Background
Methods
Search strategy
(I) QUALITATIVE SUBJECT HEADINGS | exp QUALITATIVE RESEARCH exp. INTERVIEWS AS TOPIC exp. FOCUS GROUPS NURSING METHODOLOGY RESEARCH ATTITUDE TO HEALTH |
(II) QUALITATIVE FREE TEXT TERMS | Qualitative ADJ5 (theor* OR study OR studies OR research OR analysis) ethno.ti,ab emic OR etic. ti,ab phenomenolog*.ti,ab hermeneutic*.ti,ab heidegger* OR husserl* OR colaizzi* OR giorgi* OR glaser OR strauss OR (van AND kaam*) OR (van AND manen) OR ricoeur OR spiegelberg* OR merleau).ti,ab constant ADJ3 compar*.ti,ab focus ADJ3 group*.ti,ab grounded ADJ3 (theor* OR study OR studies OR research OR analysis).ti,ab narrative ADJ3 analysis.ti,ab discourse ADJ3 analysis.ti,ab (lived OR life) ADJ3 experience*.ti,ab (theoretical OR purposive) ADJ3 sampl*.ti,ab (field ADJ note*) OR (field ADJ record*) OR fieldnote*.ti,ab participant* ADJ3 observ*.ti,ab action ADJ research.ti,ab (digital ADJ record) OR audiorecord* OR taperecord* OR videorecord* OR videotap*).ti,ab (cooperative AND inquir*) OR (co AND operative AND inquir*) OR (co-operative AND inquir*) .ti,ab (semi-structured OR semistructured OR unstructured OR structured) ADJ3 interview*.ti,ab (informal OR in-depth OR indepth OR “in depth”) ADJ3 interview*.ti,ab (“face-to-face” OR “face to face”) ADJ3 interview*.ti,ab “IPA” OR “interpretative phenomenological analysis”.ti,ab “appreciative inquiry”.ti,ab (social AND construct*) OR (postmodern* OR post-structural*) OR (post structural* OR poststructural*) OR (post modern*) OR post-modern* OR feminis*).ti,ab humanistic OR existential OR experiential.ti,ab |
(III) PAIN SUBJECT HEADINGS | exp BACK PAIN/OR exp. CHRONIC PAIN/OR exp. LOW BACK PAIN/OR exp. MUSCULOSKELETAL PAIN/OR exp. PAIN/OR exp. PAIN CLINICS/. exp. FIBROMYALGIA/ exp. PAIN MANAGEMENT/ |
(IV) PAIN FREE TEXT TERMS | (chronic* OR persistent* OR long-stand* OR longstand* OR unexplain* OR un-explain*) fibromyalgia “back ache” OR back-ache OR backache “pain clinic” OR pain-clinic* pain adj5 syndrome* |
Inclusion/exclusion criteria
Quality appraisal
Data extraction and synthesis
Results
AUTHOR YEAR | COUNTRY | PARTICIPANTS | DATA COLLECTION | ANALYSIS | AIM OF STUDY |
---|---|---|---|---|---|
BALDACCHINO 2010 [33] | SCOTLAND, UK | 29 physicians | 2 focus groups/19 interviews | Framework analysis | To describe physicians’ attitudes and experience of prescribing opioids for chronic non-cancer pain with a history of substance abuse. |
BARRY 2010 [34] | USA | 23 physicians | Semi-structured interview | Grounded theory | To identify barriers and facilitators to opioid treatment of chronic non-cancer pain patients |
BERG 2009 [35] | USA | 16 physicians and ‘assistants’ | Semi-structured interview | Thematic analysis | To explore providers’ perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy. |
BRIONES-VOZMEDIANO 2013 [36] | SPAIN | 9 mixed HCPs: (GPs, physicians, physiotherapists, rheumatologists, psychologists, psychiatrist) | Semi-structured interview | Discourse Analysis | To explore experiences of fibromyalgia management, namely diagnostic approach, therapeutic management and the health professional-patient relationship. |
ESQUIBEL 2014 [37] | USA | 21 family practitioners | In-depth interviews | Immersion-crystallization | To explore the experiences of adults receiving opioid therapy for relief of chronic non-cancer pain and that of their physicians |
FONTANA 2008 [38] | USA | 9 advanced practice nurses | Semi-structured interview | No specific method identified | To critically examine subjective factors that influence prescribing practices of registered nurses for patients with chronic non-malignant pain. |
