID: PMC9822844 DOI: 10.1080/01459740.2022.2110090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Clinicians typically view the intersection between hepatitis C and injection drug use in terms of simultaneity - with transmission occurring via shared needles - or sequentially - with some states requiring that people stop using drugs prior to treatment. Yet, for patients, the connection between substance use and HCV infection can follow a more complex temporal pathway. In this article, we explore the non-linear temporality of "reliving" as it shapes HCV illness experience, its complex intersection with injection drug use, and the barriers patients face as they reckon with existing healthcare system responses and treatment modalities.
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Affiliation(s)
| | - Bailey Helbert
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Julie Schexnayder
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Terry Knick
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - China Scherz
- Department of Anthropology, University of Virginia, Charlottesville, Virginia, USA
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Henry SG, Fenton JJ, Campbell CI, Sullivan M, Weinberg G, Naz H, Graham WM, Dossett ML, Kravitz RL. Development and Testing of a Communication Intervention to Improve Chronic Pain Management in Primary Care: A Pilot Randomized Clinical Trial. Clin J Pain 2022; 38:620-631. [PMID: 36037051 PMCID: PMC9481730 DOI: 10.1097/ajp.0000000000001064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Effective communication skills are essential for optimally managing chronic pain and opioids. This exploratory, sequential mixed methods study tested the effect of a novel framework designed to improve pain-related communication and outcomes. METHODS Study 1 developed a novel 5-step framework for helping primary care clinicians discuss chronic pain and opioids with patients. Study 2 pilot tested an intervention for teaching this framework using standardized patient instructors-actors trained to portray patients and provide immediate clinician feedback-deployed during regular clinic hours. Primary care physicians were randomized to receive either the intervention or pain management recommendations from the Centers for Disease Control and Prevention. Primary outcomes were pain-related interference at 2 months and clinician use of targeted communication skills (coded from transcripts of audio-recorded visits); secondary outcomes were pain intensity at 2 months, clinician self-efficacy for communicating about chronic pain, patient experience, and clinician-reported visit difficulty. RESULTS We enrolled 47 primary care physicians from 2 academic teaching clinics and recorded visits with 48 patients taking opioids for chronic pain who had an appointment scheduled with an enrolled physician. The intervention was not associated with significant changes in primary or secondary outcomes other than clinician self-efficacy, which was significantly greater in the intervention group. DISCUSSION This study developed a novel framework and intervention for teaching clinician pain-related communications skills. Although the intervention showed promise, more intensive or multicomponent interventions may be needed to have a significant impact on clinicians' pain-related communication and pain outcomes.
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Affiliation(s)
- Stephen G Henry
- Departments of Internal Medicine
- University of California Davis Center for Healthcare Policy and Research, CA
| | - Joshua J Fenton
- Family and Community Medicine, University of California Davis, Sacramento, CA
- University of California Davis Center for Healthcare Policy and Research, CA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Mark Sullivan
- Department of Anesthesiology and Pain Medicine and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Gary Weinberg
- University of California Davis Center for Healthcare Policy and Research, CA
| | - Hiba Naz
- University of California Davis Center for Healthcare Policy and Research, CA
| | - Wyatt M Graham
- University of California Davis School of Medicine, Sacramento, CA
| | | | - Richard L Kravitz
- Departments of Internal Medicine
- University of California Davis Center for Healthcare Policy and Research, CA
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Carroll JJ, Lira MC, Lunze K, Colasanti JA, Del Rio C, Samet JH. Painful Subjects: Treating Chronic Pain among People Living with HIV in the Age of Opioid Risk. Med Anthropol Q 2021; 35:141-158. [PMID: 33152133 PMCID: PMC8359200 DOI: 10.1111/maq.12618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/02/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
Public narratives often attribute the opioid overdose epidemic in the United States to liberal prescribing practices by health care providers. Consequently, new monitoring guidelines for the management of opioid prescriptions in patients with chronic pain have become recognized as key strategies for slowing this tide of overdose deaths. This article examines the social and ontological terrain of opioid-based pain management in an HIV clinic in the context of today's opioid overdose epidemic. We engage with anthropological analyses of contemporary drug policy and the nonverbal/performative ways patients and clinicians communicate to theorize the social context of the opioid overdose epidemic as a "situation," arguing that the establishment of new monitoring strategies (essentially biomedical audit strategies) trouble patient subjectivity in the HIV clinic-a place where that subjectivity has historically been protected and prioritized in the establishment of care.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, Elon University.,Department of Medicine, Brown University
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center
| | - Karsten Lunze
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center.,School of Medicine, Boston University
| | - Jonathan A Colasanti
- Hubert Department of Global Health, Rollins Scholl of Public Health of Emory University.,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Carlos Del Rio
- Hubert Department of Global Health, Rollins Scholl of Public Health of Emory University.,Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Boston Medical Center.,Department of Community Health Sciences, Boston University School of Public Health
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7
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Medicalization of sciatica and its treatment. SOCIAL THEORY & HEALTH 2021. [DOI: 10.1057/s41285-021-00161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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8
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Primary Care Clinicians' Beliefs and Strategies for Managing Chronic Pain in an Era of a National Opioid Epidemic. J Gen Intern Med 2020; 35:3542-3548. [PMID: 32909230 PMCID: PMC7728906 DOI: 10.1007/s11606-020-06178-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks and benefits of opioid therapy. OBJECTIVE To better understand PCCs' approaches to managing patients with chronic pain and explore implications for technological and administrative interventions. DESIGN We conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1-5 interviews. PARTICIPANTS PCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana. APPROACH Interviews included discussion of participants' general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically. KEY RESULTS PCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable. CONCLUSIONS PCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support.
