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. Author manuscript; available in PMC: 2025 Dec 23.
Published in final edited form as: Pain Manag Nurs. 2024 Nov 8;26(2):149–155. doi: 10.1016/j.pmn.2024.10.001

Development and Validation of the Decisions to use Opioids Measure

Brittany E Punches 1,2, Jennifer L Brown 3, Michael S Lyons 2, Gordon L Gillespie 4, Edward W Boyer 2, Alison R Anderson 5, Stephanie Carreiro 6, Jason J Bischof 2, Emily Kauffman 2, Henry Young 2, David Spatholt 2, Alai Tan 1, Macarius Donneyong 7, Andy Ni 8, Tamilyn Bakas 4
PMCID: PMC12720183  NIHMSID: NIHMS2124573  PMID: 39521629

Abstract

Background:

Millions experience inadequately managed acute pain each year. Opioids are an important tool for managing pain; however, recent reductions in opioid prescriptions have exacerbated preexisting challenges in pain management. Moreover, patient expectations and desires for pain management may drive additional opioid use. There is an important need to characterize patient motivations for using opioids in order to develop promising interventions. The aim of this study was to develop the Decisions To use Opioids (DTO) measure.

Methods:

We used an exploratory sequential mixed methods design to create items for the DTO measure. Qualitative data from patient interviews and focus groups informed the development of items for the DTO. We evaluated the content validity of candidate items with nine experts using the content validity index (CVI) and conceptual significance. Face validity was assessed via cognitive interviews with five ED participants who experienced acute pain.

Results:

We generated an initial pool of 52 items. Expert ratings provided evidence of content validity on 40 items, as indicated by an item CVI score of 0.83 or higher. Nine items with CVI scores of < 0.83 were retained and revised due to the conceptual significance. The remaining three items were discarded.

Conclusions:

This study provided evidence of content and face validity of the DTO measure for emergency department patients. Further psychometric evaluation is needed to gather data regarding the DTO’s internal consistency, construct validity, and criterion validity.

Introduction

Over 57 million in the US experience acute pain each year (Nahin, 2015; Rikard, 2023; US Department of Health and Human Services, 2019), with recent reductions in therapeutic opioid use exacerbating existing challenges in pain management (Dowell, 2022; Food and Drug Administration, 2019; Oliver & Carlson, 2020; Punches, Brown, et al., 2022) Estimated societal pain cost exceeds $560 billion annually in the U.S. (Gaskin & Richard, 2012). A subset of patients with acute pain will transition to adverse long-term consequences such as chronic pain, functional disability, or opioid use disorder (Dowell, 2022; Dueñas et al., 2016; Henschke et al., 2015; Smith et al., 2001; Smith & Hillner, 2019). Opioids can be an important tool to address the epidemic of unrelieved pain, but also may contribute to trajectories including risky opioid use and opioid use disorder (Beauchamp et al., 2020; Punches, Ancona, et al., 2021; Punches, Stolz, et al., 2022). Moreover, it is not possible to avoid opioid use entirely, particularly for acute pain, and decisions on opioid use are a shared responsibility between clinicians and patients.

Although recreational opioid use plays a role in the current opioid crisis, the initial exposure to opioids often occurs with acute pain management (Butler et al., 2016; Punches, Brown, et al., 2022; Stumbo et al., 2017). Specifically, with respect to opioid analgesia, initial exposures for new (acute) painful conditions may become the groundwork for repeat exposures and potential long-term opioid use (Butler et al., 2016; Punches, Ancona, et al., 2021; Punches, Brown, et al., 2022; Punches, Stolz, et al., 2022). Reducing opioid prescribing to prevent misuse and diversion is important (CDC, 2024), but this is a significant challenge due to the legitimate need to manage acute pain and patient preferences for pain management (Blomqvist, 2003; Punches, Brown, et al., 2022; Schwaller & Fitzgerald, 2014; Turner et al., 2022). Previous studies have also identified that patients are willing and able to obtain non-medical opioids (pharmaceutical opioids from other than their own medical provider, used differently than prescribed, or non-pharmaceutical opioids) to manage their pain if providers do not prescribe them (Beauchamp et al., 2020; Han et al., 2017; Punches, Brown, et al., 2022).

