Background & Aims

In the changing landscape of chronic pain care, prescribers face difficult decisions about opioids. Guidelines recommend tapering when potential harms of maintaining the current opioid regimen outweigh the benefits. Unfortunately, prescribers often assess harms and benefits in the absence of evidence-based criteria. Thus, these assessments, as well as opioid management decisions, are largely guided by prescribers’ judgements, experience, and local norms/policies. Little is known about how prescribers consider various factors when making these determinations. In this mixed methods study, we examined prescribers’ rationales for opioid management decisions for virtual patients with chronic pain. We focused on prescribers’ rationales for decisions that were at odds with current CDC guidelines – specifically, decisions to abruptly discontinue opioid therapy or to increase the dose of a short-acting opioid (in the context of long term opioid therapy [LTOT]).

Methods

Physicians (“prescribers,” n=100) were instructed to imagine they were taking over the care of 12 fictional patients with chronic pain who had been maintained on LTOT by a previous clinician. Virtual patient vignettes varied by race (Black/White), gender (male/female), and prior opioid risk behaviors (low/medium/high). Prescribers indicated how they would manage each patient’s existing opioid prescription and then described their rationale for these decisions. We identified patient cases for which prescribers indicated they would either discontinue the opioid immediately or increase the dose. We used a thematic approach to qualitatively analyze prescribers’ rationales for these decisions. Two coders separately reviewed the written responses for emergent themes and created an initial set of codes. They then met to find consensus on final codes, which they independently applied to the responses in two iterative passes. After each pass, the coders met to resolve discrepancies.

Results

47 prescribers discontinued LTOT immediately for at least one patient (n=95 of 1,200 encounters); 43 gave rationales. Of these patients, 39% were Black and 49% were women. 78% of these patients had high- or medium-risk opioid behaviors; the most common was refusing urine drug screen (UDS; n=19). 5 themes emerged from prescribers’ rationales for immediately discontinuing LTOT: Lines of treatment, High risk for adverse events, Pain uncontrolled, Treat psychological comorbidities first, and Pursue alternative treatment target(s). 19 prescribers increased the current opioid dose for at least one patient (n=42); 16 gave rationales. Of these 42 patients, 28% were Black and 44% were women. 61% of these patients had high- or medium-risk opioid behaviors; the most common was unsanctioned dose escalation (n=8). 5 themes emerged from prescribers’ rationales for increasing the dose: Pain uncontrolled, Acute exacerbation, Temporary dose increase, Opioid-related risk, and Multimodal pain treatment.

Conclusions

Nearly half of prescribers discontinued LTOT immediately in at least one patient case. Prescribers were most likely to make this decision when patients refused in-office UDS. These quantitative results align with qualitative data in which prescribers frequently cited directly observed risk behaviors as a rationale to discontinue LTOT. Together, these findings suggest that observed risk behaviors have high impact on prescribers’ decisions to discontinue LTOT immediately. Approximately 20% of prescribers increased the current opioid dose in at least one patient case. Prescribers were most likely to make this decision when patients regularly took more than prescribed. This was surprising, as unsanctioned dose escalation is considered a high-risk behavior. Interestingly, Black and women patients were underrepresented in cases where LTOT was discontinued immediately and in cases where the opioid dose was increased. These findings inform future work to improve risk assessment and pain care.

References

1. Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR. Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1

2. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR. Recommendations and Reports, 65(1), 1–49. https://doi.org/10.15585/mmwr.rr6501e1

3. Passik, S. D. (2006). Pain Management Misstatements: Ceiling Effects, Red and Yellow Flags. Pain Medicine, 7(1), 76–77. https://doi.org/10.1111/j.1526-4637.2006.00095.x

4. Jamison, R. N., Butler, S. F., Budman, S. H., Edwards, R. R., & Wasan, A. D. (2010). Gender differences in risk factors for aberrant prescription opioid use. The Journal of Pain, 11(4), 312–320. https://doi.org/10.1016/j.jpain.2009.07.016

Presenting Author

Kristina Bogdan

Poster Authors

Alexis D. Grant, MA

MA

Indiana University-Indiana

Lead Author

Kristina Bogdan

Indiana University-Indianapolis

Lead Author

Adam T. Hirsh

Ph.D.

Indiana University Purdue University-Indianapolis

Lead Author

Topics

  • Assessment and Diagnosis