Primary Care Clinicians' Beliefs and Strategies for Managing Chronic Pain in an Era of a National Opioid Epidemic.

BACKGROUND: Little is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks and benefits of opioid therapy. OBJECTIVE: To better understand PCCs' approaches to managing patients with chronic pain and explore implications for technological and administrative interventions. DESIGN: We conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1-5 interviews. PARTICIPANTS: PCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana. APPROACH: Interviews included discussion of participants' general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically. KEY RESULTS: PCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable. CONCLUSIONS: PCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support.

Juvenile Probation Officer Self-Assessed Mental Health Competency as a Predictor of Case Management Practices.

Justice-involved youth endorse high rates of mental health problems. Juvenile probation is the most common disposition in the justice system and juvenile probation officers (JPOs) are crucial for connecting justice-involved youth with appropriate care. We examined the role of mental health competency on the use of self-report case management strategy types (deterrence, restorative justice, and treatment) by JPOs and whether jurisdiction-level differences were relevant. Results suggest that mental health competency predicted use of restorative justice and treatment strategies and all three strategy types varied at the county level. The role of mental health competency in use of treatment strategies is relevant to connecting justice-involved youth to mental health care. Furthermore, a substantial amount of the variance predicting the use of all three strategies was accounted for at the county level.

Developmental trajectories of religiosity, sexual conservatism and sexual behavior among female adolescents.

Understanding the role of socio-sexual cognitions and religiosity on adolescent sexual behavior could guide adolescent sexual health efforts. The present study utilized longitudinal data from 328 young women to assess the role of religion and socio-sexual cognitions on sexual behavior accrual (measuring both coital and non-coital sexual behavior). In the final triple conditional trajectory structural equation model, religiosity declined over time and then increased to baseline levels. Additionally, religiosity predicted decreased sexual conservatism and decreased sexual conservatism predicted increased sexual behavior. The final models are indicative of young women's increasing accrual of sexual experience, decreasing sexual conservatism and initial decreasing religiosity. The results of this study suggest that decreased religiosity affects the accrual of sexual experience through decreased sexual conservatism. Effective strategies of sexual health promotion should include an understanding of the complex role of socio-sexual attitudes with religiosity.

Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care.

OBJECTIVES: The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design. METHODS: We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts. RESULTS: We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality. CONCLUSION: Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.

How opioid prescribing policies influence primary care clinicians' treatment decisions and conversations with patients with chronic pain.

OBJECTIVE: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain. DESIGN: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies. RESULTS: Opioid prescribing policies influenced clinicians' treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3). CONCLUSIONS: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

Factors That Influence Changes to Existing Chronic Pain Management Plans.

BACKGROUND: The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain. METHODS: We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers. RESULTS: Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations. CONCLUSIONS: Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.

An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy.

Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis (n = 10), spondylosis (n = 6), and low back pain (n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.

Decision-Centered Design of Patient Information Visualizations to Support Chronic Pain Care.

BACKGROUND: For complex patients with chronic conditions, electronic health records (EHRs) contain large amounts of relevant historical patient data. To use this information effectively, clinicians may benefit from visual information displays that organize and help them make sense of information on past and current treatments, outcomes, and new treatment options. Unfortunately, few clinical decision support tools are designed to support clinical sensemaking. OBJECTIVE: The objective of this study was to describe a decision-centered design process, and resultant interactive patient information displays, to support key clinical decision requirements in chronic noncancer pain care. METHODS: To identify key clinical decision requirements, we conducted critical decision method interviews with 10 adult primary care clinicians. Next, to identify key information needs and decision support design seeds, we conducted a half-day multidisciplinary design workshop. Finally, we designed an interactive prototype to support the key clinical decision requirements and information needs uncovered during the previous research activities. RESULTS: The resulting Chronic Pain Treatment Tracker prototype summarizes the current treatment plan, past treatment history, potential future treatments, and treatment options to be cautious about. Clinicians can access additional details about each treatment, current or past, through modal views. Additional decision support for potential future treatments and treatments to be cautious about is also provided through modal views. CONCLUSION: This study designed the Chronic Pain Treatment Tracker, a novel approach to decision support that presents clinicians with the information they need in a structure that promotes quick uptake, understanding, and action.

UNDERSTANDING HOW PRIMARY CARE CLINICIANS MAKE SENSE OF CHRONIC PAIN.

Chronic pain leads to reduced quality of life for patients, and strains health systems worldwide. In the U.S. and some other countries, the complexities of caring for chronic pain are exacerbated by individual and public health risks associated with commonly used opioid analgesics. To help understand and improve pain care, this article uses the data-frame theory of sensemaking to explore how primary care clinicians in the U.S. manage their patients with chronic noncancer pain. We conducted Critical Decision Method interviews with 10 primary care clinicians about 30 individual patients with chronic pain. In these interviews, we identified several patient, social/environmental, and clinician factors that influence the frames clinicians use to assess their patients and determine a pain management plan. Findings suggest significant ambiguity and uncertainty in clinical pain management decision making. Therefore, interventions to improve pain care might focus on supporting sensemaking in the context of clinical evidence rather than attempting to provide clinicians with decontextualized and/or algorithm-based decision rules. Interventions might focus on delivering convenient and easily interpreted patient and social/environmental information in the context of clinical practice guidelines.

Information Needs and Requirements for Decision Support in Primary Care: An Analysis of Chronic Pain Care.

Decision support system designs often do not align with the information environments in which clinicians work. These work environments may increase Clinicians' cognitive workload and harm their decision making. The objective of this study was to identify information needs and decision support requirements for assessing, diagnosing, and treating chronic noncancer pain in primary care. We conducted a qualitative study involving 30 interviews with 10 primary care clinicians and a subsequent multidisciplinary systems design workshop. Our analysis identified four key decision requirements, eight clinical information needs, and four decision support design seeds. Our findings indicate that clinicians caring for chronic pain need decision support that aggregates many disparate information elements and helps them navigate and contextualize that information. By attending to the needs identified in this study, decision support designers may improve Clinicians' efficiency, reduce mental workload, and positively affect patient care quality and outcomes.