There is an urgent and imperative need to understand factors influencing patients’ motivation to use opioids and engage patients as stakeholders in the balance of pain management and addiction risk posed by opioid use. Moreover, characterizing these patient motivating factors is useful in predicting intervention targets for increasing or decreasing opioid use; however, there are no available measures. Currently, available tools related to opioid use in the ED only screen for symptoms of opioid use disorder and potential at-risk use among persons with chronic pain, and none incorporate the patient’s knowledge, attitudes, and beliefs (Punches, Ali, et al., 2021). Measures related to patients’ attitudes and beliefs surrounding pain (e.g., catastrophizing) have limited testing in the ED and do not incorporate opioid use (Block et al., 2017; Sullivan et al., 1995). The purpose of this study was to develop and test content and face validity of the Decisions To use Opioid measure (DTO) leveraging patient interviews and focus groups as well as a panel of nine experts in acute pain, emergency care, opioid use disorder, and instrument development.

Methods

Design

We employed an exploratory sequential mixed methods approach in two phases to develop the DTO measure (Creswell & Clark, 2017). In Phase 1, we utilized qualitative interviews to explore the phenomenon of acute pain after the emergency department (ED) visit. Phase 2 involved the creation of candidate items for the DTO to measure a patient’s decision to use opioids informed by the patient’s experience of acute pain and beliefs about opioid use disorder, followed by testing face validity with patients and content validity with experts.

Qualitative Data Collection

Reported elsewhere, semi-structured qualitative interviews discussing patient experiences of acute pain and opioid use were conducted with a convenience sample of 18 ED patients (Punches, Brown, et al., 2022). These findings informed the development of a second round of focus groups and interviews with 29 ED patients, honing in on categories of patient motivating factors and decisions to use opioids, supporting the Decisions To use Opioids (DTO) framework (Punches et al., 2023). In this phase, a number of themes emerged, highlighting the specific components of individual motivating factors to use opioids. We found the themes of 1) cues to action, 2) control preferences, 3) pain management literacy, and 4) risk tolerance were major drivers of patient decision-making during an acute pain episode (Punches et al., 2023).

Item Development and Creation

In phase 2, items were informed by participant statements about motivating factors for opioid use for pain management grouped by concepts and definitions (See Table 1). Exemplar quotations were identified for each concept, informing the subsequent development of the candidate DTO item. We developed 52 candidate items based on these qualitative analyses. These items were then reviewed by three of the authors (B.P., J.B., T.B.) for clarity, relevance, and appropriateness. Candidate items were designed to be rated on a 5-point Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree).

Table 1:

