Much has been said and reported in the mainstream media about the abuse and misuse of prescription painkillers – but how often is the issue even discussed between pain patients and their doctors?
A pilot study conducted at an Indianapolis VA Hospital opened a window into that world – when five physicians and 30 chronic pain patients agreed to have audio recordings made of their conversations in the exam room.
The study by researchers from the Roudebush VA Medical Center and the Regenstrief Institute is believed to be the first to analyze doctor-patient conversations about opioids in regular primary care appointments. It is being published in the journal Patient Education and Counseling.
“Although it is well established that opioid treatment for chronic pain poses numerous uncertainties, little has been reported in previous studies about how patients and their physicians actually discuss these uncertainties in clinic appointments,” said study first author Marianne Matthias, PhD, a VA research scientist and assistant professor of communication studies at Indiana University-Purdue University Indianapolis.
“We heard candid discussions revealing concern by both patients and their physicians about a range of issues including past alcoholism and past marijuana or cocaine use.”
Some discussions about opioids were brief, such as whether to renew a prescription. Other conversations, however, revealed that physicians and patients were both uncertain about whether opioids should be prescribed. While side effects were occasionally mentioned, most of the uncertainty related to the possibility of misuse or addiction.
One patient with back pain, for example, raised the possibility of addiction and was reassured by his physician that opioids could be an appropriate treatment:
- PHYSICIAN: We’ll get you some hydrocodone to give you some relief.
- PATIENT: Is that anything that I need to be concerned about?
- PHYSICIAN: No, I was going to give you enough for one a day. If you had 40 [before] and it’s lasted you three months I’m not too worried about it.
- PATIENT: Yeah, I’m not taking them unless I have to.
- PHYSICIAN: Yeah, as long as you’re taking the hydrocodone for pain it’s not anything to be concerned about. The people who get in trouble are the people that are taking more and more, or the people that start taking it for the high that some people feel with it. I’m not worried about you.
- PATIENT: I don’t feel any high with it.
- PHYSICIAN: I’m not worried about you.
Reassurance was one of three patterns found in physician responses. Doctors also asked questions to get additional information about the patient’s opioid use or advised the patient to avoid opioids altogether.
One physician called opioids “crap.”
- PHYSICIAN: I’m hoping we could help you to cut back on this other stuff. This crap that we’re having to give you because they’re not –
- PATIENT: Good for my kidneys or anything.
- PHYSICIAN: That methadone’s not good. Period. I don’t think it’s not as dangerous as some drugs. It’s just the side effects and dealing with you know-
- PATIENT: Possible addiction and whatnot.
- PHYSICIAN: Yes, exactly.
Another doctor had a candid discussion with a patient who had a history of cocaine use.
- PHYSICIAN: Have you been using cocaine recently?
- PATIENT: No.
- PHYSICIAN: When was the last use?
- PATIENT: Uh, I don’t remember.
- PHYSICIAN: Approximate.
- PATIENT: Maybe a year – a year and a half.
- PHYSICIAN: Nothing since then?
- PATIENT: No.
- PHYSICIAN: Can I do a urine drug screen today?
- PATIENT: Uh, I got a ride. I can come back today if you want me to. I just gotta go out there and tell them that –
- PHYSICIAN: Will it be clean?
- PATIENT: Can I come tomorrow?
- PHYSICIAN: Will it be clean tomorrow?
- PATIENT: Yeah.
In the end, the doctor gave the patient the benefit of the doubt and renewed his prescription for hydrocodone – at the same time warning the patient that a positive drug test would mean that he’d stop prescribing opioids for him.
“There is an important message here for people with chronic pain and for the doctors who treat them,” says Matthias.
“If patients and their doctors have a relationship marked by mutual trust and a strong therapeutic alliance, they are better positioned to candidly discuss all chronic pain treatment options, including risks and benefits of opioid treatment, with the ultimate goal being to develop the most appropriate and effective treatment plan for each individual patient.”
Matthias noted there was “little conflict” between patients and their physicians during the exams. She believes that may be because the patients placed a high value on opioids for pain relief and were highly motivated to maintain a good relationship with their doctors to ensure that their opioids prescriptions were renewed.