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9
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Lira LL, Chandrasekar J. The State of Research in Veterans Studies: A Systematic Literature Review. JOURNAL OF VETERANS STUDIES 2020. [DOI: 10.21061/jvs.v6i2.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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10
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11
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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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12
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Affiliation(s)
- MEGAN CROWLEY‐MATOKA
- Medical Humanities and Bioethics MA ProgramNorthwestern University 420 E. Superior Street, Suite 625 Chicago IL 60611
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13
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Henry SG, Gosdin MM, White AEC, Kravitz RL. "It Sometimes Doesn't Even Work": Patient Opioid Assessments as Clues to Therapeutic Flexibility in Primary Care. J Gen Intern Med 2020; 35:1635-1640. [PMID: 31659669 PMCID: PMC7280428 DOI: 10.1007/s11606-019-05421-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/26/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Physicians' fear of difficult patient interactions is an important barrier to discontinuing long-term opioid therapy. OBJECTIVE To identify patient statements about opioids that indicate potential openness to tapering opioids or trying non-opioid pain treatments DESIGN: This is an observational study of regularly scheduled primary care visits involving discussion of chronic pain management. A coding system to characterize patient assessments about opioids, physician responses to assessments, and patient-endorsed opioid side effects was developed and applied to transcripts of video-recorded visits. All visits were independently coded by 2 authors. PARTICIPANTS Eighty-six established adult patients taking opioids for chronic pain; 49 physicians in 2 academic primary care clinics MAIN MEASURES: Frequency and topic of patients' opioid assessments; proportion of opioid assessments classified as clues (assessments indicating potential willingness to consider non-opioid pain treatments or lower opioid doses); physician responses to patient clues; frequency and type of patient-endorsed side effects KEY RESULTS: Patients made a mean of 3.2 opioid assessments (median 2) per visit. The most common assessment topics were pain relief (51%), effect on function (21%), and opioid safety (14%). Forty-seven percent of opioid assessments (mean 1.5 per visit) were classified as clues. Fifty-three percent of visits included ≥ 1 clue; 21% of visits contained ≥ 3 clues. Physicians responded to patient clues with no/minimal response 43% of the time, sympathetic/empathetic statements 14% of the time, and further explored clues 43% of the time. Fifty-eight percent of patients endorsed ≥ 1 opioid-related side effect; 10% endorsed ≥ 3 side effects. The most commonly endorsed side effects were constipation (15% of patients), sedation (15%), withdrawal symptoms (13%), and nausea (12%). CONCLUSIONS Patient statements suggesting openness to non-opioid pain treatments or lower opioid doses are common during routine primary care visits. Listening for and exploring these clues may be a patient-centered strategy for broaching difficult topics with patients on long-term opioid therapy.
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Affiliation(s)
- Stephen G Henry
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA. .,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA.
| | - Melissa M Gosdin
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Anne E C White
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
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14
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The transformations of medicalization of pain relief in the organization of perinatal care system in Quebec. SOCIAL THEORY & HEALTH 2020. [DOI: 10.1057/s41285-020-00133-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Carlin L, Zhao J, Dubin R, Taenzer P, Sidrak H, Furlan A. Project ECHO Telementoring Intervention for Managing Chronic Pain in Primary Care: Insights from a Qualitative Study. PAIN MEDICINE 2019; 19:1140-1146. [PMID: 29036381 DOI: 10.1093/pm/pnx233] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO. Design An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions. Setting University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada. Subjects Seventeen physicians and 20 allied health professionals. Methods Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions. Results Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO. Conclusions Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."
