Providers' experiences treating chronic pain among opioid-dependent drug users

Karina M. Berg, Julia H. Arnsten, Galit Sacajiu, Alison Karasz

Research output: Contribution to journalArticle

33 Citations (Scopus)

Abstract

BACKGROUND: Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and preexisting addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described. OBJECTIVE: Our objective was twofold. We sought first 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. DESIGN: Qualitative semi-structured interviews. SETTING AND PARTICIPANTS: We interviewed healthcare providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program. RESULTS: Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers' experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers. CONCLUSIONS: Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.

Original languageEnglish (US)
Pages (from-to)482-488
Number of pages7
JournalJournal of General Internal Medicine
Volume24
Issue number4
DOIs
StatePublished - Apr 2009

Fingerprint

Drug Users
Chronic Pain
Opioid Analgesics
Methadone
Pain Management
Therapeutics
Drug Prescriptions
Pain
Decision Making
Street Drugs
Substance-Related Disorders
Prescription Drug Misuse
Risk Management
Practice Guidelines
Health Personnel
Interviews

Keywords

  • Addiction
  • Chronic pain
  • Methadone
  • Opioids
  • Provider experiences
  • Qualitative

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Providers' experiences treating chronic pain among opioid-dependent drug users. / Berg, Karina M.; Arnsten, Julia H.; Sacajiu, Galit; Karasz, Alison.

In: Journal of General Internal Medicine, Vol. 24, No. 4, 04.2009, p. 482-488.

Research output: Contribution to journalArticle

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abstract = "BACKGROUND: Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and preexisting addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described. OBJECTIVE: Our objective was twofold. We sought first 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. DESIGN: Qualitative semi-structured interviews. SETTING AND PARTICIPANTS: We interviewed healthcare providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program. RESULTS: Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers' experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers. CONCLUSIONS: Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.",
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