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ABSTRACT
Background: Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. Methods: We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. Results: (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs' medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse. Conclusion: We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients' experiences of stigma and discrimination.
Acknowledgments
We acknowledge the time and effort patients and clinicians took to participate in this study and share their views and experiences on a challenging subject. An earlier version of the findings was presented in a poster at the Society for General Internal Medicine Annual Meeting in Toronto, Canada, in April 2015.
Funding
Drs. Knight, Kushel, Chang, Miaskowski, and Ceasar and Ms. Zamora were funded by a grant from the National Institute of Drug Abuse (NIDA), R01DA034625, to conduct this study. NIDA was not involved in the design, conduct, or reporting of the study. Other sources of author funding. Dr. Kushel receives funding from the National Institute on Aging (K24AG046372). Dr. Miaskowski receives support from a grant (K05 CA168960) from the National Cancer Institute. Dr. Hurstak receives fellowship support from National Institute of Health (T32HP19025). Dr. Chang receives fellowship support from the National Institute on Drug Abuse (T32 DA007250). Dr. Ceasar receives support from a School of Public Health Postdoctoral Research Fellowship in the Faculty of Health Sciences at the University of the Witwatersrand in Johannesburg, South Africa. Dr. Kushel and Dr. Hurstak receive funding from the California Healthcare Foundation for their work on a report on nonopioid alternatives for pain management in safety-net clinical settings.
Author contributions
All persons who have made significant contributions to the work reported in this article (data collection, analysis, writing, or editing assistance) fulfill the authorship criteria and are listed on the title page. Dr. Emily Hurstak and Dr. Kelly Knight had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Knight, Kushel, Miaskowski. Acquisition, analysis, or interpretation of the data: Knight, Chang, Zamora, Ceasar, Hurstak. Drafting of the manuscript: Hurstak. Critical revision of the manuscript for important intellectual content: Hurstak, Kushel, Knight, Miaskowski, Ceasar, Chang, Zamora. Obtained funding: Knight, Kushel, Miaskowski. Administrative, technical, or material support: Zamora. Study supervision: Knight.