GOOBERMAN-HILL 2011 [39] | UK | 27 general practitioners | Semi-structured interview | Thematic analysis | To explore GPs’ opinions about opioids and decision-making processes when prescribing ‘strong’ opioids for chronic joint pain. |
KAASALAINEN 2007 [40] | CANADA | 66 mixed HCPs: (Physicians (n = 9), registered practical nurses) | Semi-structured interviews/focus groups | Grounded theory | To explore the decision-making process of pain management of physicians and nurses and how their attitudes affect decisions about prescribing and administering pain medications among older adults in long-term care. |
KAASALAINEN 2010B [42] | CANADA | 53 Mixed HCPs: (15 Registered nurses, 6 registered practical nurses, 4 physicians, 20 unlicensed care practitioners, 2 pharmacists, 2 physiotherapists, 4 administrators) | 6 focus groups/interviews | Case-study analysis | To: (1) explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); (2) to develop an inter-professional approach to improve pain management in LTC. |
KILARU 2014 [41] | USA | 61 emergency physicians | Semi-structured interview | Grounded theory | To identify key themes regarding emergency physicians’ definition, awareness, use, and opinions of opioid prescribing guidelines. |
KREBS 2014 [43] | USA | 14 primary care physicians | Semi-structured interview | Immersion-crystallisation | To understand physicians’ and patients’ perspectives on recommended opioid management practices and to identify potential barriers to and facilitators of guideline-concordant opioid management in primary care. |
MCCRORIE 2015 [44] | UK | 15 general practitioners | 2 focus groups | Grounded theory | To understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. |
RUIZ 2010 [45] | USA | 19 mixed HCPs: (14 primary care physicians, 5 nurse practitioners) | 3 focus groups 9 semi-structured interviews | Grounded theory | To explore the attitudes of primary care clinicians (PCPs) toward chronic non-malignant pain management in older people. |
SEAMARK 2013 [46] | UK | 22 general practitioners | Interviews/focus groups | Thematic analysis | To describe the factors influencing GPs’ prescribing of strong opioid drugs for chronic non cancer pain. |
SIEDLECKI 2014 [47] | USA | 48 nurses | Interviews | Grounded theory | To explore and understand nurses’ assessment and decision-making behaviours related to the care of patients with chronic pain in the acute care setting. |
SPITZ 2011 [48] | USA | 26 Mixed HCPs: (23 physicians, 3 nurse practitioners) | Focus groups | Thematic analysis | To describe primary care providers’ experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults. |
STARRELS 2014 [49] | USA | 28 physicians | Open ended telephone interview | Grounded theory | To understand primary care providers’ experiences, beliefs and attitudes about using opioid treatment agreements for patients with chronic pain. |
Confidence in review findings (GRADE -CERQual assessment)
REVIEW FINDING | METHODOLOGICAL LIMITATIONS (NUMBER OF SATISFACTORY STUDIES) | RELEVANCE (PARTIAL OR DIRECT) | ADEQUACY (NUMBER OF CONCEPTS) | COHERENCE* (NUMBER OF STUDIES OUT OF 17) | OVERALL ASSESSMENT OF CONFIDENCE |
---|---|---|---|---|---|
SHOULD I, SHOULDN’T I? | ALL | 9 DIRECT | 19 | 9 [34–39, 43, 44, 48] | HIGH CONFIDENCE |
PAIN IS PAIN | ALL | 5 DIRECT, 1 PARTIAL | 8 | 6 [33, 39, 40, 42, 46, 48] | MODERATE CONFIDENCE |
WALKING A FINE LINE | ALL | 9 DIRECT, 1 PARTIAL | 16 | 8 [33, 35, 39–41, 45, 46, 48]
| MODERATE CONFIDENCE |
SOCIAL GUARDIANSHIP | ALL | 10 DIRECT, 1 PARTIAL | 17 | 11 [33–35, 37–39, 41, 43, 45, 46, 48] | HIGH CONFIDENCE |
MORAL BOUNDARY WORK | ALL | 12 DIRECT, 2 PARTIAL | 27 | 14 [33–35, 37–39, 41, 43–49] | HIGH CONFIDENCE |
REGULATIONS AND GUIDELINES | ALL | 8 DIRECT | 18 | 8 [34, 35, 38, 39, 41, 43, 48, 49] | MODERATE CONFIDENCE |
Thematic analysis
Should I, shouldn’t I?
