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Author(s): Henry, Stephen G; Feng, Bo; Verba, Susan; Kravitz, Richard L; Iosif, Ana-Maria | Abstract: BackgroundNarrative communication is often more persuasive for promoting health behaviour change than communication using facts and figures; the extent to which narrative persuasiveness is due to patients' identification with the storyteller vs engagement with the story is unclear.ObjectiveTo examine the relative impacts of patient engagement, age concordance and gender concordance on perceived persuasiveness of video-recorded narrative clips about opioid tapering.MethodsPatient raters watched and rated 48 brief video-recorded clips featuring 1 of 7 different storytellers describing their experiences with opioid tapering. The dependent variable was clips' perceived persuasiveness for encouraging patients to consider opioid tapering. Independent variables were rater engagement with the clip, rater-storyteller gender concordance and rater-storyteller age concordance (l60 vs ≥60). Covariates were rater beliefs about opioids and opioid tapering, clip duration and clip theme. Mixed-effects models accounted for raters viewing multiple clips and clips nested within storytellers.ResultsIn multivariable models, higher rater engagement with the clip was associated with higher perceived persuasiveness (coefficientn=n0.46, 95% CI 0.39-0.53, Pnln.001). Neither age concordance nor gender concordance significantly predicted perceived persuasiveness. The theme Problems with opioids also predicted perceived persuasiveness.ConclusionHighly engaging, clinically relevant stories are likely persuasive to patients regardless of the match between patient and storyteller age and gender. When using patient stories in tools to promote health behaviour change, stories that are clinically relevant and engaging are likely to be persuasive regardless of storytellers' demographics.Patient or public contributionPatients were involved as storytellers (in each clip) and assessed the key study variables.

BACKGROUND: Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms. OBJECTIVE: To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients’ likelihood of transitioning to long-term use after an initial opioid prescription. DESIGN: Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017. METHODS AND MAIN MEASURES: Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient’s initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic). KEY RESULTS: Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents. CONCLUSIONS: Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days’ supply or milligram morphine equivalents. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06555-x.

Objective To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up. Design Retrospective cohort study. Setting Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States. Subjects Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018. Methods Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers. Results The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72–.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%–70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%–14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48–.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92–.94]). Conclusions In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources when describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions.

BACKGROUND:Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016. METHODS:Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death. RESULTS:After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR]=1.19; 95% CI=1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR=0.94; 95% CI=0.90, 0.98). CONCLUSION:There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

Drug, and specifically opioid-related, overdoses remain a major public health problem in the United States. Multiple studies have examined individual risk factors associated with overdose risk, but research developing clinical risk prediction tools for overdose has only emerged in the last few years. We conducted a comprehensive review of the literature on patient-level factors associated with opioid-related overdose risk, with an emphasis on clinical risk prediction models for opioid-related overdose in the United States. Studies that developed and/or validated clinical prediction models were closely reviewed and evaluated to determine the state of the field. We identified 12 studies that reported risk prediction models for opioid-related overdose risk. Published models were developed from a variety of data sources, including Veterans Health Administration data, Medicare data, commercial insurance data, and statewide linked datasets. Studies reported model performance using measures of discrimination, usually at good-to-excellent levels, though they did not always assess calibration. C-statistics were better for models that included clinical predictors (c-statistics: 0.75-0.95) compared to models without them (c-statistics: 0.69-0.82). External validation of models was rare, and we found no studies evaluating implementation of models or risk prediction tools into clinical practice. A common feature of these models was a high rate of false positives, largely because opioid-related overdose is rare in the general population. Thus, efforts to implement prediction models into practice should take into account that published models overestimate overdose risk for many low-risk patients. Future prediction models assessing overdose risk should employ external validation and address model calibration. In order to translate findings from prediction models into clinical public health benefit, future studies should focus on developing clinical prediction tools based on prediction models, implementing these tools into clinical practice, and evaluating the impact of these models on treatment decisions, patient outcomes, and, ultimately, opioid overdose rates.

