Sources and Impact of Time Pressure on Opioid Management in the Safety-Net

A Machine Learning Application to Classify Patients at Differing Levels of Risk of Opioid Use Disorder: Clinician-Based Validation Study

Background

Despite restrictive opioid management guidelines, opioid use disorder (OUD) remains a major public health concern. Machine learning (ML) offers a promising avenue for identifying and alerting clinicians about OUD, thus supporting better clinical decision-making regarding treatment.

Objective

This study aimed to assess the clinical validity of an ML application designed to identify and alert clinicians of different levels of OUD risk by comparing it to a structured review of medical records by clinicians.

Methods

The ML application generated OUD risk alerts on outpatient data for 649,504 patients from 2 medical centers between 2010 and 2013. A random sample of 60 patients was selected from 3 OUD risk level categories (n=180). An OUD risk classification scheme and standardized data extraction tool were developed to evaluate the validity of the alerts. Clinicians independently conducted a systematic and structured review of medical records and reached a consensus on a patient's OUD risk level, which was then compared to the ML application's risk assignments.

Results

A total of 78,587 patients without cancer with at least 1 opioid prescription were identified as follows: not high risk (n=50,405, 64.1%), high risk (n=16,636, 21.2%), and suspected OUD or OUD (n=11,546, 14.7%). The sample of 180 patients was representative of the total population in terms of age, sex, and race. The interrater reliability between the ML application and clinicians had a weighted kappa coefficient of 0.62 (95% CI 0.53-0.71), indicating good agreement. Combining the high risk and suspected OUD or OUD categories and using the review of medical records as a gold standard, the ML application had a corrected sensitivity of 56.6% (95% CI 48.7%-64.5%) and a corrected specificity of 94.2% (95% CI 90.3%-98.1%). The positive and negative predictive values were 93.3% (95% CI 88.2%-96.3%) and 60.0% (95% CI 50.4%-68.9%), respectively. Key themes for disagreements between the ML application and clinician reviews were identified.

Conclusions

A systematic comparison was conducted between an ML application and clinicians for identifying OUD risk. The ML application generated clinically valid and useful alerts about patients' different OUD risk levels. ML applications hold promise for identifying patients at differing levels of OUD risk and will likely complement traditional rule-based approaches to generating alerts about opioid safety issues.

"Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety

BACKGROUND

There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics.

OBJECTIVE

To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm.

DESIGN

Qualitative study based on semi-structured interviews.

PARTICIPANTS

Twenty-five primary care physicians practicing in the USA.

APPROACH

Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted.

KEY RESULTS

Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility.

CONCLUSIONS

Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.

Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics

While the epidemiological literature recognizes associations between chronic non-cancer pain (CNCP), opioid use disorder (OUD), and interpersonal trauma stemming from physical, emotional, sexual abuse or neglect, the complex etiologies and interplay between interpersonal and structural traumas in CNCP populations are underexamined. Research has documented the relationship between experiencing multiple adverse childhood experiences (ACEs) and the likelihood of developing an OUD as an adult. However, the ACEs framework is criticized for failing to name the social and structural contexts that shape ACE vulnerabilities in families. Social scientific theory and ethnographic methods offer useful approaches to explore how interpersonally- and structurally-produced traumas inform the experiences of co-occurring CNCP, substance use, and mental health. We report findings from a qualitative and ethnographic longitudinal cohort study of patients with CNCP (n = 48) who received care in safety-net settings and their primary care providers (n = 23). We conducted semi-structured interviews and clinical and home-based participant observation from 2018 to 2020. Here we focus our analyses on how patients and providers explained and situated the role of patient trauma in the larger clinical context of reductions in opioid prescribing to highlight the political landscape of the United States opioid overdose crisis and its impact on clinical interactions. Findings reveal the disproportionate burden structurally-produced, racialized trauma places on CNCP, substance use and mental health symptoms that shapes patients' embodied experiences of pain and substance use, as well as their emotional experiences with their providers. Experiences of trauma impacted clinical care trajectories, yet providers and patients expressed limited options for redress. We argue for an adaptation of trauma-informed care approaches that contextualize the structural determinants of trauma and their interplay with interpersonal experiences to improve clinical care outcomes.

The intersection of drug use discrimination and racial discrimination in the management of chronic non-cancer pain in United States primary care safety-net clinics: Implications for healthcare system and clinic-level changes

BACKGROUND

Clinicians' bias related to patients' race and substance use history play a role in pain management. However, patients' or clinicians' understandings about discriminatory practices and the structural factors that contribute to and exacerbate these practices are underexamined. We report on perceptions of discrimination from the perspectives of patients with chronic non-cancer pain (CNCP) and a history of substance use and their clinicians within the structural landscape of reductions in opioid prescribing in the United States.