HPCs found it harder to approach analgesic prescribing where the disease aetiology was unknown, for example, in fibromyalgia.When we’re practicing alongside other people who have come to completely different conclusions, it really makes you think … have I been making the wrong decisions; did we get different information and come to different conclusions? Do we have different values that underlie our decision-making? [35] (physician, USA)
There was a sense that clinical education did not prepare HCPs adequately for these decisions.Because you don’t really know what’s happening there. The aetiology of the disease is not really known and you have few means of knowing what you’re doing. You’re treating the pain and you don’t know why there is no response [36] (rheumatologist, Spain)They are in pain, you give them something for the pain and: ‘it doesn’t do me any good … it relieved the pain a little but the pain has come back’ … . No matter what you give them, the pain doesn’t go away [36] (GP, Spain)
Uncertainty was also compounded by the sense that specialist referrals were either restricted or unproductive. Some HCPs felt unsupported in managing the most difficult cases and explored the possibility of more specialist services: for example, for patients with chronic pain and substance abuse:We took an advanced pharm[acology] class, and we discussed it in one lecture, but that was it. Isn't that ridiculous considering how many people we see in pain? [38] (practise nurse, USA)
Often I find that they are not accomplishing any more than I was and [patients] are often sent back to me with them [pain specialists] essentially saying, ‘we did our best.’ It’s very frustrating, because if they were easy patients they wouldn’t have been seeing them … they wouldn’t have been referred … I would love for there to be a separate clinic where I could refer patients for management of their chronic pain and substance abuse simultaneously. Kind of take me out of the picture [34] (physician, USA)
Pain is pain
However, although in theory ‘pain is pain’, HCPs described factors that would make them less likely to prescribe opioids in practice for chronic non-malignant pain. For example, whereas for malignant pain the aim might be to achieve complete pain relief, in non-malignant pain the HPC would need to consider the balance of risks and benefits of long term opioid prescription over time:I had a guy last week who'd been stabbed and he'd been in ITU … and he had to discharge himself because they wouldn't give him any pain control … he wasn't even getting his prescribed dose of methadone he was getting under dosed for his addiction and his pain control … there's a protocol … but they choose not to know about it and it's just pure stigma. [33] (physician, UK)At the end of the day, if someone’s got chronic pain it doesn’t matter if they’re addicted to painkillers if it sorts out their quality of life [39] (GP, UK)
Some HCPs queried whether enough attention was given to chronic non-malignant pain when the focus was mainly on pain control in palliative patients.I don’t regard them [malignant and non-malignant pain] the same … with [malignant pain] … your aim always is to get complete relief of pain … over a finite period of time. For chronic pain … you’ve got to weigh up … the potential side effects… I think there has to be an acceptance that you are not necessarily going to get them pain free because they’ve got the rest of their lives to live as well … so your two end points are different [46] (GP, UK)
The only people in my practice that I prescribe [opioids] to would be people who are palliative … . [on the other hand] we tend to focus too much on pain control for palliation as opposed to just everyday clients. Certainly nobody wants to die in pain, but nobody wants to live in pain either [40] (physician, Canada)
Walking a fine line
There were additional concerns about prescribing opioids to older adults because of the potential severity and impact of adverse effects. In theory a person’s age should not affect decisions, but in practise, there was a sense that it does.I mean there are two mistakes you make. You can make the mistake of under treating or of giving medicines that end up being sold or used for unintended purposes. You’re going to make errors both ways, and I think it’s generally better to risk opiates being misused versus not treating someone’s pain [35] (physician, USA)