Background Prescription drug monitoring programs (PDMPs) are primary prevention tools to reduce substance use disorders (SUD) and sequelae. Evidence regarding perceptions of PDMPs from different primary care providers, which may impact PDMP utilization for women, is unavailable. Objective To examine perceived PDMP effectiveness among obstetrician-gynecologists (OB/GYNs) compared to primary care physicians (PCPs). Methods Independent surveys of PDMP users in Florida, Kentucky, and California were evaluated based on a Likert-type item to assess perception of PDMP effectiveness in reducing prescription drug abuse and diversion. Response distributions of OB/GYNs versus PCPs were compared using chi-square tests. Results In Florida, there were 41 OB/GYN and 511 PCP respondents; Kentucky, 46 OB/GYNs and 265 PCPs; and California, 41 OB/GYNs and 162 PCPs. In each state OB/GYNs viewed PDMPs as less effective, positive, or useful compared to PCPs (p ≤ 0.01, all states): Florida: 64.1% OB/GYN vs. 83.7% PCP “agree positive impact”; Kentucky: 45.0% OB/GYN vs. 68.5% PCP “effective”. California: 73.2% OB/GYN vs. 86.4% PCP “useful”. Conclusions These results suggest OB/GYNs view their state's PDMP as less effective than do PCPs, which may present barriers to PDMP utilization and decrease opportunities for SUD interventions. Engagement of all healthcare team members is needed to inform future strategies and policies to increase PDMP effectiveness.

BackgroundPhysicians' fear of difficult patient interactions is an important barrier to discontinuing long-term opioid therapy.ObjectiveTo identify patient statements about opioids that indicate potential openness to tapering opioids or trying non-opioid pain treatments DESIGN: This is an observational study of regularly scheduled primary care visits involving discussion of chronic pain management. A coding system to characterize patient assessments about opioids, physician responses to assessments, and patient-endorsed opioid side effects was developed and applied to transcripts of video-recorded visits. All visits were independently coded by 2 authors.ParticipantsEighty-six established adult patients taking opioids for chronic pain; 49 physicians in 2 academic primary care clinics MAIN MEASURES: Frequency and topic of patients' opioid assessments; proportion of opioid assessments classified as clues (assessments indicating potential willingness to consider non-opioid pain treatments or lower opioid doses); physician responses to patient clues; frequency and type of patient-endorsed side effects KEY RESULTS: Patients made a mean of 3.2 opioid assessments (median 2) per visit. The most common assessment topics were pain relief (51%), effect on function (21%), and opioid safety (14%). Forty-seven percent of opioid assessments (mean 1.5 per visit) were classified as clues. Fifty-three percent of visits included ≥ 1 clue; 21% of visits contained ≥ 3 clues. Physicians responded to patient clues with no/minimal response 43% of the time, sympathetic/empathetic statements 14% of the time, and further explored clues 43% of the time. Fifty-eight percent of patients endorsed ≥ 1 opioid-related side effect; 10% endorsed ≥ 3 side effects. The most commonly endorsed side effects were constipation (15% of patients), sedation (15%), withdrawal symptoms (13%), and nausea (12%).ConclusionsPatient statements suggesting openness to non-opioid pain treatments or lower opioid doses are common during routine primary care visits. Listening for and exploring these clues may be a patient-centered strategy for broaching difficult topics with patients on long-term opioid therapy.

