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Communication between nurse care managers and patients who take opioids for chronic pain: Strategies for exploring aberrant behavior

Jane M. Liebschutz, MD, MPH, Allison V. Lange, MD, Orlaith D. Heymann, MA, Karen E. Lasser, MD, MPH, Pamela Corey, MSN, EdD, RN, CHSE, Christopher W. Shanahan, MD, MPH, Hannah S. Kopinski, BA, Jawad M. Husain, MD, Phoebe A. Cushman, MD, MS, Victoria A. Parker, EdM, DBA

Abstract


Objective: One approach to potential misuse of prescription opioids by patients with chronic pain is team-based collaborative primary care, with primary care visits complemented by frequent visits with nurse care managers (NCMs) specializing in addiction care. However, little is known about the communication strategies NCMs employ in these visits. This study aimed to describe strategies NCMs used with patients when discussing aberrancies encountered during opioid monitoring.

Design: Observational study of NCM-patient interactions. Patients' primary care providers had been randomized to the treatment arm of a study evaluating an intervention, of which NCM visits were part, to change opioid prescribing patterns. The overall intervention was found to be successful.

Setting: Four primary care settings.

Participants: Two NCMs and 41 patients.

Main outcome measure: Forty one interactions between two NCMs and 41 unique patients were directly observed, and the detailed field notes coded for strategies using conventional content analysis.

Results: Five themes describing strategies that NCMs use to navigate aberrant patient behavior emerged: (1) NCM develops therapeutic relationship with patient; (2) NCM encourages adherence to monitoring strategies by contextualizing intensive opioid management for patient; (3) NCM inquires into discrepancies between patient's narrative and objective data to further understand aberrancy; (4) NCM assesses patient's medication use and pain to obtain more information about aberrancy and determine risk for opioid misuse; and (5) NCM educates patient and makes recommendations to guide appropriate medication use.

Conclusions: These findings provide a potential model for the replication of intensive care management strategies utilizing NCMs in primary care.


Keywords


opioids, chronic pain, primary care, nurse care manager

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References


Cheatle M, Barker C: Improving opioid prescription practices and reducing patient risk in the primary care setting. J Pain Res. 2014; 7: 301-311. doi:10.2147/JPR.S37306.

Walker MJ, Webster LR: Risk factors for drug diversion in a pain clinic patient population. J Opioid Manag. 2012; 8(6): 351-362. doi:10.5055/jom.2012.0135.

Rudd RA, Aleshire N, Zibbell JE, et al.: Increases in drug and opioid overdose death—United States, 2000-2014. MMWR. 2016; 64(50): 1378-1382. doi:10.15585/mmwr.mm6450a3.

Manchikanti L, Manchukonda R, Pampati V, et al.: Evaluation of abuse of prescription and illicit drugs in chronic pain patients receiving short-acting (hydrocodone) or long-acting (methadone) opioids. Pain Physician. 2005; 8(3): 257-261.

Paulozzi LJ, Jones CM, Mack KA, et al.: Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR. 2011; 60(43): 1487-1492.

Warner M, Chen LH, Makuc DM, et al.: Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief. 2011; (81): 1-8.

Rasyidi E, Wilkins JN, Danovitch I: Training the next generation of providers in addiction medicine. Psychiatr Clin N Am. 2012; 35(2): 461-480. doi:10.1016/j.psc.2012.04.001.

Breuer B, Pappagallo M, Tai JY, et al.: U.S. Board-certified pain physician practices: Uniformity and census data of their locations. J Pain. 2007; 8(3): 244-250. doi:10.1016/j.jpain.2006.08.009.

Matteliano D, Chang Y-P: Describing prescription opioid adherence among individuals with chronic pain using urine drug testing. Pain Manag Nurs. 2015; 16(1): 51-59. doi:10.1016/j.pmn.2014.04.001.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130. doi:10.1016/j.jpain.2008.10.008.

Lange A, Lasser KE, Xuan Z, et al.: Variability in opioid prescription monitoring and evidence of aberrant medication taking behaviors in urban safety-net clinics: Pain. 2015; 156(2): 335-340. doi:10.1097/01.j.pain.0000460314.73358.ff.