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Affiliation(s)
- Leslie Carlin
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Jane Zhao
- Outpatient Services -Project ECHO, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Ruth Dubin
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Paul Taenzer
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Hannah Sidrak
- The Tweed Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea Furlan
- Department of Medicine, Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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16
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Johannessen LEF. The commensuration of pain: How nurses transform subjective experience into objective numbers. Soc Sci Med 2019; 233:38-46. [PMID: 31170648 DOI: 10.1016/j.socscimed.2019.05.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
Commensuration-the transformation of different qualities into a common metric-has recently received increased scholarly attention. While mostly studied at the meso- or macroscale, this article extends the focus to microscale commensuration. Based on fieldwork in a Norwegian emergency medical service, the article analyses how nurses rated patients' pain intensity on a scale from zero to ten. While nurses were instructed to score pain by combining patients' self-report with their own 'objective' assessment, the article finds that their actual assessments relied almost solely on the latter. After exploring nurses' objections against the use of self-report, the article reconstructs the principles, methods and beliefs underlying nurses' 'objective' approach to pain scoring. In so doing, the article demonstrates how a fundamental aspect of human experience was filtered through nurses' professional gaze-to the advantage of some patients and the disadvantage of others. The article also advances theorising on microscale commensuration, thus providing guidance for future studies of how the world is transformed through the everyday production of numbers.
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Affiliation(s)
- Lars E F Johannessen
- Centre for the Study of Professions, OsloMet - Oslo Metropolitan University, Pb 4, St. Olavs Plass, 0130, Oslo, Norway.
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17
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Webster F, Rice K, Katz J, Bhattacharyya O, Dale C, Upshur R. An ethnography of chronic pain management in primary care: The social organization of physicians' work in the midst of the opioid crisis. PLoS One 2019; 14:e0215148. [PMID: 31042733 PMCID: PMC6493733 DOI: 10.1371/journal.pone.0215148] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study reports on physicians' experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities. METHODS Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings. FINDINGS In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse. INTERPRETATION Our findings show that care providers find the treatment of patients with chronic pain-especially those patients also experiencing poverty-to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients' social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.
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Affiliation(s)
- Fiona Webster
- Arthur and Sonia Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Kathleen Rice
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Women’s College Research Institute, Toronto, ON, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Ross Upshur
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Väänänen A, Turtiainen J, Kuokkanen A, Petersen A. From silence to diagnosis: the entry of the mentally problematic employee into medical practice. SOCIAL THEORY & HEALTH 2019. [DOI: 10.1057/s41285-019-00101-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Communication about chronic pain and opioids in primary care: impact on patient and physician visit experience. Pain 2019; 159:371-379. [PMID: 29112009 DOI: 10.1097/j.pain.0000000000001098] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.
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Abstract
Social representation theory provides a framework for studying how scientific knowledge affects common sense and communication through inquiries into everyday discourse. This qualitative study examined social representations of chronic pain from 4 sources: North American newspapers; "Chronic Illness Cat" memes from the social media web site, Pinterest; video blogs on YouTube; and from a 2014 film, Cake, and interviews and comments concerning it. Using thematic analysis, we first identified social representations found in our 4 sources and others found in 1 or 2 of them. Second, we analyzed the sources for their rhetorical intentions. Vlogs directly and memes indirectly were first-person accounts, self-authorizing statements of the truth of chronic pain, whereas newspaper articles and the film were third-person accounts of pain, the differences between these perspectives affecting what was said. We conclude that the medium shapes the message.
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Rubin S, Burke N, Van Natta M, Yen I, Shim JK. Like a Fish out of Water: Managing Chronic Pain in the Urban Safety Net. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2018; 59:487-500. [PMID: 30229682 DOI: 10.1177/0022146518798103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The subjective nature of pain has always rendered it a point of entry for power and corresponding stratifying processes within biomedicine. The opioid crisis has further exacerbated these challenges by increasing the stakes of prescribing decisions for providers, which in turn has resulted in greater treatment disparities. Using the theoretical frame of cultural health capital (CHC) to account for these disparities in pain management as they unfold at both the macro- and the microlevel, we present findings from an interdisciplinary study of two complex care management programs in urban safety-net hospitals that serve high-utilizing patients. CHC, which considers the ways in which patient-provider interactions reflect and often reinforce broader social inequities, allows for a consideration of power as it circulates through and beyond the patient-provider encounter. Within the current sociopolitical era of pain management, attention must be paid to the stratifying processes that structure how suffering is addressed.
