(252) - How do primary care clinicians and patients discuss risks, benefits, and goals in chronic opioid therapy?

Abstract

In 2016, the Centers for Disease Control and Prevention (CDC) published the Guideline for Prescribing Opioids for Chronic Pain. Several recommendations focus on ensuring clinician-patient discussions of therapeutic risks, benefits, and treatment goals. To help understand how current care practices align with the CDC guideline, this study describes clinician-patient discussions about opioid-related risks, benefits, and goals during primary care visits related to chronic pain. We qualitatively analyzed twenty-six primary care visit discussions between a primary care clinician and a patient receiving opioids for chronic pain. Two reviewers identified and agreed on common themes using an inductive thematic approach. Next, two reviewers holistically reviewed transcripts to identify distinct visit discussion profiles. We identified three visit discussion profiles: as-directed opioid use, opioid misuse, and complex use. First, when discussions indicated patients were taking opioids as directed, clinicians spent little or no time discussing risks and occasionally suggested dose reduction goals. Second, when discussions indicated patients were misusing opioids, clinicians typically mentioned risks, but described them briefly or indirectly, and commonly emphasized dose reduction goals. Third, when discussions indicated patients had comorbidities, such as renal dysfunction, risks and dose reduction goals were not discussed. Across all profiles, clinicians frequently discussed non-opioid treatments, suggesting an implied goal of using non-opioid therapy. Finally, across all profiles, many patients indicated pain relief from opioids. But, patients and clinicians often described benefits as limited and needing to be balanced with risks. We found that chronic opioid-related risks, benefits, and goal discussions may be related to patients' medication adherence and patients' health complexity. Consistent with CDC recommendations, clinician-patient discussions often implied goals of non-opioid alternatives for pain therapy. However, in some cases, including cases of medication misuse, discussions of risks were often minimally detailed, which could hinder patient understanding and shared treatment decision-making.