OBJECTIVES: Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed for chronic musculoskeletal pain, despite limited evidence of effectiveness and well-documented adverse effects. We assessed the effects of participating in a structured, personalized self-experiment (“N-of-1 trial”) on analgesic prescribing in patients with chronic musculoskeletal pain. METHODS: We randomized 215 patients with chronic pain to participate in an N-of-1 trial facilitated by a mobile health app or to receive usual care. Medical records of participating patients were reviewed at enrollment and 6 months later to assess analgesic prescribing. We established thresholds of ≥ 50, ≥ 20, and > 0 morphine milligram equivalents (MMEs) per day to capture patients taking relatively high doses only, patients taking low-moderate as well as relatively high doses, and patients taking any dose of opioids, respectively. RESULTS: There was no significant difference between the N-of-1 and control groups in the percentage of patients prescribed any opioids (relative odds ratio (ROR) = 1.05; 95% confidence interval [CI] = 0.61 to 1.80, p = 0.87). There was a clinically substantial but statistically not significant reduction of the percentage of patients receiving ≥ 20 MME (ROR = 0.58; 95% CI = 0.33 to 1.04, p = 0.07) and also in the percentage receiving ≥ 50 MME (ROR = 0.50; 95% CI = 0.19 to 1.34, p = 0.17). There was a significant reduction in the proportion of patients in the N-of-1 group prescribed NSAIDs compared with control (relative odds ratio = 0.53; 95% CI = 0.29 to 0.96, p = 0.04), with no concomitant increase in average pain intensity. There was no significant change in use of adjunctive medications (acetaminophen, gabapentenoids, or topicals). DISCUSSION: These exploratory results suggest that participation in N-of-1 trials may reduce long-term use of NSAIDs; there is also a weak signal for an effect on use of opioids. Additional research is needed to confirm these results and elucidate possible mechanisms. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02116621. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05303-0) contains supplementary material, which is available to authorized users.

OBJECTIVE: To compare effectiveness of a narrative-based educational video versus an informational pamphlet for increasing patients’ self-efficacy and intention to taper their opioid use. METHODS: Five thousand participants recruited from MTurk were screened to identify eligible patients. Eligible participants (n = 365, 49.9% female, mean age = 37 years) were randomized to either watch the narrative video or read the pamphlet. Linear regression models were used for the main analysis. RESULTS: Participants’ perceptions of tapering effectiveness were higher in the video group (mean = 4.06) than the pamphlet group (mean = 3.67), adjusted mean difference = 0.34, 95%CI 0.13 – 0.54, P < 0.001. Participants’ perceptions of tapering self-efficacy were also higher in the video group (mean = 3.97) than the pamphlet group (mean = 3.60), adjusted mean difference = 0.32, 95%CI 0.09 – 0.55, P < 0.001. Perceived tapering effectiveness and self-efficacy were both positively associated with post-intervention tapering intention (Spearman rank correlation coefficient = 0.38 and 0.53, respectively, both P < 0.001). CONCLUSION: A narrative-based video about opioid tapering enhanced patients’ perceptions of the effectiveness of tapering and their tapering self-efficacy. PRACTICE IMPLICATIONS: Narrative-based videos may be effective for changing patient attitudes about opioid tapering.

Background Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience. Methods This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty. Results We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03). Conclusions In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care practice.

OBJECTIVES: Opioid use disorder remains undertreated in the United States. One of the primary mechanisms for expanding access to treatment has been the use of buprenorphine. In this study, we compare prescribing trends of buprenorphine paid through Medicaid versus other payer sources. METHODS: Combined data from California’s prescription drug monitoring program and California’s Department of Health Care Services was used to obtain statewide quarterly prescription rates for buprenorphine, indicated for the treatment of opioid use disorder, from 2012 to 2018. RESULTS: From 2012 to 2018, the rate of individuals treated with buprenorphine in Medicaid increased by 657% (1.39 to 10.5 Medicaid beneficiaries per 10,000) with increases beginning in 2014 and continuing through 2018. Rate of individual prescribing among non-Medicaid sources increased by 93.7% (6.54 to 12.7 non-Medicaid individuals per 10,000) with most increases occurring prior to 2014. CONCLUSIONS: California Medicaid has made considerable gains in buprenorphine access, with access growing steadily even after expansions through the Affordable Care Act plateaued. In contrast, recent gains in buprenorphine access for individuals without Medicaid are uninspiring, indicating that initiatives to improve buprenorphine access to patients without Medicaid are urgently needed.