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Affiliation(s)
- Sara Rubin
- 1 University of California, San Francisco, CA, USA
| | | | | | - Irene Yen
- 1 University of California, San Francisco, CA, USA
- 2 University of California, Merced, CA, USA
| | - Janet K Shim
- 1 University of California, San Francisco, CA, USA
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22
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Adams ET, Cohen EL, Bernard A, Darnell W, Helme DW. Trauma Trainees' Multiple Competing Goals in Opioid Prescription Communication. QUALITATIVE HEALTH RESEARCH 2018; 28:1983-1996. [PMID: 29984621 DOI: 10.1177/1049732318784896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prescription opioids and heroin account for more than half of all drug overdose fatalities, costing an estimated 115 American lives every day. The ongoing opioid epidemic devastates communities and represents a tremendous burden to the national economy and health care system. In 2016, the Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy proposed action to train prescribers on the proper dispensing of opioids, which are indispensable pharmacologic resources for treating acute pain resulting from a traumatic injury or surgery. Trauma surgeons who prescribe opioids for severe pain embark on patient consultations with multiple and conflicting goals respective to their roles as a healers of the suffering, regulators of illicit substances, members of a greater medical system working to contain an opioid epidemic, and moral beings with a distinct set of preferences, experiences, social norms, and practice philosophies. Semistructured interviews with 17 trauma and surgical residents and fellows at a southeastern academic medical center in the United States generated descriptive data regarding prescribing practices and patient communication. Guided by the multiple goals framework, the current research presents three prominent themes depicting the problematic convergence of identity, task, and relational goals during opioid-prescribing conversations between trauma trainees and their patients.
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23
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Holliday S, Hayes C, Dunlop A, Morgan S, Tapley A, Henderson K, Larance B, Magin P. Protecting Pain Patients. The Evaluation of a Chronic Pain Educational Intervention. PAIN MEDICINE 2018; 18:2306-2315. [PMID: 28340143 DOI: 10.1093/pm/pnx018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Advocacy and commercially funded education successfully reduced barriers to the provision of long-term opioid analgesia. The subsequent escalation of opioid prescribing for chronic noncancer pain has seen increasing harms without improved pain outcomes. Methods This was a one-group pretest-posttest design study. A multidisciplinary team developed a chronic pain educational package for general practitioner trainees emphasizing limitations, risk-mitigation, and deprescribing of opioids with transition to active self-care. This educational intervention incorporated prereadings, a resource kit, and a 90-minute interactional video case-based workshop incorporated into an education day. Evaluation was via pre- and postintervention (two months) questionnaires. Differences in management of two clinical vignettes were tested using McNemar's test. Results Of 58 eligible trainees, 47 (response rate = 81.0%) completed both questionnaires (36 of whom attended the workshop). In a primary analysis including these 47 trainees, therapeutic intentions of tapering opioid maintenance for pain (in a paper-based clinical vignette) increased from 37 (80.4%) pre-intervention to 44 (95.7%) postintervention (P = 0.039). In a sensitivity analysis including only trainees attending the workshop, 80.0% pre-intervention and 97.1% postintervention tapered opioids (P = 0.070). Anticipated initiation of any opioids for a chronic osteoarthritic knee pain clinical vignette reduced from 35 (74.5%) to 24 (51.1%; P = 0.012) in the primary analysis and from 80.0% to 41.7% in the sensitivity analysis (P = 0.001). Conclusions Necessary improvements in pain management and opioid harm avoidance are predicated on primary care education being of demonstrable efficacy. This brief educational intervention improved hypothetical management approaches two months subsequently. Further research measuring objective changes in physician behavior, especially opioid prescribing, is indicated.
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Affiliation(s)
- Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, New South Wales, Australia
| | - Chris Hayes
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Integrated Pain Service, New Lambton Heights, New South Wales, Australia
| | - Adrian Dunlop
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, New South Wales, Australia
| | - Simon Morgan
- General Practice Training Valley to Coast, Mayfield, New South Wales, Australia
| | - Amanda Tapley
- General Practice Training Valley to Coast, Mayfield, New South Wales, Australia
| | - Kim Henderson
- General Practice Training Valley to Coast, Mayfield, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, New South Wales, Australia
| | - Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,General Practice Training Valley to Coast, Mayfield, New South Wales, Australia
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24
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Knight KR. Women on the Edge: Opioids, Benzodiazepines, and the Social Anxieties Surrounding Women's Reproduction in the U.S. "Opioid Epidemic". CONTEMPORARY DRUG PROBLEMS 2017; 44:301-320. [PMID: 31537950 PMCID: PMC6752216 DOI: 10.1177/0091450917740359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The current "opioid epidemic" provides an opportunity to identify age-old social anxieties about drug use while opening up new lines of inquiry about how and why drug use epidemics become gendered. This paper reflects on the intertwined phenomena of opioid and benzodiazepine prescribing to U.S. women to examine how gender, race, and class inform social anxieties about reproduction and parenting. Multiple discourses abound about the relationship between women and the "opioid epidemic." Epidemiological reports attribute premature death among White women to the deadly combination of opioids and antianxiety medications. The National Institute on Drug Abuse reports that "every 25 minutes a baby is born suffering from opioid withdrawal," leading to costly hospital stays for infants and the potential for mother-child separation and other forms of family adjudication postpartum. Primary care providers are reluctant to distinguish diagnoses of chronic noncancer pain from anxiety among their female patients. Taken together, these discourses beg the question: What exactly are we worried about? I compare and contrast the narratives of two anxious women on opioids to raise larger structural questions about pregnancy, parenting, and drug use and to interrogate the public narrative that women on opioids threaten the American family and thwart the American Dream.
