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Fereydooni S, Lorenz K, Azarfar A, Luckett T, Phillips JL, Becker W, Giannitrapani K. Identifying provider, patient and practice factors that shape long-term opioid prescribing for cancer pain: a qualitative study of American and Australian providers. BMJ Open 2024; 14:e082033. [PMID: 38514141 PMCID: PMC10961503 DOI: 10.1136/bmjopen-2023-082033] [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] [Received: 11/14/2023] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Prescribing long-term opioid therapy is a nuanced clinical decision requiring careful consideration of risks versus benefits. Our goal is to understand patient, provider and context factors that impact the decision to prescribe opioids in patients with cancer. METHODS We conducted a secondary analysis of the raw semistructured interview data gathered from 42 prescribers who participated in one of two aligned concurrent qualitative studies in the USA and Australia. We conducted a two-part analysis of the interview: first identifying all factors influencing long-term prescribing and second open coding-related content for themes. RESULTS Factors that influence long-term opioid prescribing for cancer-related pain clustered under three key domains (patient-related, provider-related and practice-related factors) each with several themes. Domain 1: Patient factors related to provider-patient continuity, patient personality, the patient's social context and patient characteristics including racial/ethnic identity, housing and socioeconomic status. Domain 2: Provider-related factors centred around provider 'personal experience and expertise', training and time availability. Domain 3: Practice-related factors included healthcare interventions to promote safer opioid practices and accessibility of quality alternative pain therapies. CONCLUSION Despite the differences in the contexts of the two countries, providers consider similar patient, provider and practice-related factors when long-term prescribing opioids for patients with cancer. Some of these factors may be categorised as cognitive biases that may intersect in an already disadvantaged patient and exacerbate disparities in the treatment of their pain. A more systematic understanding of these factors and how they impact the quality of care can inform appropriate interventions.
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Affiliation(s)
| | - Karl Lorenz
- Stanford University, Stanford, California, USA
| | - Azin Azarfar
- University of Florida, Gainesville, Florida, USA
| | - Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology, Sydney, New South Wales, Australia
| | - William Becker
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Karleen Giannitrapani
- VA Center for Innovation to Implementation, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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Harsanyi H, Cuthbert C, Schulte F. The Stigma Surrounding Opioid Use as a Barrier to Cancer-Pain Management: An Overview of Experiences with Fear, Shame, and Poorly Controlled Pain in the Context of Advanced Cancer. Curr Oncol 2023; 30:5835-5848. [PMID: 37366920 DOI: 10.3390/curroncol30060437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/10/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Cancer-related pain affects a majority of patients with advanced cancer and is often undertreated. The treatment of this pain is largely reliant on the use of opioids, which are essential medicines for symptom management and the maintenance of quality of life (QoL) for patients with advanced cancer. While there are cancer-specific guidelines for the treatment of pain, widespread publication and policy changes in response to the opioid epidemic have drastically impacted perceptions of opioid use. This overview therefore aims to investigate how manifestations of opioid stigma impact pain management in cancer settings, with an emphasis on the experiences of patients with advanced cancer. Opioid use has been widely stigmatized in multiple domains, including public, healthcare, and patient populations. Physician hesitancy in prescribing and pharmacist vigilance in dispensing were identified as barriers to optimal pain management, and may contribute to stigma in the context of advanced cancer. Evidence in the literature suggests that opioid stigma may result in patient deviations from prescription instructions, which generally leads to pain undertreatment. Patients reflected on experiencing shame and fear surrounding their prescription opioid use and feeling uncomfortable communicating with their healthcare providers on these topics. Our findings indicate that future work is required to educate patients and providers in order to de-stigmatize opioid use. Through alleviating stigma, patients may be better able to make decisions regarding their pain management which lead to freedom from cancer-related pain and improved QoL.
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Affiliation(s)
- Hannah Harsanyi
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Colleen Cuthbert
- Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Fiona Schulte
- Division of Psychosocial Oncology, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
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Hamlish T, Pasquinelli M, Gastala N, Huber M, Manst D, Andersen K, Jarrett JB, Neeb C, Tuite J, Maes P, Sung C, Fleurimont J, Feldman L. A team-based approach to effective management of pain and opioid use disorder in patients with cancer: Case report. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100196] [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] Open
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Mai Q, Li X, Yang D, Zhang X, Peng K, Hao Y. Effects of acupressure on cancer-related pain management: a systematic review and meta-analysis of randomized controlled trials. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Giannitrapani KF, Silveira MJ, Azarfar A, Glassman PA, Singer SJ, Asch SM, Midboe AM, Zenoni MA, Gamboa RC, Becker WC, Lorenz KA. Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study. J Gen Intern Med 2021; 36:1867-1874. [PMID: 33948790 PMCID: PMC8298631 DOI: 10.1007/s11606-021-06747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN Qualitative research. PARTICIPANTS We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.
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Affiliation(s)
- K F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - M J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, University of Michigan, Ann Arbor, MI, USA.,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - A Azarfar
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,University of Central Florida, Orlando, FL, USA
| | - P A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S J Singer
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - S M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - A M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - M A Zenoni
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - R C Gamboa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - W C Becker
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - K A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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