Morasco BJ, Duckart JP, Dobscha SK: Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med. 2011; 26(9): 965-971. doi:10.1007/s11606-011-1734-5.

Starrels JL, Becker WC, Weiner MG, et al.: Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic Pain. J Gen Intern Med. 2011; 26(9): 958-964. doi:10.1007/s11606-011-1648-2.

Starrels JL, Wu B, Peyser D, et al.: It made my life a little easier: Primary care providers’ beliefs and attitudes about using opioid treatment agreements. J Opioid Manag. 2014; 10(2): 95-102. doi:10.5055/jom.2014.0198.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016; 65(1): 1-49. doi:10.15585/mmwr.rr6501e1.

Lasser KE, Shanahan C, Parker V, et al.: A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol. J Subst Abuse Treat. 2016; 60: 101-109. doi:10.1016/j.jsat.2015.06.018.

Alford DP, LaBelle CT, Kretsch N, et al.: Collaborative care of opioid-addicted patients in primary care using buprenorphine: Five-year experience. Arch Intern Med. 2011; 171(5): 425-431. doi:10.1001/archinternmed.2010.541.

Bodenheimer T: Patient self-management of chronic disease in primary care. JAMA. 2002; 288(19): 2469-2475. doi:10.1001/jama.288.19.2469.

Bodenheimer T: Improving primary care for patients with chronic illness. JAMA. 2002; 288(14): 1775-1779. doi:10.1001/jama.288.14.1775.

Chhina HK, Bhole VM, Goldsmith C, et al.: Effectiveness of academic detailing to optimize medication prescribing behavior of family physicians. J Pharm Pharm Sci. 2013; 26(4): 511-529.

Liebschutz, JM, Xuan, Z, Shanahan, CW, et al.: Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: A cluster-randomized controlled trial. JAMA Internal Med. 2017; 177(9): 1265-1272. doi:10.1001/jamainternmed.2017.2468.

Dobscha SK, Corson K, Perrin NA, et al.: Collaborative care for chronic pain in primary care: A cluster randomized trial. JAMA. 2009; 301(12): 1242-1252. doi:10.1001/jama.2009.377.

Kroenke K, Bair MJ, Damush TM, et al.: Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA. 2009; 301(20): 2099-2110. doi:10.1001/jama.2009.723.

Kroenke K, Krebs EE, Wu J, et al.: Telecare collaborative management of chronic pain in primary care: A randomized clinical trial. JAMA. 2014; 312(3): 240-248. doi:10.1001/jama.2014.7689.

Von Korff M, Balderson BHK, Saunders K, et al.: A trial of an activating intervention for chronic back pain in primary care and physical therapy settings: Pain. 2005; 113(3): 323-330. doi:10.1016/j.pain.2004.11.007.

Bair MJ, Matthias MS, Nyland KA, et al.: Barriers and facilitators to chronic pain self-management: A qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med. 2009; 10(7): 1280-1290. doi:10.1111/j.1526-4637.2009.00707.x.

Matthias MS, Bair MJ, Nyland KA, et al.: Self-management support and communication from nurse care managers compared with primary care physicians: A focus group study of patients with chronic musculoskeletal pain. Pain Manag Nurs. 2010; 11(1): 26-34. doi:10.1016/j.pmn.2008.12.003.

Matthias MS, Miech EJ, Myers LJ, et al.: An expanded view of self-management: Patients’ perceptions of education and support in an intervention for chronic musculoskeletal pain. Pain Med. 2012; 13(8): 1018-1028. doi:10.1111/j.1526-4637.2012.01433.x.

Matthias MS, Miech EJ, Myers LJ, et al.: “There's more to this pain than just pain”: How patients' understanding of pain evolved during a randomized controlled trial for chronic pain. J Pain. 2012; 13(6): 571-578. doi:10.1016/j.jpain.2012.03.007.

Michie S, Fixsen D, Grimshaw JM, et al.: Specifying and reporting complex behaviour change interventions: The need for a scientific method. Implement Sci. 2009; 4(1): 40. doi:10.1186/1748-5908-4-40.

Patton MQ, Patton MQ: Qualitative Research and Evaluation Methods. 3 ed. Thousand Oaks, CA: Sage Publications, 2002.