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Affiliation(s)
- Kelly R. Knight
- Department of Anthropology, History, and Social Medicine (DAHSM), University of California–San Francisco, San Francisco, CA, USA
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Abstract
This review discusses a growing body of scholarship at the intersection of anthropology and science and technology studies (STS) that examines how drugs are rendered efficacious in laboratories, therapeutic settings, and everyday lives. This literature foregrounds insights into how commercial interests and societal concerns shape the kinds of pharmaceutical effects that are actualized and how some efficacies are blocked in response to moral concerns. The work brought together here reveals how regulatory institutions and health policy makers seek to stabilize pharmaceutical actions while, on the front lines of care, pharmacists, health workers, and users tinker with dosages and indications to tailor pharmaceutical actions to specific circumstances. We show that there is no pure (pharmaceutical) object that precedes its socialization. Pharmaceuticals are not “discovered”; they are made and remade in relation to shifting contexts. This review outlines five key areas of ethnographic and STS research that examines such fluid drugs.
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Affiliation(s)
- Anita Hardon
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam 1001 NA, Netherlands
| | - Emilia Sanabria
- Laboratoire d'Anthropologie des Enjeux Contemporains (LADEC), École Normale Supérieure de Lyon, 69364 Lyon, France
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26
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Buchbinder M. Keeping out and getting in: reframing emergency department gatekeeping as structural competence. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:1166-1179. [PMID: 28422296 PMCID: PMC5600633 DOI: 10.1111/1467-9566.12566] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sociologists have tended to frame medical gatekeeping as an exclusionary social practice, delineating how practitioners and clerical staff police the moral boundaries of medicine by keeping out patients who are categorised as 'bad', 'deviant', or otherwise problematic. Yet medical gatekeeping, understood more broadly, can include not only keeping patients out of particular clinical settings, but also redirecting them to alternative sources of care. In this article, I draw on qualitative analysis of audio-recorded patient-provider interactions in a United States emergency department (ED) to illustrate medical gatekeeping as a two-step process of, first, categorising certain patient complaints as unsuitable for treatment within a particular setting, and second, diverting patients to alternative sites for care. I refer to these as the restrictive and facilitative components of medical gatekeeping to denote how each relates to patients' access to care, recognising that both components of medical gatekeeping are part of a coordinated organisational strategy for managing resource scarcity. By illustrating how ED providers reveal intimate knowledge of structural vulnerabilities in diverting socioeconomically disadvantaged patients with chronic back pain to clinical sites that are better equipped to provide care, I suggest that we rethink the emphasis on restrictive practices in sociological accounts of medical gatekeeping.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, Center for Bioethics, University of North Carolina, Chapel Hill, USA
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27
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Opioid pharmacovigilance: A clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use. Soc Sci Med 2017; 186:87-95. [PMID: 28599142 DOI: 10.1016/j.socscimed.2017.05.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 11/20/2022]
Abstract
There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of "opioid pharmacovigilance," characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids.