Patient-clinician interactions are central to technical and interpersonal processes of medical care. Video recordings of these interactions provide a rich source of data and a stable record that allows for repeated viewing and analysis. Collecting video recordings requires navigating ethical and feasibility constraints; further, realizing the potential of video requires specialized research skills. Interdisciplinary collabo-rations involving practitioners, medical educators, and social scientists are needed to provide the clinical perspectives, methodological expertise, and capacity needed to make collecting video worthwhile. Such collaboration ensures that research questions will be based on scholarship from the social sciences, resonate with practice, and produce results that fit educational needs. However, the literature lacks suggested practices for building and sustaining interdisciplinary research collaborations involving video data. In this paper, we provide concrete advice based on our experience collecting and analyzing a single set of video-recorded clinical encounters and non-video data, which have so far yielded nine distinct studies. We present the research process, timeline, and advice based on our experience with interdisciplinary collaboration. We found that integrating disciplines and traditions required patience, compromise, and mutual respect; learning from each other enhanced our enjoyment of the process, our productivity, and the clinical relevance of our research.&nbsp

Background and aims Prescription drug monitoring programs (PDMP), defined as state-level databases used in the United States that collect prescribing information when controlled substances are dispensed, have varied substantially between states and over time. Little is known about the combinations of PDMP features that, collectively, may produce the greatest impact on prescribing and overdose. We aimed to (1) identify the types of PDMP models that have developed from 1999 to 2016, (2) estimate whether states have transitioned across PDMP models over time and (3) examine whether states have adopted different types of PDMP models in response to the burden of opioid overdose. Methods A latent transition analysis of PDMP models based on an adaptation of nine PDMP characteristics classified by prescription opioid policy experts as potentially important determinants of prescribing practices and prescription opioid overdose events. Results We divided the time-period into three intervals (1999-2004, 2005-09, 2010-16), and found three distinct PDMP classes in each interval. The classes in the first and second interval can be characterized as 'no/weak', 'proactive' and 'reactive' types of PDMPs, and in the third interval as 'weak', 'cooperative' and 'proactive'. The meaning of these classes changed over time: until 2009, states in the 'no/weak' class had no active PDMP, whereas states in the 'proactive' class were more likely to proactively provide unsolicited information to PDMP users, provide open access to law enforcement, and require more frequent data reporting than states in the 'reactive' class. In 2010-16, the 'weak' class resembled the 'reactive' class in previous intervals. States in the 'cooperative' class in 2010-16 were less likely than states in the 'proactive' class to provide unsolicited reports proactively or to provide open access to law enforcement; however, they were more likely than those in the 'proactive' class to share PDMP data with other states and to report more federal drug schedules. Conclusions Since 1999, US states have tended to transition to more robust classes of prescription drug monitoring programs. Opioid overdose deaths in prior years predicted the state's prescription drug monitoring program class but did not predict transitions between prescription drug monitoring program classes over time.

BackgroundPrescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.PurposeTo examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.Data sourcesEligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.Study selectionObservational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.Data extraction2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.Data synthesisOf 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n= 8), program features only (n= 2), PDMP implementation and program features (n= 5), PDMP implementation with mandated provider review combined with pain clinic laws (n= 1), and PDMP robustness (n= 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.LimitationFew studies, high ROB, and heterogeneous analytic methods and outcome measurement.ConclusionEvidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences.Primary funding sourceNational Institute on Drug Abuse and Bureau of Justice Assistance.

Objective Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research. Methods A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development. Results The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids. Conclusions Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.

Author(s): Holmes-Rovner, Margaret; Srikanth, Akshay; Henry, Stephen G; Langford, Aisha; Rovner, David R; Fagerlin, Angela | Abstract: BackgroundDecision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters.ObjectiveTo characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer.Participants252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics.MethodsQualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated.ResultsBooklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (Pn=n.027) and more time in the encounter (Pn=n.027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk.ConclusionsResults show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.

Objective: To describe trends in prevalent and incident stimulant prescribing between 2008 and 2017 in California. Method: Statewide trends were estimated by age and sex category for prevalent (any) and incident (no prescriptions in the preceding 2 years) stimulant prescribing while adjusting for area-level covariates. Results: Prevalent prescribing rates increased by 126%, while incident prescribing increased 23%. Patients aged 25 to 44 years experienced over 200% increases in prevalent prescribing and 34% to 55% increases in incident prescribing. Among patients older than 25, women had consistently higher prescribing rates than men. ZIP code tabulation areas with the largest minority populations had the lowest baseline prescribing rates but experienced the greatest annual prescription rate increases. Conclusion: Adult stimulant prescribing increased substantially for early working aged adults. Prescription rates were greater for women than men.