METHODS

We interviewed 46 clinicians and 94 patients, using semi-structured interview guides, from eight safety-net primary care clinics across the San Francisco Bay Area from 2013 to 2020. We used a modified grounded theory approach to code and analyze transcripts.

RESULTS

Clinicians discussed using opioid prescribing guidelines with the goals of increased opioid safety and reduced bias in patient monitoring. While patients acknowledged the validity of clinicians' concerns about opioid safety, they indicated that clinicians made assumptions about opioid misuse towards Black patients and patients suspected of substance use. Clinicians discussed evidence of discrimination in opioid prescribing at the clinic-wide level; racialized stereotypes about patients likely to misuse opioids; and their own struggles to overcome discriminatory practices regarding CNCP management.

CONCLUSION

While clinicians and patients acknowledged opioid safety concerns, the practical application of opioid prescribing guidelines impacted how patients perceived and engaged with CNCP care particularly for patients who are Black and/or report a history of substance use. We recommend healthcare system and clinic-level interventions that may remediate discriminatory practices and associated disparities.

"Cookbook medicine": Exploring the impact of opioid prescribing limits legislation on clinical practice and patient experiences

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.

Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic increased use of telehealth for the management of opioid use disorder and chronic non-cancer pain in primary care safety net clinical systems. Significant barriers to telehealth exist, little is known about how these barriers impact urban safety net, primary care providers and their patients. The objective of this study was to qualitatively assess the benefits and challenges of telehealth for management of chronic non-cancer pain, opioid use disorder, and multi-morbidity in primary care, safety net clinical systems.

METHODS

We interviewed patients with chronic non-cancer pain and history of substance use (n = 22) and their primary care clinicians (n = 7) in the San Francisco Bay Area, March-July 2020. We recorded, transcribed, coded, and content analyzed interviews.

RESULTS

COVID-19 shelter-in-place orders contributed to increases in substance use and uncontrolled pain, and posed challenges for monitoring opioid safety and misuse through telehealth. None of the clinics used video visits due to low digital literacy/access. Benefits of telehealth included decreased patient burden and missed appointments and increased convenience and control of some chronic conditions (e.g., diabetes, hypertension). Telehealth challenges included loss of contact, greater miscommunication, and less comprehensive care interactions.

CONCLUSIONS

This study is one of the first to examine telehealth use in urban safety net primary care patients with co-occurring chronic non-cancer pain and substance use. Decisions to continue or expand telehealth should consider patient burden, communication and technology challenges, pain control, opioid misuse, and medical complexity.

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide.

OBJECTIVE

To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans.

DESIGN

A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020.

PARTICIPANTS

A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event.

INTERVENTION

A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide.

MAIN MEASURES

Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality.

KEY RESULTS

Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61).

CONCLUSIONS

Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes.

TRIAL REGISTRATION

ISRCTN16012111.

Continuity of opioid prescribing among older adults on long-term opioids

OBJECTIVES

To describe the continuity of opioid prescribing and prescriber characteristics among older adults with chronic noncancer pain (CNCP) who are on long-term opioid therapy (LTOT) and to evaluate the association of continuity of opioid prescribing and prescriber characteristics with the risk of opioid-related adverse events.

STUDY DESIGN

Nested case-control design.

METHODS

This study employed a nested case-control design using a 5% random sample of the national Medicare administrative claims data for 2012-2016. Eligible individuals experiencing a composite outcome of opioid-related adverse events were defined as cases and matched to controls using incidence density sampling. Continuity of opioid prescribing (operationalized using the Continuity of Care Index) and prescriber specialty were assessed among all eligible individuals. Conditional logistic regression was conducted to assess the relationships of interest after accounting for known confounders.

RESULTS

Individuals with low (odds ratio [OR], 1.45; 95% CI, 1.08-1.94) and medium (OR, 1.37; 95% CI, 1.04-1.79) continuity of opioid prescribing were found to have greater odds of experiencing a composite outcome of opioid-related adverse events compared with individuals with high prescribing continuity. Fewer than 1 in 10 (9.2%) older adults starting a new LTOT episode received at least 1 prescription from a pain specialist. Receiving a prescription from a pain specialist was not significantly associated with the outcome in adjusted analyses.

CONCLUSIONS

We found that higher continuity of opioid prescribing, but not provider specialty, was significantly associated with fewer opioid-related adverse outcomes among older adults with CNCP.

Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research

Background

Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy.

Aim

The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature.

Methods

Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded.

Results

Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation).

Conclusions

Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.

Expanding access to medications for opioid use disorder in primary care clinics: an evaluation of common implementation strategies and outcomes

BACKGROUND

To combat the opioid epidemic in the USA, unprecedented federal funding has been directed to states and territories to expand access to prevention, overdose rescue, and medications for opioid use disorder (MOUD). Similar to other states, California rapidly allocated these funds to increase reach and adoption of MOUD in safety-net, primary care settings such as Federally Qualified Health Centers. Typical of current real-world implementation endeavors, a package of four implementation strategies was offered to all clinics. The present study examines (i) the pre-post effect of the package of strategies, (ii) whether/how this effect differed between new (start-up) versus more established (scale-up) MOUD practices, and (iii) the effect of clinic engagement with each of the four implementation strategies.

METHODS

Forty-one primary care clinics were offered access to four implementation strategies: (1) Enhanced Monitoring and Feedback, (2) Learning Collaboratives, (3) External Facilitation, and (4) Didactic Webinars. Using linear mixed effects models, RE-AIM guided outcomes of reach, adoption, and implementation quality were assessed at baseline and at 9 months follow-up.

RESULTS

Of the 41 clinics, 25 (61%) were at MOUD start-up and 16 (39%) were at scale-up phases. Pre-post difference was observed for the primary outcome of percent of patient prescribed MOUD (reach) (β_time = 3.99; 0.73 to 7.26; p = 0.02). The largest magnitude of change occurred in implementation quality (ES = 0.68; 95% CI = 0.66 to 0.70). Baseline MOUD capability moderated the change in reach (start-ups 22.60%, 95% CI = 16.05 to 29.15; scale-ups -4.63%, 95% CI = -7.87 to -1.38). Improvement in adoption and implementation quality were moderately associated with early prescriber engagement in Learning Collaboratives (adoption: ES = 0.61; 95% CI = 0.25 to 0.96; implementation quality: ES = 0.55; 95% CI = 0.41 to 0.69). Improvement in adoption was also associated with early prescriber engagement in Didactic Webinars (adoption: ES = 0.61; 95% CI = 0.20 to 1.05).

CONCLUSIONS

Rather than providing an all-clinics-get-all-components package of implementation strategies, these data suggest that it may be more efficient and effective to tailor the provision of implementation strategies based on the needs of clinic. Future implementation endeavors could benefit from (i) greater precision in the provision of implementation strategies based on contextual determinants, and (ii) the inclusion of strategies targeting engagement.

Time on shift in the emergency department and decision to prescribe opioids to patients without chronic opioid use

Objective To study the effect of time on shift on the opioid prescribing practices of emergency physicians among patients without chronic opioid use.Methods We analyzed pain-related visits for five painful conditions from 2010 to 2017 at a single academic hospital in Boston. Visits were categorized according to national guidelines as conditions for which opioids are “sometimes indicated” (fracture and renal colic) or “usually not indicated” (headache, low back pain, and fibromyalgia). Using conditional logistic regression with fixed effects for clinicians, we estimated the probability of opioid prescribing for pain-related visits as a function of shift hour at discharge, time of day, and patient-level confounders (age, sex, and pain score).Results Among 16,115 visits for which opioids were sometimes indicated, opioid prescribing increased over the course of a shift (28% in the first hour compared with 40% in the last hour; adjusted odds ratio, 1.06; 95% confidence interval, 1.02–1.10; adjusted P-trend <0.01). However, among visits for which opioids are usually not indicated, relative to the first hour, opioid prescriptions progressively fell (40% in the first hour compared with 23% in the last hour; adjusted odds ratio, 0.93; 95% confidence interval, 0.91–0.96; adjusted P-trend <0.01).Conclusion As shift hour progressed, emergency physicians became more likely to prescribe opioids for conditions that are sometimes indicated, and less likely to prescribe opioids for nonindicated conditions. Our study suggests that clinical decision making in the emergency department can be substantially influenced by external factors such as clinician shift hour.

The Role of Informatics in Implementing Guidelines for Chronic Opioid Therapy Risk Assessment in Primary Care: A Narrative Review Informed by the Socio-Technical Model

Approximately 2 million Americans live with opioid use disorder (OUD), most of whom also have chronic pain. The economic burden of chronic pain and prescription opioid misuse runs into billions of dollars. Patients on prescription opioids for chronic non-cancer pain (CNCP) are at increased risk for OUD and overdose. By adhering to the Center for Disease Control and Prevention (CDC) opioid prescribing guidelines, primary care providers (PCPs) have the potential to improve patient outcomes. But numerous provider, patient, and practice-specific factors challenge adherence to guidelines in primary care. Many of the barriers may be mediated by informatics interventions, but gaps in knowledge and unmet needs exist. This narrative review examines the risk assessment and harm reduction process in a socio-technical context to highlight the gaps in knowledge and unmet needs that can be mediated through informatics intervention.