Instrument Development Matrix

Concept and definition Representative quotes Proposed Items
Cues to action - This is the internal or external stimulus needed to trigger the decision-making process.
Perceived severity of pain - This refers to a person’s feelings on the seriousness of having pain. “Because if you have a real bad pain, like a aching pain where it’s starting to affect your work, your work performance on to the point, we didn’t change sleep and you already have a let’s say... the pain is so severe to the point where is messing with their sleep or they can’t sit around comfortably or at a job.” (40 y/o Black male) I believe my pain is severe if my sleep is bothered.
I believe my pain is severe if I cannot go to work.
“I have younger grandkids. You know I’m saying and I’m constantly on the go in the evening. When I’m dealing with pain, I’m dealing with kids now and I gotta take care of home and all this ‘cause I’m a single grandparent. I take some[thing] strong so the next day I don’t like to feel the pain I’m in.” (57 y/o Black female) I believe my pain is severe if I cannot do all of the things I want to.
“I would be in so much pain to where I would be crying” (45 y/o Black female) *I believe my pain is severe if it makes me cry or scream.*
“They gave me a shot but that didn’t help me, and then they told me to go home and take ibuprofen or Tylenol and that didn’t help.” (39 y/o Black, Hispanic female) I believe I should take an opioid medication if the pain is not going away
Interaction with Provider “The doctors 9 times out of 10, when they give you the medicine, they know what they’re doing. They know, especially when they tell you the hours they take it like they telling you that for a reason.” (32 y/o Black male) I believe I should take an opioid medication if I was given a schedule for taking them
I believe I should take an opioid medication if I was given instructions on how to take them
“I let the pain get so bad and then try to take it... you know my doctors have told me, ‘Take it as prescribed if needed.’ If you’re in pain, you take it every you know, six hours, whatever their prescribed time is.” (45 y/o Black female) I believe I should take an opioid medication if the doctor thought the pain was bad enough
Other External Factors “I had refused to [take an opioid]…it took a lot of convincing from family as well as my doctors to do something because it had came to the point to where I was in so much pain. It was debilitating to where I couldn’t move. You know I couldn’t do my everyday activities because it hurts so bad.” (45 y/o Black female) I believe I should take an opioid medication if my family or friends thought I should take them
Control preferences - Individuals’ beliefs about healthcare and the degree that they have expectations and trust with healthcare, providers, and pain management.
Trust of healthcare “But I’m not gonna take a bunch of medicine that makes me painless, because pain in our body Is an alarm system that says there’s something wrong… I wouldn’t take a pain medicine if I thought it was just gonna mask my problem and the problem wasn’t going to go away.” (78 y/o White male) I am responsible for my pain getting worse or better.
I will not just take medication because my doctor said to.
“I would prefer to go with what my doctor tells me to do because I believe they know more about medication. They went to school for that” (53 y/o Black male) I trust my doctor’s opinion about what can be done for my pain.
“I just, yeah. I don’t like pills. But if it’s prescribed to me by my doctors, then I will take it for whatever amount of time I’m supposed to take it.” (39 y/o Black male) Following the doctor’s orders is the best way for my pain to get better.
“but I listened, listen to my doctor. You know you gotta give your Doctor little bit of a doubt that you know they know what they’re doing. They said ‘I didn’t know’, you can’t sit here and say you didn’t know when you the professional. You could suggest. Well when you tell me to do something and I do it” (48 y/o Black male) The doctor should know how to make my pain go away.
Expectations for Pain Management “Because they gave me two different refills and I think mine was only for two weeks’ worth of pain medicine…Sometimes I could try to get more pain pills or anything like that from off the street” (29 y/o Black male) If my doctor does not prescribe an opioid for pain and I want one I will seek opioids from somewhere else.
“Cause they feel like the opioid is stronger and It’s gonna work better than like that regular medicine” (32 y/o Black male) If I go to the ER for pain, I want a prescription for something I cannot receive over the counter.
“They prescribed an opioid. And when I specifically said I didn’t want that, they still did not give me a different prescription or even want to have a conversation… but that still left a really bad taste in my mouth and especially because I made them aware of the reasons why I didn’t want that prescription.” (22 y/o White male) I prefer to make the decision about whether or not I get an opioid prescription for pain.
Pain Management Literacy: This refers to a person’s knowledge, beliefs, and attitudes towards opioid use and alternatives to opioids for pain management.