Clinical guidelines discourage prescribing opioids for chronic pain, but give minimal advice about how to discuss opioid tapering with patients. We conducted focus groups and interviews involving 21 adults with chronic back or neck pain in different stages of opioid tapering. Transcripts were qualitatively analyzed to characterize patients' tapering experiences, build a conceptual model of these experiences, and identify strategies for promoting productive discussions of opioid tapering. Analyses revealed 3 major themes. First, owing to dynamic changes in patients' social relationships, emotional state, and health status, patients' pain and their perceived need for opioids fluctuate daily; this finding may conflict with recommendations to taper by a certain amount each month. Second, tapering requires substantial patient effort across multiple domains of patients' everyday lives; patients discuss this effort superficially, if at all, with clinicians. Third, patients use a variety of strategies to manage the tapering process (eg, keeping an opioid stash, timing opioid consumption based on planned activities). Recommendations for promoting productive tapering discussions include understanding the social and emotional dynamics likely to impact patients' tapering, addressing patient fears, focusing on patients' best interests, providing anticipatory guidance about tapering, and developing an individualized tapering plan that can be adjusted based on patient response. Perspective: This study used interview and focus group data to characterize patients' experiences with opioid tapering and identify communication strategies that are likely to foster productive, patient-centered discussions of opioid tapering. Findings will inform further research on tapering and help primary care clinicians to address this important, often challenging topic.

Objectives. To estimate the effect of California’s prescription drug monitoring program’s (PDMP) registration mandate on use of the PDMP. Methods. We evaluated the effect of California’s mandatory PDMP registration law by fitting time series models on the percentage of clinicians registered for California’s PDMP and the percentage of clinicians who were active PDMP users (users who created ≥ 1 patient prescription reports in a given month) from 2010 through 2017. We also compared PDMP use among early PDMP adopters (clinicians who registered > 8 months before the mandatory registration deadline) versus late adopters (clinicians who registered ≤ 8 months before the deadline). Results. Mandatory registration was associated with increases in active PDMP users: 53.5% increase for prescribers and 17.9% for pharmacists. Early adopters were 4 times more likely to be active PDMP users than were late adopters. Conclusions. Mandatory registration was associated with increases in PDMP registration and use, but most new registrants did not become active users. Public Health Implications. Mandatory PDMP registration increases PDMP use but does not result in widespread PDMP usage by all clinicians prescribing controlled substances.

Background : In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California. Methods : Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients’ mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers’ mean daily MME prescribed; prescribers’ mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents. Results : Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients’ mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers’ mean daily dose prescribed (95 %CI: -10.0, -1.3). Conclusions : California’s implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP’s without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

Objective. To describe the development and initial application of the Chronic Pain Coding System. Design. Secondary analysis of data from a randomized clinical trial. Setting. Six primary care clinics in northern California. Subjects. Forty-five primary care visits involving 33 clinicians and 45 patients on opioids for chronic noncancer pain. Methods. The authors developed a structured coding system to accurately and objectively characterize discussions about pain and opioids. Two coders applied the final system to visit transcripts. Intercoder agreement for major coding categories was moderate to substantial (kappa = 0.5–0.7). Mixed effects regression was used to test six hypotheses to assess preliminary construct validity. Results. Greater baseline pain interference was associated with longer pain discussions ( P = 0.007) and more patient requests for clinician action ( P = 0.02) but not more frequent negative patient evaluations of pain ( P = 0.15). Greater clinician-reported visit difficulty was associated with more frequent disagreements with clinician recommendations ( P = 0.003) and longer discussions of opioid risks ( P = 0.049) but not more frequent requests for clinician action ( P = 0.11). Rates of agreement versus disagreement with patient requests and clinician recommendations were similar for opioid-related and non-opioid–related utterances. Conclusions. This coding system appears to be a reliable and valid tool for characterizing patient-clinician communication about opioids and chronic pain during clinic visits. Objective data on how patients and clinicians discuss chronic pain and opioids are necessary to identify communication patterns and strategies for improving the quality and productivity of discussions about chronic pain that may lead to more effective pain management and reduce inappropriate opioid prescribing.

