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

Abstract

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.

Identifying provider, patient and practice factors that shape long-term opioid prescribing for cancer pain: a qualitative study of American and Australian providers

“…We undertook a secondary qualitative analysis of two research studies in the USA and Australia aiming to understand providers’ decision-making process when weighing the risks versus benefits of LTOT for patients with cancer. A more detailed explanation of data collection and interview guide are available in previous publications 5 10. Reporting adheres to the Consolidated Criteria for Reporting Qualitative Research 11…”

“…Providers were based in two VHA centres on each US coast. Australian providers were recruited via email listservs, conferences/forums, phone, email and direct interaction 5 10. Using a quasi-randomised approach, we sampled from various regions with the aid of Google Maps 10.…”

“…This makes LTOT a challenging clinical decision requiring careful consideration of risks versus benefits 5. Providers consider multiple factors before prescribing opioids including pain severity, the underlying cause (eg, cancer or comorbidities), prognosis, history of substance use or mental illness and alternative treatment modalities 5.…”

“…This makes LTOT a challenging clinical decision requiring careful consideration of risks versus benefits 5. Providers consider multiple factors before prescribing opioids including pain severity, the underlying cause (eg, cancer or comorbidities), prognosis, history of substance use or mental illness and alternative treatment modalities 5. Since guidance and screening tools unique to patients with cancer have only recently been developed and are not routinely employed in the clinic, providers express a lack of confidence in the management of these patients 6–8.…”

Cross Disciplinary Role Agreement is Needed When Coordinating Long‐Term Opioid Prescribing for Cancer: a Qualitative Study

“…We undertook this analysis within the Opioid CHOICE Study which aimed to improve prescribing practices for long-term opioid therapy (LTOT) for cancer pain management in the VA. 31,32 We used semi-structured interviews to query providers who were involved in prescribing long-term (defined as greater than 90 days) opioid pain management for cancer pain about the following: how providers executed and coordinated tasks involved in prescribing (i.e., shared decision making with the patient, informed consent, information about tapering and disposal, prescription drug safety monitoring, response to changes in a patient's underlying condition or pain, use of non-opioid alternatives), challenges providers faced, and potential solutions to overcome these challenges.…”