Although HCPs felt that opioids should be used to manage older peoples’ pain, they also discussed how the risks and benefits of prescribing opioids would require assessment on an individual basis.But there are safety issues, and at the end of the day if they came to grief and fell over, fell down the stairs and broke something, died, then, you know, you’d feel guilty about giving them adequate pain relief in your view, but excessive side effects, drowsiness, what have you, that contributed to some major event on their part. So we walk at a fine line sometimes between giving adequate pain relief and giving safe treatment [39] (GP, UK)
Older people metabolize medication differently than younger people, so you don’t want to give them medication that’s going to impair their ability to function … A lot of them drive even though they may be even much older, so you don’t want falls. You don’t want automobile accidents. You don’t want injuries. You don’t want to interfere with their ability to make judgments and so on, so I don’t like using opioids in elderly people at all … [however] my feeling is that they should be used, but we need to, again, look at each person individually, and then determine which person benefits from opioid therapy [45] (HPC not stated, USA)
Social guardianship
Some HCPs discussed indicators of potential abuse (for example: lost prescriptions, early requests for medication, frequent attendance), although acknowledged that these might actually indicate poorly managed pain.I am a naysayer on opiates … too much of my day is spent policing how many [opioids] have been prescribed and how many times a patient is a return patient and how often they visited requesting opiate prescriptions [41] (emergency physician, USA)If you prescribe to a population where you think diversion is going on, you definitely have a responsibility. I also worry about who is getting the drug, is it my son? I mean, we are members of society after all… . I think it is okay to go into a relationship with some mistrust. It is survival in the business we are in [38] (advanced practice nurse, USA)
If people are taking it genuinely for pain they tend to stick to the prescribed dosage … addicts tend to be the ones who are always ordering early … you don't lose your tablets if you are … getting great benefit from them for pain [33] (physician, UK)The concern would be is this pain real, or is it just put on to obtain opioid? … I mean, an assessment of the pain and whether I think it’s genuine or not. I think it’s very difficult; it’s something I’m currently dealing with at the moment, and not very successfully [46] (GP, UK)
Moral boundary work
Pain with no biomedical diagnosis, vague symptoms or dissonance between a patient’s report of pain and professional observation could trigger suspicion.For those patients that have a legitimate reason for wanting to take it and if I can trust them—that they are not selling, they’re not abusing, and most of these are older patients of mine. They never request early refills, they don’t go to the [emergency room] in between visits to get them—there’s no need for me to do periodic drug screenings and so forth (primary care physician, USA) [43]
Non-clinical moral judgments or gut-feelings contributed to prescribing decisions. HCPs recalled episodes when they had made a mistake by trusting ‘the wrong’ patient. Over time they described how they had become better at making the right decision.A lot of patients you can tell … that they really need it … based on their underlying pathology, for example, a patient who has a cancer or a real anatomic foundation for it … now this is not 100% reliable, but you have to count on more observation, combined with other clinical data. So after 2 or 3 visits, you pretty much know who is abusing and who is not [43] (primary care physician, USA)I think for patients who have chronic pain it’s more challenging and I think that’s the place where I’m constantly rethinking my practice… You’re always on the fence: am I doing the right thing for my patient? [41] (Emergency physician, USA)
However, some sensed the dangers of judging a book by its cover and acknowledged that basing clinical decisions on their gut feeling was not fair or accurate.The way I behave now prescribing for everything is a sort of rather woolly, nebulous product of everything I’ve done… You just pick it up over the years, so I’m sure I’ve been moulded by the successes and the failures which have come my way … we all learn on the hoof, don’t we?’ … I think everybody’s fingers get burnt with people who you give the opioids to with a more trusting attitude than maybe you should have [46] (GP, UK)I’ve had trust in people, and it’s been betrayed … I find I’m not always that great a judge of who to trust and who not to trust… . I think people feel like they’ve been violated, you know, cheated, like they’ve been taken advantage of. I feel some of that, too. Ultimately you feel you’ve made a poor judgment, and you get mad at yourself … My impression was that he had a true ankle problem. Then you find out it was all lies … you’re allowed to make mistakes [35] (physician, USA)