Colon-Emeric CS: Patterns of medical and nursing staff communication in nursing homes: Implications and insights from complexity science. Qual Health Res. 2006; 16(2): 173-188. doi:10.1177/1049732305284734.

Morse JM: The significance of saturation. Qual Health Res. 1995; 5(2): 147-149. doi:10.1177/104973239500500201.

Hsieh H-F: Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9): 1277-1288. doi:10.1177/1049732305276687.

Banja JD: Empathy in the physician's pain practice: Benefits, barriers, and recommendations. Pain Med. 2006; 7(3): 265-275. doi:10.1111/j.1526-4637.2006.00159.x.

Banja JD: Toward a more empathic relationship in pain medicine. Pain Med. 2008; 9(8): 1125-1129. doi:10.1111/j.1526-4637.2008.00459.x.

Matthias MS, Parpart AL, Nyland KA, et al: The patient–provider relationship in chronic pain care: Providers’ perspectives. Pain Med. 2010; 11(11): 1688-1697. doi:10.1111/j.1526-4637.2010.00980.x.

Di Blasi Z, Harkness E, Ernst E, et al.: Influence of context effects on health outcomes: A systematic review. Lancet. 2001; 357(9258): 757-762. doi:10.1016/S0140-6736(00)04169-6.

Price O, Wibberley C: An exploratory study investigating the impact of the procedures used to manage patient substance misuse on nurse-patient relationships in a medium secure forensic unit: Substance misuse procedures and nurse-patient relationships. J Psychiatr Ment Health Nurs. 2012; 19(8): 672-680. doi:10.1111/j.1365-2850.2011.01842.x.

Nicolaidis C: Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med. 2011; 12(6): 890-897. doi:10.1111/j.1526-4637.2011.01117.x.

Vallerand A, Nowak L: Chronic opioid therapy for nonmalignant pain: The patient's perspective. Part II—Barriers to chronic opioid therapy. Pain Manag Nurs. 2010; 11(2): 126-131. doi:10.1016/j.pmn.2009.03.006.

Alford DP: Opioid prescribing: Can the art become more science? J Gen Intern Med. 2013; 28(10): 1253-1254. doi:10.1007/s11606-013-2493-2.

Newman S, Steed L, Mulligan K: Self-management interventions for chronic illness. Lancet. 2004; 364(9444): 1523-1537. doi:10.1016/S0140-6736(04)17277-2.

Warsi A, LaValley MP, Wang PS, et al.: Arthritis self-management education programs: A meta-analysis of the effect on pain and disability. Arthritis Rheum. 2003; 48(8): 2207-2213. doi:10.1002/art.11210.

Morasco BJ, Gritzner S, Lewis L, et al.: Systematic review of prevalence, correlates, and treatment outcomes for chronic noncancer pain in patients with comorbid substance use disorder: Pain. 2011; 152(3): 488-497. doi:10.1016/j.pain.2010.10.009.

Denvir PM: When patients portray their conduct as normal and healthy: An interactional challenge for thorough substance use history taking. Soc Sci Med. 2012; 75(9): 1650-1659. doi:10.1016/j.socscimed.2012.06.021.

Edmond MB, Aletraris L, Paino M, et al.: Treatment strategy profiles in substance use disorder treatment programs: A latent class analysis. Drug Alcohol Depend. 2015; 153: 109-115. doi:10.1016/j.drugalcdep.2015.05.047.

Hilario EY, Griffin ML, McHugh RK, et al.: Denial of urinalysis-confirmed opioid use in prescription opioid dependence. J Subst Abuse Treat. 2015; 48(1): 85-90. doi:10.1016/j.jsat.2014.07.003.

Dean AC, Kohno M, Morales AM, et al.: Denial in methamphetamine users: Associations with cognition and functional connectivity in brain. Drug Alcohol Depend. 2015; 151: 84-91. doi:10.1016/j.drugalcdep.2015.03.004.

Hibbard JH, Greene J: What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Aff. 2013; 32(2): 207-214. doi:10.1377/hlthaff.2012.1061.

O'Malley PA: Prescription opioid abuse update for the clinical nurse specialist. Clin Nurse Spec. 2012; 26(1): 19-21. doi:10.1097/NUR.0b013e31823f8a19.




DOI: http://dx.doi.org/10.5055/jom.2018.0449

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