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Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult
Jessica J Wyse1,2, Linda Ganzini3,4, Steven K Dobscha3,4
1Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, 97239, USA. wyse@ohsu.edu.
Journal of General Internal Medicine
|April 24, 2019
Summary
Clinicians use verbal strategies to manage long-term opioid therapy (LTOT) risks, addressing patient misuse and aberrant behaviors effectively. These heuristics improve efficiency and reduce emotional tension during care discussions.
Area of Science:
- Pain Management
- Clinical Practice
- Opioid Therapy
Background:
- Growing evidence highlights risks associated with long-term opioid therapy (LTOT) for chronic pain.
- Clinical guidelines recommend practices to mitigate opioid-related risks.
- Limited research exists on how clinicians implement these guidelines in patient encounters.
Purpose of the Study:
- To identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors in patients on LTOT.
- To understand how clinicians respond to opioid misuse and the resources/constraints they face.
Main Methods:
- Secondary analysis of individual interviews with 24 physicians and nurse practitioners.
- Interviews conducted across 22 Veterans Health Administration (VA) facilities in the USA.
- Qualitative content analysis using a developed codebook to identify themes and sub-themes.
Main Results:
- Clinicians face challenges in discussing opioid misuse, including patient objections and clinician ambivalence.
- Verbal heuristics (setting expectations, following orders, safety, standardization) are used to structure difficult conversations.
- These heuristics help routinize care, redirect responsibility, and manage emotional aspects of encounters.
Conclusions:
- Verbal heuristics are a key strategy for clinicians managing LTOT and addressing opioid misuse.
- These strategies enhance efficiency and emotional management in patient care discussions.
- Further understanding of these practices can inform guideline implementation and clinician support.