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28
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Pryma J. “Even my sister says I'm acting like a crazy to get a check”: Race, gender, and moral boundary-work in women's claims of disabling chronic pain. Soc Sci Med 2017; 181:66-73. [DOI: 10.1016/j.socscimed.2017.03.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 11/25/2022]
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Abstract
While cultural responses to misfortune have long been an area of anthropological inquiry, this article examines the first person experience of misfortune and regret. I specifically explore why people take personal blame for consequences for which they were not entirely responsible, building on Bernard Williams’s discussion of ‘moral luck’ and ‘agent-regret’. I argue that the liberation of responsible human agency from ‘false causes’ – a promise made by the myth of moral progress – does not apply in all circumstances, as the processing of grief in the wake of misfortune reveals how modern subjects do not ‘know any better’ either. While Evans-Pritchard’s account of the Azande describes how they respond to misfortune by selecting the socially relevant cause in which to intervene, even while knowing the plurality of causes at play, I consider cases where people select the ethically relevant cause, turning the arrow of blame toward themselves. Why this happens in the first place relates to whether there was something personally at stake. I draw on Marshall Sahlins’s notion of the ‘mutuality of being’ to show how the blurring of identities and acts within relations involving an other for whom one bears a special responsibility goes a long way to explain an actor’s devotion to self-blame and punishment. The ‘mutuality of being’ is hardly a given, and it is the problem of moral luck and personal regret that can illuminate how social life oscillates between mutuality and disconnection. While agent-regret is conducive to moral learning, the agony of self-blame may also be understood as the actor’s way of participating in the web that constitutes his or her history. While discussions of regret have happened on the margins of philosophy, the same may be said of its place in anthropology. This suggests that we still have not taken moral experience seriously enough, as a matter of great theoretical significance.
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Affiliation(s)
- Teresa Kuan
- Chinese University of Hong Kong, Hong Kong SAR
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30
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Buchman DZ, Ho A, Goldberg DS. Investigating Trust, Expertise, and Epistemic Injustice in Chronic Pain. JOURNAL OF BIOETHICAL INQUIRY 2017; 14:31-42. [PMID: 28005251 DOI: 10.1007/s11673-016-9761-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 10/23/2016] [Indexed: 05/24/2023]
Abstract
Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management.
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Affiliation(s)
- Daniel Z Buchman
- University Health Network, Bioethics Program, Joint Centre for Bioethics and Dalla Lana School of Public Health, University of Toronto, 399 Bathurst Street, McLaughlin Block, 8th Floor, Room 443, Toronto, ON, M5S 2S8, Canada.
| | - Anita Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore and W. Maurice Young Centre for Applied Ethics, University of British Columbia, Block MD11, Clinical Research Centre, 10 Medical Drive, Singapore, 117597, Singapore
| | - Daniel S Goldberg
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Fullginiti Pavilion Room 205, 13080 E. 19th Avenue, Aurora, CO, 80045, United States
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31
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Moloney ME. 'Sometimes, it's easier to write the prescription': physician and patient accounts of the reluctant medicalisation of sleeplessness. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:333-348. [PMID: 27594300 DOI: 10.1111/1467-9566.12485] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The medicalisation of sleep is a rich and growing area of sociological interest. Previous research suggests that medicalisation is occurring within the context of physician office visits, but the inner workings remain unclear. This study is the first to provide perspectives on the office visit interaction from both sleepless patients (n = 27) and the physicians (n = 8) who treat them. Analyses of semi-structured qualitative interviews reveal that sleep-related conversations are typically patient-initiated in routine office visits. Physicians and patients conceptualised insomnia as a symptom of another issue (depression), an everyday problem of living (stress) or the result of a natural life process (aging). Lack of sleep was not necessarily linked to daytime impairment. Even though sleep aids were routinely requested and prescribed, patients and physicians consistently expressed attitudes of reluctance toward the use of sedative hypnotics. I call this a case of 'reluctant medicalisation' and highlight the liminal space between pathology and normalcy inhabited by patients and physicians. I also build on recent work acknowledging the dynamics between macro and micro levels of medicalisation and illustrate the influence of multilevel 'engines' (consumerism, biotechnology, managed care and physicians) in patients' and physicians' accounts. A virtual abstract of this paper can be viewed at: https://youtu.be/7uLHOJPHF0I.
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Roy N, Kizhakke Veetil D, Khajanchi MU, Kumar V, Solomon H, Kamble J, Basak D, Tomson G, von Schreeb J. Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths. BMC Health Serv Res 2017; 17:142. [PMID: 28209192 PMCID: PMC5314603 DOI: 10.1186/s12913-017-2085-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/09/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery. METHODS All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI). RESULTS During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging. CONCLUSION Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.
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Affiliation(s)
- Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | | | | | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Harris Solomon
- Department of Cultural Anthropology and Global Health, Global Health Institute, Duke University, 205 Friedl Building, Box 90091, Durham, 27708 NC USA
| | - Jyoti Kamble
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Debojit Basak
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Abstract
In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response.