Perceptions of Opioid Use - This refers to a person’s knowledge, attitudes, and beliefs about the effectiveness and benefits of taking opioids as well as any barriers or physical reasons for the inability to take or access opioids. “I take some[thing] strong ... I don’t like to feel the pain I’m in for one thing and then I wanted to be relieved other where I just wanna go to sleep because I haven’t done so much enduring that with the pain too... I just wanna take a shower, take some pain medicine so I can relax because the more pain you in the more mentally it can bother you mentally. You know I’m saying I can’t afford for nothing dancing in my head.” (57 y/o Black female) Opioids help control pain
I like the way opioids make me feel
I will take an opioid because I cannot be in pain
Opioids help me relax when in pain.
“Be aware of their personality, how they act when they come in, or how their… kind of a….if they are like pushing issues as far as getting the medication.” (78 y/o White male) Doctors should limit prescriptions for opioids even if someone is in pain.
“As far as in emergency, they’re only gonna give that to you for the short term, say maybe three to five days, or maybe. Seven days at the most” (66 y/o Black female) Opioid prescriptions should only be used for a short time.
“I feel like people automatically think you’re a junkie if you’re on pain medication, which is not the case” (35 y/o White female) I don’t want to take an opioid because people might think I’m an addict.
“And maybe it’s just one of those feelings that just can be addictive and maybe just those side effects alone could very well discourage someone from taking it.” (20 y/o White male) I would be less likely to use opioids if I felt ”high”/woozy after taking them.
“I still don’t like the way…that opiates make me feel I don’t like the tiredness. I don’t like the ...I guess you could call it foggy feeling sometimes. I don’t like that feeling.” (45 y/o Black female) I would be less likely to use opioids if they make me feel groggy/tired.
“And then Monday morning I took one and then of course by that time I was getting nauseous. ‘cause that’s what they do, to me they make me sick at my stomach.” (79 y/o White female) I would be less likely to use opioids if I had side effects after taking them (nausea, constipation).
“Because they don’t want to get addicted to it ...And there’s a huge chance that you’re gonna get addicted to it.” (47 y/o Black female) I would be less likely to use opioids if they could cause addiction.
Perceptions of Alternatives to Opioids - An individual’s knowledge, attitudes, and beliefs regarding benefits and barriers to use of alternatives to opioids. “At times [an opioid is] the cheapest available. Like right now I’m struggling with this pain. I need to be at work, I don’t have enough time to pursue my own healing and so you end up maybe giving into a pill that you can pop and feel better. A few hours, pop another pill. As opposed to maybe getting sessions of physical therapy and extensive imaging to find out what’s really is the problem and therefore manage it appropriately.” (53 y/o Black Male) Opioids are cheaper than other ways to manage my pain.
“So, they give her things like ibuprofen and Tylenol and things like that. That really don’t help. You know? it’s just made it… It’s made it hard because of people…You know the doctor even told her …you know, if it hadn’t been for it being so abused…that you know it’s just hard now.” (45 y/o Black female) Opioids are the only pain medicines that work for me.
“Just depending on what type of person you are, you know what you do, how much knowledge you know about, like the medicine or whatever. You know you could be like oh, I just got prescribed, you know, oxy codeine. And I know this can be highly addictive or very strong medicine and can honestly be lethal depending on how much you take it. You just kind of have to be conscious and aware of like you yourself as a person and what you’re actually being prescribed, and then you know kind of sit there and think man, is this something that I want to take?” (20 y/o White male) I know other ways to manage my pain besides opioids.
Perceived self-efficacy of pain management-This refers to the level of a person’s confidence in his or her ability to successfully manage their pain. “They gave me hydrocodone and ... they didn’t do anything for me. So I guess my pain level is more intense to other people to where I really need something really really strong and I never did drugs or anything...I when I’m in pain, I’m in pain, and I want something to stop the pain.” (57 y/o Black female) I need stronger pain medicine than others do.
“For the first day after the surgery they had given me some Vicodin or whatever it was as a pain killer, and they said and/or you could use Tylenol. Well, I took two of those [tylenol] and I wasn’t feeling too bad and so I just did the Tylenol and I put up with some pain. You know it’s sometimes we get soft and we’re not willing to deal with some pain and like I can deal with some.” (78 y/o White male) I am confident I can handle pain without opioids.
“They just resort to like an ibuprofen or Tylenol or something along those lines, and you know hope for the best. Then maybe it’s just something so minor that those type of medications help. And then if like the pain or whatever you’re feeling still like persists, then I think they would take it a step further and go to say in ER or a just call in to a primary care.” (20 y/o White male) I will try something else (such as rest, ice) besides an opioid first.