Determinants of long-term opioid prescribing in an urban population- a cross sectional study

BACKGROUND

Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure.

AIM

To describe the predictors of long-term opioid prescribing (LTOP), (≥3 opioid prescriptions in a 90-day period).

DESIGN AND SETTING

A retrospective cross-sectional study in 41 General Practices in South London.

METHOD

Multi-level multivariable logistic regression to investigate the determinants of LTOP.

RESULTS

2,679 (0.8%) out of 320,639 registered patients ≥18 years were identified as having LTOP. Patients Were most likely to have LTOP, if: they had ≥5 long term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1), in comparison to no LTCs, ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), smokers compared to non-smokers (AOR 2.2, CI 2.0-2.5), females compared to males (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual long-term conditions (LTCs), the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4).

CONCLUSION

LTOP was significantly higher in those aged ≥75 years, with multi-morbidity or specific LTCs: sickle cell disease, osteoarthritis, rheumatoid arthritis, depression, and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.

Psychometric Properties of a Healthcare Provider Burden Scale: Preliminary Results

Measures are lacking of the clinical burden that healthcare providers perceive in treating chronic conditions. This study presents a preliminary psychometric evaluation of a novel self-report measure of provider burden in the treatment of chronic pain. Data for eight burden items were available from vignette studies examining the effects of patient pain severity and medical evidence on clinical burden and judgments for chronic pain. Participants (N = 922) were 109 physicians and 813 non-physicians, all acting in the role of physician (232 community members without chronic pain, 105 community members with chronic pain, and 476 American Chronic Pain Association members with chronic pain). Factor analyses of burden items yielded one-factor solutions in all samples, with high factor loadings and adequate explained variance. Internal consistency reliability was uniformly high (≥ .87). Burden scores were significantly higher among physicians compared to non-physicians; non-physician groups did not differ on any burden score. Significant correlations of burden score with indicators of psychosocial complications in patient care supported scale validity. Burden score was not associated with gender, age, or education. Results provide initial support for the psychometric properties of a Healthcare Provider Burden Scale (HPBS). Research utilizing larger and representative healthcare provider groups is needed.

Treating risk, risking treatment: experiences of iatrogenesis in the HIV/AIDS and opioid epidemics

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis.

Painful Subjects: Treating Chronic Pain among People Living with HIV in the Age of Opioid Risk

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.

The DWQ-EMR Embedded Tool to Enhance the Family Physician-Caregiver Connection: A Pilot Case Study

The number of family caregivers to individuals with dementia is increasing. Family physicians are often the first point of access to the health care system for individuals with dementia and their caregivers. Caregivers are at an increased risk of developing negative physical, cognitive and affective health problems themselves. Caregivers also describe having unmet needs to help them sustain care in the community. Family physicians are in a unique position to help support caregivers and individuals with dementia, but often struggle with keeping up with best practice dementia service knowledge. The Dementia Wellness Questionnaire was designed to serve as a starting point for discussions between caregivers and family physicians by empowering caregivers to communicate their needs and concerns and to enhance family physicians' access to specific dementia support information. The DWQ aims to alert physicians of caregiver and patient needs. This pilot study aimed to explore the experiences of physicians and caregivers of people using the Questionnaire in two family medicine clinics in Ontario, Canada. Interviews with physicians and caregivers collected data on their experiences using the DWQ following a 10-month data gathering period. Data was analyzed using content analysis. Results indicated that family physicians may have an improved efficacy in managing dementia by having dementia care case specific guidelines integrated within electronic medical records. By having time-efficient access to tailored supports, family physicians can better address the needs of the caregiver-patient dyad and help support family caregivers in their caregiving role. Caregivers expressed that the Questionnaire helped them remember concerns to bring up with physicians, in order to receive help in a more efficient manner.

How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain

PURPOSE

To understand how patients and providers weigh the risks and benefits of long-term opioid therapy (LTOT) for cancer pain.