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Buchman DZ, Ho A, Illes J. You Present like a Drug Addict: Patient and Clinician Perspectives on Trust and Trustworthiness in Chronic Pain Management. PAIN MEDICINE 2016; 17:1394-406. [PMID: 26759389 DOI: 10.1093/pm/pnv083] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 11/07/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Past research has demonstrated that trust is central to an effective therapeutic relationship, but the role of trust in chronic pain management is not well understood. The objective of this study was to provide an in-depth examination of how adults living with chronic pain negotiate trust and demonstrate trustworthiness with clinicians in therapeutic encounters. METHODS This qualitative study focused on adults living in an urban setting in British Columbia, Canada. Semi-structured interviews (N = 27) were conducted with participants with chronic low back pain. The results were triangulated by two feedback groups comprising re-contacted interview participants (n = 4) and physicians with expertise in pain and addiction management (n = 6). RESULTS Grounded theory analysis of the adult patient interviews and feedback groups yielded four major themes: 1) threats to trustworthiness and iatrogenic suffering; 2) communicating the invisible and subjective condition of chronic pain; 3) motive, honesty, and testimony; and 4) stigmatized identities. The following two themes emerged from the analysis of the physician feedback group: 1) challenges of the practice context, and 2) complicated clinical relationships. CONCLUSIONS We found that perceived trustworthiness is important in therapeutic encounters as it helps to negotiate tensions with respect to subjective pain symptoms, addiction, and prescription opioid use. An attitude of epistemic humility may help both clinicians and patients cultivate a trustworthy clinical environment, manage the challenges associated with uncertain testimony, place trust wisely, and promote optimal pain care.
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Affiliation(s)
- Daniel Z Buchman
- *National Core for Neuroethics, Division of Neurology, Department of Medicine, and
| | - Anita Ho
- W. Maurice Young Centre for Applied Ethics, the University of British Columbia, Vancouver, British Columbia, Canada Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Judy Illes
- *National Core for Neuroethics, Division of Neurology, Department of Medicine, and
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Abstract
This review traces the literatures in cultural anthropology and neighboring disciplines that are focused on addiction as an object of knowledge and intervention, and as grounds for self-identification, sociality, and action. Highlighting the production of disease categories, the staging of therapeutic interventions, and the ongoing work of governance, this work examines addiction as a key site for the analysis of contemporary life. It likewise showcases a general movement toward accounts of addiction that foreground complexity, contingency, and multiplicity.
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Affiliation(s)
- William Garriott
- Law, Politics, and Society Program, Drake University, Des Moines, Iowa 50311
| | - Eugene Raikhel
- Department of Comparative Human Development, University of Chicago, Chicago, Illinois 60637
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"Just Advil": Harm reduction and identity construction in the consumption of over-the-counter medication for chronic pain. Soc Sci Med 2015; 146:147-54. [PMID: 26517291 DOI: 10.1016/j.socscimed.2015.10.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 01/20/2023]
Abstract
Direct-to-consumer marketing has sparked ongoing debate concerning whether ads empower consumers to be agents of their own care or shift greater control to the pharmaceutical industry. Ads for over-the-counter (OTC) medications in particular portend to offer simple, harmless solutions for meeting the demands of social life. Rather than join the longstanding debate between consumer agency and social control in pharmaceutical advertising, I approach self-medication with over-the-counter (OTC) analgesics using Harm Reduction as a framework. From this perspective, consumption of OTC analgesics by chronic pain sufferers is a means of seeking some level of relief while also avoiding the stigma associated with prescription pain medication. Qualitative methods are used to analyze data from two sources: (1) semi-structured qualitative interviews with 95 participants in a trial examining the effectiveness of Traditional Chinese Medicine for Temporomandibular Disorders (TMD) from 2006 to 2011 in Tucson, AZ and Portland, OR; and (2) print, online, and television advertisements for three major brands of OTC pain medication. Participants described their use of OTC medications as minimal, responsible, and justified by the severity of their pain. OTC medication advertising, while ostensibly ambiguous and targeting all forms of pain, effectively lends support to the consumption of these medications as part of the self-projects of chronic pain sufferers, allowing them to reconcile conflicting demands for pain relief while being stoic and maintaining a positive moral identity. Describing OTC medication as "just over-the-counter" or "not real pain medication," sufferers engage in ideological harm reduction, distinguishing themselves from "those people who like taking pain medication" while still seeking relief. Justifying one's use of OTC medication as minimal and "normal," regardless of intake, avoids association with the addictive potential of prescription pain medications and aligns the identity of the chronic pain sufferer with a culturally sanctioned identity as stoic bearer of pain.