“Pain tolerance, you know is different for everybody. Yeah, I kind of have a high pain tolerance just because of the field of work I work in. I, you know I do welding I get burnt. I get hurt all the time so your body will naturally get used to it. And you know you’ll … eventually. You know you won’t even feel a stubbed toe or something small anymore.” (20 y/o White male) I able to tolerate a high amount of pain
Pain Anxiety - This refers to a person’s subjective perception of chances of, reactions, and tolerance to pain. “I have chronic pain myself, but I tried to stay active and keep my mind off of it and you know I do things from yoga to see a personal trainer to physical therapy” (27 y/o White female) I am often in pain.
I am worried about pain often.
“When it comes to [pain] I’m a baby, I have to get something for it.” (27 y/o White female) I am afraid of pain.
“I think I have a high pain tolerance because I am in constant chronic low, low grade that sometimes spikes. But of course, I mind being in pain. Nobody. I don’t think anybody wants to be in pain.” (51 y/o Black female) *I am at risk for chronic pain.
Risk Tolerance: This refers to a person’s subjective perception of the risk of acquiring opioid use disorder (OUD), feelings on the seriousness of developing OUD, and acceptance of the risk of opioid use despite known risks.
Perceived susceptibility to OUD - This refers to a person’s subjective perception of the risk of acquiring opioid use disorder (OUD). “If you’ve got an addictive personality, and more prone to it, they just might have that fear of starting something that they’re not gonna be able to stop.” (51 y/o Black female) I am not at risk of opioid addiction because of my personality.
“Maybe I’m wrong but I have in the few cases in my life been exposed to heavy narcotics. And I’ve just never had a problem with addiction. I just never have...I don’t think I have a propensity for that type of behavior.” (59 y/o White male) I am not at risk of opioid addiction because I have used them in the past without a problem.
“I know that I had a relative that was addicted…Not just to opiates... and so is my brother so very close to home and I’m like…. This is a person that I thought was strong, so I’m like if it could get him…It could get me. And that’s why I like I said I stayed away from it.” (45 y/o Black female) I am not at risk of opioid addiction because it doesn’t run in my family.
“I don’t think I’m at risk for [OUD]…I have a pretty strong mind for real...I don’t feel like I’m in need for nothing. I mean, like I just, if I’m healthy I eat every day, sleep, all the normal stuff. I can get through my day just fine.” (24 y/o Black male) I am not at risk of opioid addiction because I have a strong mind.
*I am not at risk of opioid addiction because I don’t have health problems.
“But you know honestly, how can you get addicted to pain medicine if you have a pain” (29 y/o Black male) I am not at risk of opioid addiction because I have real pain.
Risk Acceptance - This is when a participant describes when they are knowledgeable about the risks of opioid use and choose to take an opioid for pain despite the known risks. “When it comes to [pain] I’m a baby, I have to get something for it.’ (27 y/o White female) I don’t care about the possibility of becoming addicted, when I have pain I want it gone.
“They need to take them for what they’re prescribed for, and that’s it and not – let me take an extra two or three because my pain a little bit extra. You need to take them as prescribed.” (39 y/o Black male) I am not at risk of opioid addiction because I take them the way they are prescribed.
“I think if they take it for the reason that they need to be taking it for, that’s fine. …So I guess when they taking it for the wrong reason“ (40 y/o Black male) I am not at risk of opioid addiction because I take them for what they are prescribed for.
“Whereas if you are actually in so much pain that you know even if there might be an issue or something along the way. I’m sure they would be the resources there to help overcome that but being in pain and being in a serious situation, probably it would be worth taking medicine.” (20 y/o White male) Even if a doctor thought I was at risk for opioid addiction, I would take opioids if I need them.
Perceived severity of opioid use disorder - This refers to a person’s feelings on the seriousness of developing OUD “But I do not want to deal [with] the opioid at all...I was prescribed that one time and I felt. I didn’t feel comfortable…I mean the pain was subsided, but I was not feeling confident taking it. With a chance of me getting too addicted to it and everything else.” (53 y/o Black male) I am afraid of becoming addicted to pain pills.
“I start backing off and sometimes that’s not a good decision because I’ll end up hurting worse and realize no. You shouldn’t have backed off yet, so you have to go back to taking what’s prescribed, but I’m …I’m …my mindset is always work to get off of this as soon as possible.” (79 y/o White female) If I take an opioid, I want to get off of it quickly so I don’t get hooked.
“Yeah, I don’t abuse my pain medicine ‘cause I don’t want to become that type of person that’s on the streets begging for a high. It’s not that for me, it’s really not that for me.” (47 y/o Black female) It is okay to take an opioid because pills aren’t as risky as drugs off the street.
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*