There’s a disconnect … even if it’s the sweetest little 85-year-old woman who looks like your grandmother, versus, you know, some guy from the ghetto wearing his pants down at his knees … it shouldn’t really matter [49] (physicians, USA)
Regulations and guidelines
HCPs described fears legislative reprimand.You’re there to help them and they can tell you their deepest, darkest secrets, but yet you’re policing them… . I’m not a big drug screen person, to be honest, because I like to see the person as a person. I’m not clouded by all this other stuff … You can’t do your job when you are thinking about these things [43] (primary care physician, USA)There could be negative implications to that if patients are actually leaving the emergency department because of the way they interpret that [regulations] poster … there’s potential that sick patients could actually leave your emergency department when they need help [41] (emergency physician, USA)
Others described a negative view of opioid prescribing agreements and drug screening as striking a blow at the heart of a patient-clinician relationship by creating mistrust and hostility.My name is on that bottle. If they lose it and someone else takes it and they die, who do you think they are going to come to? What if it is a kid who takes it just for fun—my name is on that, not yours. … I had a patient die. He took the entire bottle, and the police came to see me because they found him dead with the empty bottle with my name on it, and I say to patients now, ‘I am only going to give you a small amount, because I don't want you found dead with my name on your bottle.’ [38] (Advanced practice nurse, USA)
Some HPCs described a more positive attitude to regulation. For example, opioid agreements could be useful in establishing boundaries and opening up honest discussion.It can really strike a major blow to trust in the doctor patient relationship when you ask someone to sign a piece of paper … A huge power play on the part of the doctor … if there is already mistrust between the patient and the doctor, it could heighten that mistrust … .It takes work on the provider’s part, to make it an alliance-building instrument instead of a punitive contract [49] (physician, USA)
Some used guidelines as leverage or to justify decisions and thus help them to deal with ‘challenging’ patients.I think it improves the care, because you are able to then have more open and frank discussions around their pain … . and [about] other things going on in their life … In the best of circumstances it actually will make for a deeper more trusting relationship [49] (physician, USA)
I tell them this is standard protocol. I’m not singling you out. I’m not picking on you. I’m not treating you like an addict. This would happen to anybody. If you take our chronic pain meds long enough, anybody will become physically dependent on them [43] (primary care physician, USA)[An agreement] gives me leverage or comfort in discontinuing the medication if the patient violates the agreement, because we’ve kind of laid it out from the beginning that those behaviors were not okay… . it made my life a little easier, but I’m not sure it did the patients a giant service [49] (physician, USA)
Summary and conceptual framework
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‘Should I, shouldn’t I?’ demonstrates feelings of ambiguity about describing opioids for chronic non-malignant pain; ‘Pain is pain’ demonstrates that although the ideal aim is to alleviate pain, in practice there are reasons why a HCP might not prescribe opioids to people with chronic non-malignant pain; ‘Walking a fine line’ describes the need to balance the benefits and adverse effects of opioids; ‘Social guardianship’ describes a culture hostile to opioid use and a feeling of personal responsibility to police and protect society; ‘Moral boundary work’ describes the work of deciding whose pain is ‘real’; ‘Regulations and guidelines’ describes ambivalence towards external regulation and guidelines.