Introduction The purpose of this study is to extend prior research on barriers to use of a prescription drug monitoring program by examining psychosocial correlates of intended use among physicians and pharmacists. Methods Overall, 1,904 California physicians and pharmacists responded to a statewide survey (24.1% response rate) from August 2016 to January 2017. Participants completed an online survey examining attitudes toward prescription drug misuse and abuse, prescribing practices, prescription drug monitoring program design and ease of use, professional obligations, and normative beliefs regarding prescription drug monitoring program use. Data were analyzed in 2017. Results Perceived prescription drug monitoring program usefulness and normative beliefs fully mediated the relationship between concern about prescription drug abuse and intentions to use the prescription drug monitoring program. Clinicians’ sense of professional and moral obligation to use the prescription drug monitoring program was unrelated to intention to use the prescription drug monitoring program despite a positive relationship with concern about misuse and abuse. Compared with physicians, pharmacists reported greater concern about prescription drug misuse, greater professional and moral obligation to use prescription drug monitoring program, and greater rating of prescription drug monitoring program usefulness. Conclusions Interventions that target normative beliefs surrounding prescription drug monitoring program use and how to use prescription drug monitoring programs effectively are likely to be more effective than those that target professional obligations or moralize to the medical community.

BACKGROUND: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. OBJECTIVE: To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. DESIGN: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles—a 62-year-old man with advanced lung cancer and uncontrolled pain—differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. PARTICIPANTS: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians’ mean age was 52 years (SD = 27.17), 59% male, and 64% white. MAIN MEASURES: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS: SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). CONCLUSIONS: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. TRIAL REGISTRATION: NCT01501006

Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.

Objective Assess patient-physician agreement on management goals for chronic musculoskeletal pain and its associations with patient and physician visit experiences. Materials and methods Pre-visit and post-visit questionnaires for 87 primary care visits that involved patients taking opioids for chronic musculoskeletal pain and primary care resident physicians. After each visit, patients and physicians independently ranked 5 pain treatment goals from most to least important. Results In total, 48% of patients ranked reducing pain intensity as their top priority, whereas 22% ranked finding a diagnosis as most important. Physicians ranked improving function as the top priority for 41% of patients, and ranked reducing medication side effects as most important for 26%. The greatest difference between patient and physician rankings was for reducing pain intensity. In regression analyses, neither overall agreement on goals (ie, the physician's first or second priority included the patient's top priority) nor difference in patient versus physician ranking of pain intensity was significantly associated with patient-reported visit experience (β for overall agreement, -0.08; 95% confidence interval [CI], -0.45 to 0.30; P=0.69; β for intensity, -0.06; 95% CI, -0.17 to 0.04; P=0.24) or physician-reported visit difficulty (β for overall agreement, 1.92; 95% CI, -2.70 to 6.55; P=0.41; β for intensity, 0.42; 95% CI, -0.87 to 1.71; P=0.53). Discussion Patients and physicians prioritize substantially different goals for chronic pain management, but there is no evidence that agreement predicts patient experience or physician-reported visit difficulty. Primary care physicians may have adapted to new recommendations that emphasize functional goals and avoidance of long-term opioid therapy, whereas patients continue to focus on reducing pain intensity.

Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are “typical” or “activated” (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors. https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.