METHODS

Researchers used VA approved audio-recording devices to record interviews. ATLAS t.i., a qualitative analysis software, was used for analysis of transcribed interview data. Participants included 20 Veteran patients and 20 interdisciplinary providers from primary care- and oncology-based practice settings. We conducted semistructured interviews and analyzed transcripts used thematic qualitative methods. Interviews explored factors that affect decision making about appropriateness of LTOT for cancer related pain. We saturated themes for providers and patients separately.

RESULTS

Factors affecting patient decision-making included influence from various information sources, persuasion from trusted providers, and sometimes deferral of the decision to their provider. Relative prioritization of pain management as the focal patient concern varied with some patients describing comparatively more fear of chemotherapy than opioid analgesics, comparatively more knowledge of opioids in relation to other drugs;patients expressed a preference to spend the limited time they have with their oncologist discussing cancer treatment rather than opioid use. Factors affecting provider decision making included prognosis, patient goals, patient characteristics, and provider experience and biases. Providers differed in how they weigh the relative importance of alleviating pain or avoiding opioids in the face of treating patients with cancer and histories of substance abuse.

CONCLUSION

Divergent perspectives on factors need to be considered when weighing risks and benefits. Policies and interventions should be designed to reduce variation in practice to promote equal access to adequate pain management. Improved shared decision-making initiatives will take advantage of patient decision-making factors and priorities.

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BACKGROUND

Nursing brings a unique lens to care of patients with pain and opioid misuse.

AIMS

This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.

DESIGN

The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

DATA SOURCES

Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.

ANALYSIS METHOD

Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature.

RESULTS

Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).

CONCLUSION

Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.

IMPLICATIONS FOR NURSING

This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

A crack in the wall: Chronic pain management in integrative group medical visits

Amidst a national crisis of opioid overdose, substantial uncertainty remains over how to safely and effectively address chronic pain. In response to this crisis, safety-net primary care clinics are instituting integrative group medical visits (IGMVs) for chronic pain management. Through two qualitative studies of IGMVs, we found that these groups acted as workarounds implemented by clinicians seeking to innovate upon standard pain management protocols. While clinical uncertainty is often framed as a problem to be managed, in this instance, overlapping uncertainties provided an opportunity through which enterprising clinicians could generate reform at the local level. However, these clinician-led changes were incremental, situational, and partial, and occurred outside of broader systemic reform. In the following article, we draw on 46 interviews with clinicians and staff associated with IGMVs and observations of 34 sessions of 22 distinct IGMVs. We begin by describing the structure of the IGMVs we observed. We analyze the multiple uncertainties surrounding chronic pain and its treatment at the time of our data collection, just before the opioid crisis was declared a national public health emergency. We then demonstrate how clinicians tinkered with existing pain management protocols via their involvement with IGMVs. Lastly, we discuss the conditions of possibility that allowed for the existence of IGMVs at our study sites, as well as the conditions of limitation that restricted the expansion of these groups. Our research points to the potential of IGMVs for treating chronic pain, while showing that IGMVs continue as an innovation by individual clinicians, not as a result of broader reforms.

Patient Interviewing Strategies to Recognize Substance Use, Misuse, and Abuse in the Dental Setting

Brief and effective clinical interviewing is critical for identifying patient risk factors, including those associated with substance use. Dental practitioners may perceive identifying patient substance misuse and abuse as a complex undertaking or may consider this clinical assessment beyond the scope of their training and practice. This article describes interviewing strategies that will help dental providers communicate effectively and empathically with their patients to collect relevant clinical information related to substance use, misuse, and abuse and provide better care for their patients.

Time Pressure During Primary Care Office Visits: a Prospective Evaluation of Data from the Healthy Work Place Study

BACKGROUND

The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear.

OBJECTIVE

To quantify associations between time pressure, workplace characteristics ,and clinician outcomes.

DESIGN

Prospective analysis of data from the Healthy Work Place randomized trial.

PARTICIPANTS

168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast.

MAIN MEASURES AND METHODS

Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs).

KEY RESULTS

Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p < 0.05), women versus men (78% vs 55%, p < 0.01), and clinicians with larger numbers of complex psychosocial (81% vs 59%, p < 0.01) and Limited English Proficiency patients (95% vs 57%, p < 0.001). Time pressure in new patient visits was associated with lack of control, clinician stress, and intent to leave (ESs small to moderate, p < 0.05). Time pressure in follow-up visits was associated with chaotic workplaces and burnout (small to moderate ESs, p's < 0.05). Time pressure improved over time in workplaces with values alignment and an emphasis on quality.

CONCLUSIONS

Time pressure, more common in women and general internists, was related to chaos, control and culture, and stress, burnout, and intent to leave. Future studies should evaluate these findings in larger and more geographically diverse samples.