A Multicentered Randomized Controlled Trial Comparing the Effectiveness of Pain Treatment Communication Tools in Emergency Department Patients With Back or Kidney Stone Pain.

Objectives. To compare the effectiveness of 3 approaches for communicating opioid risk during an emergency department visit for a common painful condition. Methods. This parallel, multicenter randomized controlled trial was conducted at 6 geographically disparate emergency department sites in the United States. Participants included adult patients between 18 and 70 years of age presenting with kidney stone or musculoskeletal back pain. Participants were randomly assigned to 1 of 3 risk communication strategies: (1) a personalized probabilistic risk visual aid, (2) a visual aid and a video narrative, or 3) general risk information. The primary outcomes were accuracy of risk recall, reported opioid use, and treatment preference at time of discharge. Results. A total of 1301 participants were enrolled between June 2017 and August 2019. There was no difference in risk recall at 14 days between the narrative and probabilistic groups (43.7% vs 38.8%; absolute risk reduction = 4.9%; 95% confidence interval [CI] = -2.98, 12.75). The narrative group had lower rates of preference for opioids at discharge than the general risk information group (25.9% vs 33.0%; difference = 7.1%; 95% CI = 0.64, 0.97). There were no differences in reported opioid use at 14 days between the narrative, probabilistic, and general risk groups (10.5%, 10.3%, and 13.3%, respectively; P = .44). Conclusions. An emergency medicine communication tool incorporating probabilistic risk and patient narratives was more effective than general information in mitigating preferences for opioids in the treatment of pain but was not more effective with respect to opioid use or risk recall. Trial Registration. Clinical Trials.gov identifier: NCT03134092. (Am J Public Health. 2022;112(S1):S45-S55. https://doi.org/10.2105/AJPH.2021.306511).

Personalized risk communication and opioid prescribing in association with nonprescribed opioid use: A secondary analysis of a randomized controlled trial.

BACKGROUND: To determine the impact of personalized risk communication and opioid prescribing on nonprescribed opioid use, we conducted a secondary analysis of randomized controlled trial participants followed prospectively for 90 days after an emergency department (ED) visit for acute back or kidney stone pain. METHODS: A total of 1301 individuals were randomized during an encounter at four academic EDs into a probabilistic risk tool (PRT) arm, a narrative-enhanced PRT arm, or a general risk information arm (control). In this secondary analysis, both risk tool arms were combined and compared with the control arm. We used logistic regressions to determine associations between receiving personalized risk information, receiving an opioid prescription in the ED, and nonprescribed opioid use in general and by race. RESULTS: Complete follow-up data were available for 851 participants; 23.3% (n = 198) were prescribed opioids (34.2% of White vs. 11.6% of Black participants, p < 0.001). Fifty-six (6.6%) participants used nonprescribed opioids. Participants in the personalized risk communication arms had lower nonprescribed opioid use odds (adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.4-0.83). Black versus White participants had greater nonprescribed opioid use odds (aOR 3.47, 95% CI 2.05-5.87, p < 0.001). Black participants who were prescribed opioids had a lower marginal probability of using nonprescribed opioids versus those who were not (0.06, 95% CI 0.04-0.08, p < 0.001 vs. 0.10, 95% CI 0.08-0.11, p < 0.001). The absolute risk difference in nonprescribed opioid use for Black and White participants, respectively, in the risk communication versus the control arm, was 9.7% and 0.1% (relative risk ratio 0.43 vs. 0.95). CONCLUSIONS: Among Black but not White participants, personalized opioid risk communication and opioid prescribing were associated with lower odds of nonprescribed opioid use. Our findings suggest that racial disparities in opioid prescribing-which have been previously described within the context of this trial-may paradoxically increase nonprescribed opioid use. Personalized risk communication may effectively reduce nonprescribed opioid use, and future research should be designed specifically to explore this possibility in a larger cohort.

