It made my life a little easier: Primary care providers’ beliefs and attitudes about using opioid treatment agreements

Starrels, Joanna L.; Wu, Bryan; Peyser, Deena; Fox, Aaron D.; Batchelder, Abigail; Barg, Frances K.; Arnsten, Julia H.; Cunningham, Chinazo O.

doi:10.5055/jom.2014.0198

Cited by 28 publications

(27 citation statements)

References 30 publications

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“…These strategies should target women with pain and substance use early on to ensure improved engagement and retention in care. Furthermore, our study reinforces the importance of research on opioid treatment for pain among illicit substance users with HIV, 11,35 particularly because our study suggests that pain may be influencing retention in care in this vulnerable population.…”

Section: Discussionsupporting

confidence: 69%

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

et al. 2016

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Background Pain is highly prevalent among HIV-positive individuals, with women representing a large subset of those with pain. However, little is known about the relationship between pain and retention in HIV medical care. Among a cohort of HIV-positive women of color, we evaluated the association between pain and retention in care, as measured by missed clinic visits. Methods The Health Resources and Services Administration’s Women of Color Initiative was a multi-site observational cohort study evaluating demonstration projects to engage HIV-positive women in medical care. From November 2010 to July 2013, 921 women were enrolled in the study across nine U.S. sites; baseline interviews collected data on socio-demographic, clinical, and risk behavior characteristics. Pain was assessed at baseline based on number of days in pain over the last 30 days and was categorized as no pain (0 days), infrequent pain (1–13 days), and frequent pain (14–30 days), with 14 days being the median. Missed visits over the one-year follow-up period, evaluated by chart abstraction, were dichotomized as ≤1 missed visit vs. >1 missed visit. We conducted multivariate logistic regression to assess the association between pain at baseline and missed visits, adjusting for pertinent covariates. Results Among our sample (N=862), 52.2% of women reported no pain, 23.7% reported infrequent pain and 24.1% reported frequent pain. Forty-five percent had >1 missed visit during the one-year follow-up period. Overall, we did not find a significant association between pain and missed visits (aOR 2.30; 95% CI 1.00–5.25). However, in planned stratified analyses, among women reporting current substance use at baseline, reporting frequent pain was associated with a higher odds of missed visits as compared with reporting no pain (aOR=15.14; 95% CI 1.78–128.88). Conclusion In our overall sample, pain was not significantly associated with missed visits. However, frequent pain was associated with missed visits among HIV-positive women of color who reported substance use at baseline. A better understanding of the relationship between pain and missed visits could guide efforts to improve retention in care in this population.

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Section: Discussionsupporting

confidence: 69%

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

et al. 2016

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“…1,19,24 Further, implementing guideline-based opioid prescribing practices, particularly when it leads to discontinuing opioids, could negatively impact the provider-patient relationship and lead to termination of care. Qualitative studies of HIV-infected patients with chronic pain and primary care providers who are not focused on HIV also raised concerns that guideline-based opioid prescribing practices negatively impacted the doctor-patient relationship, 35,36,47 but we are not aware of studies that have quantified this risk. Thus, there is a real but undetermined risk that HIV-infected patients could fall out of care and suffer negative HIV-related outcomes.…”

Section: Discussionmentioning

confidence: 99%

When Human Immunodeficiency Virus (HIV) Treatment Goals Conflict with Guideline-Based Opioid Prescribing: A Qualitative Study of Hiv Treatment Providers

et al. 2016

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Background HIV-infected patients have high prevalence of chronic pain and opioid use, making HIV care a critical setting for improving the safety of opioid prescribing. Little is known about HIV treatment providers’ perspectives about opioid prescribing to patients with chronic pain. Methods We administered a questionnaire and conducted semi-structured telephone interviews with 18 HIV treatment providers (infectious disease specialists, general internists, family practitioners, nurse practitioners, and physician assistants) in Bronx, NY. Open-ended interview questions focused on providers’ experiences, beliefs, and attitudes about opioid prescribing and about use of guideline-based opioid prescribing practices (conservative prescribing, and monitoring for and responding to misuse). Transcripts were thematically analyzed using a modified grounded theory approach. Results Eighteen HIV treatment providers included 13 physicians, 4 nurse practitioners, and 3 physician assistants. They were 62% female, 56% white, and practiced as HIV providers for a mean of 14.6 years. Most reported always or almost always using opioid treatment agreements (56%) and urine drug testing (61%) with their patients on long-term opioid therapy. HIV treatment providers tended to view opioid prescribing for chronic pain within the “HIV paradigm,” a set of priorities and principles defined by three key themes: 1) primacy of HIV goals, 2) familiarity with substance use, and 3) the clinician as ally. The HIV paradigm sometimes supported, and sometimes conflicted with guideline-based opioid prescribing practices. For HIV treatment providers, perceived alignment with the HIV paradigm determined whether and how guideline-based opioid prescribing practices were adopted. For example, the primacy of HIV goals superseded conservative opioid prescribing when providers prescribed opioids with the goal of retaining patients in HIV care. Conclusion Our findings highlight unique factors in HIV care that influence adoption of guideline-based opioid prescribing practices. These factors should be considered in future research and initiatives to address opioid prescribing in HIV care.

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“…Our console also incorporates the pitch or level of loss, both professional and personal, that can contribute to the harmony or dissonance of a therapeutic encounter. The reviewers also identified 76 concepts in 17 153,155,157,161,174,175,177,187,[189][190][191]198,208,211,213,217,218 of the 77 studies that uniquely explored the experience of prescribing opioids to patients with chronic non-malignant pain. The reviewers discussed and organised the 76 concepts (see Appendix 3) into 19 conceptual categories (Table 12), and then into six themes that underpin HCPs' experience of prescribing opioids to patients with chronic non-malignant pain:…”

Section: Conceptual Modelmentioning

confidence: 99%

“…Walking a fine line All 9 direct, 2 partial 20 11 153,157,162,177,187,188,190,194,208,211,217 High confidence Social guardianship All 10 direct, 1 partial 17 11 153,155,157,174,175,177,190,191,208,211,217 High confidence All 12 direct, 2 partial 27 14 153,155,157,174,175,177,190,191,198,208,211,213,217,218 High confidence All 8 direct 18 8 155,157,175,177,190,191,217,218 Moderate confidence FINDINGS NIHR Journals Library www.journalslibrary.nihr.ac.uk…”

Section: Opioid Agreements: Positive Viewmentioning

confidence: 99%

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Toye

Seers

Barker

2018

Health Serv Deliv Res

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Background People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research. Objectives (1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs. Design We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument. Data sources We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings. Results We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (see Report Supplementary Material 1; URL: www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy. Limitations There are no agreed methods for determining confidence in QESs. Conclusions We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain. Future work Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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It made my life a little easier: Primary care providers’ beliefs and attitudes about using opioid treatment agreements

Cited by 28 publications

References 30 publications

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women

When Human Immunodeficiency Virus (HIV) Treatment Goals Conflict with Guideline-Based Opioid Prescribing: A Qualitative Study of Hiv Treatment Providers

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

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