Objective To investigate associations between ratings of “thin slices” from recorded clinic visits and perceived patient-centeredness; to compare ratings from video recordings (sound and images) versus audio recordings (sound only). Methods We analyzed 133 video-recorded primary care visits and patient perceptions of patient-centeredness. Observers rated thirty-second thin slices on variables assessing patient affect, physician affect, and patient-physician rapport. Video and audio ratings were collected independently. Results In multivariable analyses, ratings of physician positive affect (but not patient positive affect) were significantly positively associated with perceived patient-centeredness using both video and audio thin slices. Patient-physician rapport was significantly positively associated with perceived patient-centeredness using audio, but not video thin slices. Ratings from video and audio thin slices were highly correlated and had similar underlying factor structures. Conclusion Physician (but not patient) positive affect is significantly associated with perceptions of patient-centeredness and can be measured reliably using either video or audio thin slices. Additional studies are needed to determine whether ratings of patient-physician rapport are associated with perceived patient-centeredness. Practice implications Observer ratings of physician positive affect have a meaningful positive association with patients’ perceptions of patient-centeredness. Patients appear to be highly attuned to physician positive affect during patient-physician interactions.

Although older adults are disproportionately affected by painful musculoskeletal conditions and receive more opioid analgesics than persons in other age groups, insufficient evidence is available regarding opioid harms in this age group.To examine longitudinal relationships between opioid use and falls, clinical fractures, and changes in physical performance. We hypothesized that opioid use would be associated with greater risks of falling and incident clinical fractures and greater declines in physical performance.We analyzed data from the Osteoporotic Fractures in Men Study (MrOS), a large prospective longitudinal cohort study. Participants completed baseline visits from 2000 to 2002 and were followed for 9.1 (SD 4.0) years.MrOS enrolled 5994 community-dwelling men ≥ 65 years of age. The present study included 2902 participants with back, hip, or knee pain most or all of the time at baseline.The exposure of interest was opioid use, defined at each visit as participant-reported daily or near-daily use of any opioid-containing analgesic. Among patients, 309 (13.4 %) reported opioid use at one or more visits. Participants were queried every 4 months about falls and fractures. Physical performance scores were derived from tests of grip strength, chair stands, gait speed, and dynamic balance.In the main analysis, the adjusted risk of falling did not differ significantly between opioid use and non-use groups (RR 1.10, 95% CI 0.99, 1.24). Similarly, adjusted rates of incident clinical fracture did not differ between groups (HR 1.13, 95% CI 0.94, 1.36). Physical performance was worse at baseline for the opioid use group, but annualized change in physical performance scores did not differ between groups (-0.022, 95% CI -0.138, 0.093).Additional research is needed to determine whether opioid use is a marker of risk or a cause of falls, fractures, and progressive impairment among older adults with persistent pain.

Objective. To examine encounter-level factors associated with opioid dose increases during patients’ first year on opioid therapy for chronic pain. Design. Case-control study analyzing all opioid prescriptions for patients with chronic pain during their first year after opioid initiation. Cases were patients who experienced an overall dose escalation of ≥ 30 mg morphine equivalents over the 1-year period; controls did not experience overall dose escalation. Main measures were encounter type, opioid dose change, documented prescribing rationale, documentation of guideline-concordant opioid-prescribing practices. Two coders reviewed all encounters associated with opioid prescriptions. Analysis of factors associated with dose increases and provider documentation of prescribing rationale was conducted using multiple logistic regression. Results. There were 674 encounters coded for 66 patients (22 cases, 44 controls). Fifty-three percent of opioid prescriptions were associated with telephone encounters; 13% were associated with e-mail encounters. No prescribing rationale was documented for 43% of all opioid prescriptions and 25% of dose increases. Likelihood of dose increase and documentation of prescribing rationale did not significantly differ for cases versus controls. Compared with face-to-face encounters, dose increases were significantly less likely for telephone (OR 0.18, 95% CI 0.11–0.28) and e-mail (OR 0.23, 95% CI 0.12–0.47) encounters; documentation of prescribing rationale was significantly more likely for e-mail (OR 5.06, 95% CI 1.87–13.72) and less likely for telephone (OR 0.30, 95% CI 0.18–0.51) encounters. Conclusion. Most opioid prescriptions were written without face-to-face encounters. One quarter of dose increases contained no documented prescribing rationale. Documented encounter-level factors were not significantly associated with overall opioid dose escalation.