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Holliday S, Morgan S, Tapley A, Dunlop A, Henderson K, van Driel M, Spike N, McArthur L, Ball J, Oldmeadow C, Magin P. The Pattern of Opioid Management by Australian General Practice Trainees. PAIN MEDICINE 2015; 16:1720-31. [PMID: 26118466 DOI: 10.1111/pme.12820] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 04/20/2015] [Accepted: 05/02/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVE With escalating opioid prescribing come individual and public health harms. To inform quality improvement measures, understanding of opioid prescribing is essential. We aimed to establish consultation-level prevalence and associations of opioid prescribing. DESIGN A cross-sectional secondary analysis from a longitudinal multisite cohort study of general practitioner (GP) vocational trainees: "Registrar Clinical Encounters in Training." SETTING Four of Australia's seventeen GP Regional Training Providers, during 2010-13. SUBJECTS GP trainees. METHODS Practice and trainee demographic data were collected as well as patient, clinical and educational data of 60 consecutive consultations of each trainee, each training term. Outcome factors were any opioid analgesic prescription and initial opioid analgesic prescription for a specific problem for the first time. RESULTS Overall, 645 trainees participated. Opioids comprised 4.3% prescriptions provided for 3.8% of patients. Most frequently prescribed were codeine (39.9%) and oxycodone (33.4%). Prescribing was for acute pain (29.3%), palliative care (2.6%) or other indications (68.1%). Most prescribing involved repeat prescriptions for pre-existing problems (62.7% of total). Other associations included older patients; prescriber and patient male gender; Aboriginal/Torres Strait Islander status; rural and disadvantaged locations; longer consultations; and generation of referrals, follow-up, and imaging requests. Opioid initiation was more likely for new patients with new problems, but otherwise associations were similar. Trainees rarely reported addiction risk-mitigation strategies. CONCLUSIONS Most opioids were prescribed as maintenance therapy for non-cancer pain. Demographic associations with opioid analgesic prescribing resemble those presenting for opioid dependency treatment. Our findings should inform measures by regulators and medical educators supporting multimodal pain management.
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Affiliation(s)
- Simon Holliday
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, NSW, Australia
| | - Simon Morgan
- General Practice Training Valley to Coast, Mayfield, NSW, Australia
| | - Amanda Tapley
- General Practice Training Valley to Coast, Mayfield, NSW, Australia
| | - Adrian Dunlop
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, NSW, Australia
| | - Kim Henderson
- General Practice Training Valley to Coast, Mayfield, NSW, Australia
| | - Mieke van Driel
- Discipline of General Practice, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Neil Spike
- Department of General Practice, The University of Melbourne, Victoria, Australia.,Director of Medical Education and Training, VMA General Practice Training, Melbourne, Victoria, Australia
| | - Lawrie McArthur
- Director of Medical Education and Training, Adelaide to Outback GP Training, Adelaide, South Australia
| | - Jean Ball
- Clinical Research Design, Information Technology and Statistical Support (CReDITSS), Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Chris Oldmeadow
- Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, NSW, Australia
| | - Parker Magin
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.,General Practice Training Valley to Coast, Mayfield, NSW, Australia
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Buchbinder M, Wilbur R, McLean S, Sleath B. "Is there any way I can get something for my pain?" Patient strategies for requesting analgesics. PATIENT EDUCATION AND COUNSELING 2015; 98:137-43. [PMID: 25468395 PMCID: PMC4282966 DOI: 10.1016/j.pec.2014.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 10/15/2014] [Accepted: 10/18/2014] [Indexed: 05/23/2023]
Abstract
OBJECTIVE We examined the direct and indirect means by which patients express a desire for analgesic medication. METHODS Back pain patients presenting to an academic ED were invited to participate in a study of patient-provider communication. Audio-recorded encounters were transcribed verbatim and transcripts analyzed using a qualitative approach based on conversation analysis. RESULTS Requests for analgesics were documented in 15 out of 74 interactions (20%). We identified three basic patterns: direct requests, in which the patient explicitly asked for medication; indirect requests, in which the patient hinted at a desire for medication but did not ask for it outright; and no request, in which the provider discussed a prescription without the patient requesting it. CONCLUSION Most patients did not request analgesics. When they did so, they utilized strategies of mitigation, indirection, and deference that presented themselves as deserving patients while upholding the physician's autonomy. PRACTICE IMPLICATIONS Patients come to the clinical encounter with a variety of expectations, of which a desire for an analgesic may be only part of the picture. Rather than focusing on strategies for inuring providers to inappropriate patient requests, it may be useful to devote clinical resources to examining patients' priorities and expectations for treatment.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Rachel Wilbur
- Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Samuel McLean
- Departments of Anesthesiology and Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Betsy Sleath
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Lester R. Health as moral failing: medication restriction among women with eating disorders. Anthropol Med 2014; 21:241-50. [DOI: 10.1080/13648470.2014.927824] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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