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Providers’ Experiences Treating Chronic Pain Among Opioid-Dependent Drug Users

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Abstract

BACKGROUND

Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and pre-existing addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described.

OBJECTIVE

Our objective was twofold. We sought first to explore providers’ perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy.

DESIGN

Qualitative semi-structured interviews.

SETTING AND PARTICIPANTS

We interviewed health-care providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program.

RESULTS

Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers’ experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers.

CONCLUSIONS

Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.

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References

  1. Gerrity MS, Devellis RF, Earp JA. Physicians’ reactions to uncertainty in patient care. A new measure and new insights. Med Care. 1990;28(8):724-36.

    Article  PubMed  CAS  Google Scholar 

  2. Rizzo JA. Physician uncertainty and the art of persuasion. Soc Sci Med. 1993;37(12):1451-9.

    Article  PubMed  CAS  Google Scholar 

  3. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet. 1995;345(8953):840-2.

    Article  PubMed  CAS  Google Scholar 

  4. Zerzan JT, Morden NE, Soumerai S, et al. Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002. Med Care. 2006;44(11):1005-10.

    Article  PubMed  Google Scholar 

  5. Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain. 2006;125(1-2):172-9.

    Article  PubMed  CAS  Google Scholar 

  6. Turk DC, Brody MC, Okifuji EA. Physicians’ attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain. Pain. 1994;59(2):201-8.

    Article  PubMed  CAS  Google Scholar 

  7. Tamayo-Sarver JH, Dawson NV, Cydulka RK, Wigton RS, Baker DW. Variability in emergency physician decision making about prescribing opioid analgesics. Ann Emerg Med. 2004;43(4):483-93.

    Article  PubMed  Google Scholar 

  8. Potter M, Schafer S, Gonzalez-Mendez E, et al. Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract. 2001;50(2):145-51.

    PubMed  CAS  Google Scholar 

  9. Bendtsen P, Hensing G, Ebeling C, Schedin A. What are the qualities of dilemmas experienced when prescribing opioids in general practice? Pain. 1999;82(1):89-96.

    Article  PubMed  CAS  Google Scholar 

  10. Passik SD, Kirsh KL, Whitcomb L, Dickerson PK, Theobald DE. Pain clinicians’ rankings of aberrant drug-taking behaviors. J Pain Palliat Care Pharmacother. 2002;16(4):39-49.

    Article  PubMed  Google Scholar 

  11. Collins ED, Streltzer J. Should opioid analgesics be used in the management of chronic pain in opiate addicts? Am J Addict. 2003;12(2):93-100.

    Article  PubMed  Google Scholar 

  12. Hicks RD. Pain management in the chemically dependent patient. Hawaii Med J. 1989;48(11):491-5.

    PubMed  CAS  Google Scholar 

  13. Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users: the keys to the "narc" cabinet. J Gen Intern Med. 2002;17(5):327-33.

    PubMed  Google Scholar 

  14. Trafton JA, Oliva EM, Horst DA, Minkel JD, Humphreys K. Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment. Drug Alcohol Depend. 2004;73(1):23-31.

    Article  PubMed  Google Scholar 

  15. Gilson AM, Joranson DE. U.S. policies relevant to the prescribing of opioid analgesics for the treatment of pain in patients with addictive disease. Clin J Pain. 2002;18(4 Suppl):S91-8.

    Article  PubMed  Google Scholar 

  16. Cohen MJ, Jasser S, Herron PD, Margolis CG. Ethical perspectives: opioid treatment of chronic pain in the context of addiction. Clin J Pain. 2002;18(4 Suppl):S99-107.

    Article  PubMed  Google Scholar 

  17. Michna E, Ross EL, Hynes WL, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage. 2004;28(3):250-8.

    Article  PubMed  Google Scholar 

  18. Ives TJ, Chelminski PR, Hammett-Stabler CA, et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46.

    Article  PubMed  Google Scholar 

  19. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-34.

    PubMed  CAS  Google Scholar 

  20. Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003;289(18):2370-78.

    Article  PubMed  Google Scholar 

  21. Jamison RN, Kauffman J, Katz NP. Characteristics of methadone maintenance patients with chronic pain. J Pain Symptom Manage. 2000;19(1):53-62.

