Study Identifies Strategies VA Clinicians Use to Structure Difficult Conversations Regarding Opioid Prescribing

BACKGROUND:
Clinicians are tasked with engaging in conversations about safe prescribing of opioids, which adds to the challenges in caring for patients with chronic pain. Prior research identified communication processes around opioid tapering that are preferred by patients, but less is known about clinicians' perspectives on these conversations. This qualitative study aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed long-term opioid therapy (LTOT) for chronic pain. Between March 2015 and May 2016, investigators conducted interviews with 24 physicians (83%) and nurse practitioners (17%) from 22 VA facilities across the country who had one or more Veterans in their clinical panels who were prescribed LTOT for chronic non-cancer pain. The interview guide was developed by clinician-researchers with expertise in the treatment of chronic pain, LTOT, substance use disorders, and qualitative research methods.

FINDINGS:

• Interviews identified challenges faced by clinicians in navigating conversations about opioid management, stemming from patient dissatisfaction and clinician ambivalence about enacting guideline-recommended changes.
• To manage difficult conversations, clinicians shared "verbal heuristics" – essentially a pre-packaged response or conversational short-cut – to more quickly and efficiently guide and defuse challenging, emotional conversations. Four varieties of heuristics were identified and include: safety (i.e., "I don't feel comfortable prescribing for you anymore because you're using in a way that's unsafe."); setting expectations (i.e., "no early refills even for legitimate reasons"); following orders (i.e., "we're following the rules…and have no choice"), and standardization (i.e., "I do this for all my patients.").

IMPLICATIONS:

• Future research could evaluate how patients experience the verbal heuristics detailed here – and identify those perceived to be the least relationship-challenging, as well as those associated with patient engagement and positive health outcomes over time.

LIMITATIONS:

• This qualitative research is not intended to speak to the frequency with which verbal heuristics are used, nor how representative such strategies are in clinician-patient interactions.
• Results are a secondary analysis of interviews where the primary focus was addressing barriers to urine drug testing; study findings may differ if the focus were exclusively on identifying clinician strategies for managing difficult conversations.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Drs. Wyse, Ganzini, Dobscha (Director), and Morasco are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), and Dr. Krebs is part of HSR&D's Center for Care Delivery and Outcomes Research (CCDOR).

Wyse J, Ganzini L, Dobscha S, Krebs E, and Morasco B. Setting Expectations, Following Orders, Safety, and Standardization: Clinicians’ Strategies to Guide Difficult Conversations about Opioid Prescribing. Journal of General Internal Medicine. July 2019;34(7):1200-1206.