Exploring Opioid-Related Transitions for Patients with Pain and Clinicians who Prescribe Opioids

Abstract

Background People who experience chronic pain, particularly those with a rheumatic disease (RD) such as rheumatoid arthritis, often receive care across multiple settings and are prescribed opioids as part of their pain management plan. However, as many clinicians are reluctant to continue opioid therapy for new patients with chronic or ongoing pain, opioid-related transitions (ORTs) (i.e., transitions of care involving prescribed opioids) are periods of heightened risk which remain poorly understood. This dissertation aimed, therefore, to clarify the concept of ORTs, explore related patient and clinician viewpoints, and identify patient- and clinician-level strategies to promote quality, equitable pain care for this population.Methods Opioid-related transitions were explored and contextualized using the following qualitative studies: (1) concept analysis (to define and describe ORTs), (2) rapid analysis of clinician interviews (to examine clinician perspectives of ORTs), and (3) inductive content analysis of patient interviews (to describe experiences of ORTs among individuals with RD).Results Findings from the concept analysis included the identification of six core attributes of ORTs which occur during patient-clinician and clinician-clinician interactions pertaining to opioid medication changes or transitions of care: (1) opioid-specific information, (2) clear communication, (3) shared decision-making, (4) collective responsibility, (5) knowledge exchange, and (6) weighing the risks and benefits of prescribing, managing, and monitoring opioids for the treatment of chronic pain. Predominantly negative consequences of ORTs included patient disengagement from care, reduced care-seeking behaviors, use of illicit drugs, and changes in opioid use to create a surplus of medications. Opioid policy and stigma were also identified as key factors influencing ORTs. In the clinician study, interviews with 21 interdisciplinary prescribers and non-prescribers revealed two themes: (1) multiple and varied transitions in opioid management, and (2) approaches to opioid management guided by clinician comfort. Opioid-related transitions were observed across care settings (e.g., ambulatory to pain management) and within practices or teams. Clinicians were found to approach ORTs in one of three ways: (1) accept the patient, (2) accept the patient with guardrails, or (3) defer responsibility to other providers. These decisions were largely shaped by clinician comfort with ongoing opioid prescribing, barriers in communication, power dynamics, and policy. In the patient study, interviews with 20 individuals with RD generated four themes: (1) managing together, deciding alone; (2) turbulence of opioid medication changes; (3) transitions across opioid prescribers; and (4) opioid transitions in care settings. Patients frequently reported self-directed opioid use influenced by clinician guidance, family involvement, risk mitigation strategies, and RD activity. Participants navigated transitions across medications, prescribers, and care settings, often relying on trust in clinician relationships while facing clinician-, insurance-, and pharmacy-related barriers. Hospital-based care was described as particularly high-risk, involving delays in access, unmet pain needs, and lack of patient advocacy to promote satisfactory pain management.Conclusion This dissertation establishes a definition of ORTs and offers foundational insight into their attributes, antecedents, and consequences. By integrating patient and clinician perspectives, it highlights the complexity of ORTs, the gaps in related care experienced by patients, and the strategies used by patients and clinicians to navigate them. Considered together, the findings emphasize an urgent need for improved care coordination, enhanced clinician and patient support, and best practices to guide decision-making around opioid prescribing and management during ORTs. These findings are particularly salient in cases involving RD, for which no pain management guidelines currently exist, although patients have a high prevalence of opioid use, as well as chronic and variable pain.