    Article  PubMed  CAS  Google Scholar 

  22. Crabtree BF, Miller WL. Doing Qualitative Research. California: SAGE Publications; 1999.

    Google Scholar 

  23. Landon BE, Reschovsky J, Reed M, Blumenthal D. Personal, organizational, and market level influences on physicians’ practice patterns: results of a national survey of primary care physicians. Med Care. 2001;39(8):889-905.

    Article  PubMed  CAS  Google Scholar 

  24. Vickrey BG, Gifford DR, Belin TR, et al. Practice styles of US compared to UK neurologists. Neurology. 1998;50(6):1661-8.

    PubMed  CAS  Google Scholar 

  25. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ. 2003;326(7382):196.

    Article  PubMed  Google Scholar 

  26. Coulter A, Klassen A, MacKenzie IZ, McPherson K. Diagnostic dilatation and curettage: is it used appropriately? BMJ. 1993;306(6872):236-9.

    Article  PubMed  CAS  Google Scholar 

  27. D’Aunno T, Vaughn TE. Variations in methadone treatment practices. Results from a national study. JAMA. 1992;267(2):253-8.

    Article  PubMed  CAS  Google Scholar 

  28. Willenbring ML, Hagedorn HJ, Postier AC, Kenny M. Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy clinics. Drug Alcohol Depend. 2004;75(1):97-106.

    Article  PubMed  Google Scholar 

  29. Cranney M, Walley T. Same information, different decisions: the influence of evidence on the management of hypertension in the elderly. Br J Gen Pract. 1996;46(412):661-3.

    PubMed  CAS  Google Scholar 

  30. Ghosh AK, Ghosh K. Translating evidence-based information into effective risk communication: current challenges and opportunities. J Lab Clin Med. 2005;145(4):171-80.

    Article  PubMed  Google Scholar 

  31. Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ. 2001;323(7321):1100-02.

    Article  PubMed  CAS  Google Scholar 

  32. Karasz A, Zallman L, Berg K, Gourevitch M, Selwyn P, Arnsten JH. The experience of chronic severe pain in patients undergoing methadone maintenance treatment. J Pain Symptom Manage. 2004;28(5):517-25.

    Article  PubMed  Google Scholar 

  33. Kuhn TS. The Structure of Scientific Revolutions. 3Chicago and London: The University of Chicago Press; 2008.

    Google Scholar 

  34. International Association of Pain and Chemical Dependency. Available at: http://www.iapcd.org/. Accessed November 11, 2008.

  35. Tomlin Z, Humphrey C, Rogers S. General practitioners’ perceptions of effective health care. BMJ. 1999;318(7197):1532-5.

    PubMed  CAS  Google Scholar 

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Acknowledgements

Portions of this project were presented at the Society of General Internal Medicine 29th Annual Meeting in April 2006. This study was funded by a grant from the National Institutes of Health to Dr. Arnsten (R25 DA14551). The authors thank the providers for their participation and Leah Zallman for conducting the interviews. The authors report no conflicts of interest.

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Authors and Affiliations

  1. Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

    Karina M. Berg MD, MS, Julia H. Arnsten MD, MPH & Galit Sacajiu MD, MPH

  2. Department of Psychiatry & Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

    Karina M. Berg MD, MS & Julia H. Arnsten MD, MPH

  3. Department of Epidemiology & Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

    Julia H. Arnsten MD, MPH

  4. Department of Family Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

    Galit Sacajiu MD, MPH & Alison Karasz PhD

Authors
  1. Karina M. Berg MD, MS
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  2. Julia H. Arnsten MD, MPH
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  3. Galit Sacajiu MD, MPH
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  4. Alison Karasz PhD
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Corresponding author

Correspondence to Karina M. Berg MD, MS.

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Berg, K.M., Arnsten, J.H., Sacajiu, G. et al. Providers’ Experiences Treating Chronic Pain Among Opioid-Dependent Drug Users. J GEN INTERN MED 24, 482–488 (2009). https://doi.org/10.1007/s11606-009-0908-x

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  • DOI: https://doi.org/10.1007/s11606-009-0908-x

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