Patient Perceptions About Opioid Risk Communications Within the Context of a Randomized Clinical Trial.

Importance: Opioid overdose rates continue to increase, and extant literature suggests that many individuals who use heroin were first introduced to opioids through a medical prescription. Objective: To explore patient experiences related to decisions regarding analgesia after an emergency department visit within the context of a randomized clinical trial aimed to test the efficacy of risk communication interventions on treatment preference, risk recall, and use of opioids. Design, Setting, and Participants: This qualitative study of 36 patients making decisions regarding analgesia included qualitative interviews with participants in 2 risk intervention groups. Interviews were audio recorded, transcribed, and edited to remove identifying information to protect the confidentiality of participants. Interviews were conducted from June 4, 2019, to August 6, 2019. We conducted thematic analysis from August to December 2019 using a mixed inductive and deductive approach. Participants received $20 in compensation. The study was conducted in 4 geographically diverse emergency departments in the United States. Participants were adults presenting to the emergency department with either musculoskeletal back or neck pain or kidney stone-related pain. Eligibility criteria included being aged 18 to 70 years, capable of providing informed consent, English speaking or having English comprehension, eligible for emergency department discharge within 24 hours of enrollment, and able to access email or a smartphone. Interventions: Participants enrolled from the main randomized clinical trial received 1 of 2 risk interventions: a probabilistic opioid risk tool or a narrative-enhanced probabilistic risk tool (ie, participants viewed eight 1- to 3-minute short videos of patients discussing their experiences with pain treatment and positive and negative experiences with opioid use). Main Outcomes and Measures: Factors reported by participants to have influenced their decision-making regarding acute pain and treatment. Results: Thirty-six participants were interviewed, 18 in the group who received the probabilistic risk tool alone and 18 in the group who received the additional narrative-enhanced probabilistic risk tool intervention. The median age was 38 years (range, 21-67 years), 22 individuals were female (61%), 14 were Black or African American (39%), and 14 were White (39%). Five themes emerged from the analysis in the following domains: the factors associated with the risk interventions; clinician paternalism; analgesia attributes and previous experiences; individual self-identity, attitudes, and values; and perceptions of clinician bias. Conclusions and Relevance: Most participants commented on the powerful lessons they learned from the risk interventions. More research is needed to understand how patients incorporate risk information into their decision-making process.

Stories to Communicate Individual Risk for Opioid Prescriptions for Back and Kidney Stone Pain: Protocol for the Life STORRIED Multicenter Randomized Clinical Trial.

BACKGROUND: Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative-enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain. OBJECTIVE: Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain. METHODS: This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative-enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge. RESULTS: A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms. CONCLUSIONS: This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19496.

Intimate Partner Violence Detection and Care in the Veterans Health Administration: Patient and Provider Perspectives.

BACKGROUND: Women veterans experience high rates of intimate partner violence (IPV), with associated negative health impacts. The Veterans Health Administration (VHA) has recently developed plans to implement routine IPV screening and provide IPV-related follow-up services for VHA patients. Previous research has examined barriers and facilitators to health care provider screening for IPV. The next step is to examine patients' disclosure of IPV experiences to health care providers and effective response to such disclosures. We sought to identify VHA patients' and providers' perspectives on how to facilitate effective IPV detection and care in VHA. METHODS: We conducted semistructured, qualitative interviews with 25 female veteran patients and 15 VHA health care providers. We used an inductive approach to analyzing interview transcripts and identifying themes that constituted study findings. RESULTS: Themes fell in to two broad categories: 1) barriers to disclosure and 2) barriers to an adequate response to disclosure and providing follow-up care. Barriers to disclosure of IPV to health care providers included lack of provider inquiry, lack of comfort, and concerns about the consequences of disclosure and lack of privacy. Patients and providers both indicated a need for expanded resources to respond to IPV in VHA. CONCLUSIONS: Findings support current plans for IPV program implementation in VHA and point to recommendations for practice and implications for further research.