Reassurance, agreeing to avoid opioids, and information gathering were the three most common communication strategies used by physicians and their patients with chronic pain. Those are the findings from a small pilot study conducted to determine how doctors and patients approach the inherent uncertainty of opioid use, given the absence of long-term data about opioids’ efficacy in noncancer or end-of-life pain treatment.
To conduct the study, a team led by Marianne S. Matthias, Ph.D., of the Veterans Health Administration in Indianapolis, audio-recorded the primary care visits of 30 patients with chronic musculoskeletal pain between August 2010 and March 2011.
Study participants had a score of 4 or greater on a pain scale of 0 (no pain) to 10 (worst pain imaginable); were already a patient of one of the five doctors participating in the study (three doctors were women); and had an appointment scheduled within the study’s duration. Patients were excluded if they had terminal cancer or poorly controlled psychiatric comorbidities, such as paranoia (Patient Educ. Couns. 2013 Aug. 5 (doi: 10.1016/j.pec.2013.06.021).
The age range of the patients was 27-70 years (mean age, 57 years). Back pain was the most common complaint (17 patients), and 13 patients were being treated for arthritis. In all, 20 patients were taking prescription opioids, wrote Dr. Matthias and her colleagues, who are affiliated with the VA Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice.
To help with appropriate patient recruitment, doctors in the study were told that researchers were studying communication strategies for pain management; patients were told only that the study would collect data about doctor-patient communications, in order to avoid affecting any discussions that might emerge about pain. Although discussions specifically addressing opioid use occurred in 19 visits, all patients were interviewed immediately after each recorded visit about their relationship with their doctor, and their pain and treatment.
The researchers used emergent thematic analysis to determine which communication strategies prevailed in all transcriptions of the recorded physician-patient encounters and follow-up interviews. They then independently listed the categories they believed were most persistent before all agreed upon a set of predominant themes. All transcriptions were then divided among the analysts and reevaluated according to the established categories. Every fourth set of transcriptions was analyzed by the entire team to ensure consistency.
Although researchers noted that side effects of opioid use, appropriateness of opioids, and correct titration were topics of concern for some patients, the chief concern was the risk of opioid misuse or addiction, particularly in patients with histories of substance use disorder. Using problematic integration theory, a framework of coping with uncertainty through communication, Dr. Matthias and her colleagues determined that the physicians and their patients confronted the unknowns about opioids through either reassurance, agreeing to avoid opioids in treatment, or gathering additional information.
The researchers noted that the strategies often overlapped, but all of them hinged on the quality and quantity of information available to the individual, and on the person’s probability judgment, both of which are central tenets of problematic integration theory.
In visits where reassurance occurred, particularly in patients with a history of substance abuse, uncertainty was met by candid discussions about the possibility of misuse or addiction. The researchers noted as an example of reassurance the case of a physician who reassured her patient that she was not concerned that he would become addicted to hydrocodone. Dr. Matthias and her associates wrote that this type of strategy was intended to change the other person’s probability judgment that misuse or addiction was unlikely. This strategy was reinforced by the doctor offering the patient information about hydrocodone, the investigators wrote.
Agreeing to avoid opioids entirely was a second pattern investigators observed doctors and patients using as a means of eliminating the uncertainties in opioid use. The third discrete pattern was for the doctor or patient to gather more information, such as by offering the patient more facts about hydrocodone, asking questions, or performing tests such as a urinalysis for drug use.
Dr. Matthias and her colleagues reported that uncertainty in problematic integration theory exists in relation to what an individual values. For example, the premium placed on pain relief by those prescribed opioids, motivated these patients to reassure their physicians that they were not abusing their prescriptions. The investigators hypothesized that the value placed on pain relief from opioids contributed to the lack of confrontation observed in the patient-doctor conversations.
"Regardless of whether uncertainties originated with the doctor or patient, both parties often employed partnership language ... collaboratively seeking to cope with the uncertainty of opioid treatment," Dr. Matthias and her colleagues wrote. "Many of the communication behaviors documented in this study might serve as a model for training patients and physicians to communicate effectively about opioids," the authors concluded.