Removed in revised measure

Face Validity

We examined face validity on the DTO to assess whether participants understood the item and its intent. Face validity is a process to determine if a measure appears to be measuring what is intended, with sample size recommendations ranging from n = 5 to 15 (Beatty & Willis, 2007; Peterson et al., 2017). As an aspect of “member checking” (Lincoln & Guba, 1985), we conducted cognitive interviews with five participants who were enrolled as part of a parent study (Punches et al., 2023); participants were asked to read and think aloud with each question, and then comment on clarity, relevance, appropriateness, and wording of the items. We used clarifying questions to further understand when the participant hesitated or indicated they lacked understanding (DeVellis & Thorpe, 2022; Peterson et al., 2017). Interviews were recorded, transcribed, and checked for accuracy. Questions identified as unclear or confusing for participants were revised.

Content Validity

Content validity was assessed to ensure the items reflected the domains of interest, patient motivators for opioid use (Punches et al., 2023). The 52 items were reviewed for clarity, structure, and relevance to the constructs by nine experts in emergency care, care for opioid use disorder, pain management, and instrument development, some with overlapping expertise. These experts’ opinions were solicited due to their history of clinical and/or research expertise and invited to review each item and provide feedback, score each item in terms of relevance, and offer suggestions for improvement. Items were rated by the reviewers using the following scale: 1= not relevant, 2 = slightly relevant, 3 = moderately relevant, 4 = very relevant (Lynn, 1986). Expert feedback and scoring were de-identified and collated for review.

We calculated the content validity index of each item (I-CVI) by dividing the number of content experts who scored the item with a rating of 3 (moderately relevant) or 4 (very relevant) by the total number of content experts. Next, we calculated the CVI for the entire measure (Total CVI) as a proportion of total number of items receiving a rating of three or four by the content experts. We considered items with a CVI of 0.83 or higher as acceptable and the overall scale with a CVI of 0.8 as acceptable (DeVellis & Thorpe, 2022; Lynn, 1986). If an item scored poorly, but the comments provided guidance for improvement, these revisions were made, and the item was retained.

Results

We initially collected qualitative data described elsewhere (Punches, Brown, et al., 2022; Punches et al., 2023) to inform the development of candidate items, transforming these into items in the measure. Based on content and face validity testing, we revised the initial 52 items to the final 49 items.

Face Validity

Five individuals (three men/two women) were individually interviewed as they reviewed the DTO measure; their mean age was 34.6 years, and 80% (4/5) were White (See Table 2). There were varying educational, relationship, and socioeconomic statuses, and one individual had a personal history of opioid use disorder. The items were reviewed for feedback on the question’s wording, relevance, and intent. Table 1 provides examples of the potential DTO domains to inform item development with concept definitions, representative quotes, and the proposed items for expert review.

TABLE 2:

Characteristics of Face Validity Sample

Age – years, mean (range) 34.6 (24–48)
Race/Ethnicity, N (%)
 White, Non-Hispanic White, Non-Hispanic 4 (80.0)
 Black/African American 1 (20.0)
Gender, N (%)
 Male 3 (60.0)
 Female 2 (40.0)
Marital Status, N (%)
 Married/Relationship 2 (40.0)
 Never Married/Not reported 4 (60.0)
Education, N (%)
 Some Highschool 1 (20.0)
 Highschool Graduate 1 (20.0)
 Some College 2 (40.0)
 College Graduate 1 (20.0)
Employment Status, N (%)
 Full-time/Part-time 3 (60.0)
 Not employed/student 2 (40.0)
History of Opioid Use Disorder, N (%)
 Never 4 (80.0)
 Current OUD/In treatment 1 (20.0)
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All demographic information was self-reported prior to interview

Content Validity

Content validity testing was conducted on the 52 candidate items to ensure the items reflected the domains of interest (DeVellis & Thorpe, 2022). After the experts reviewed the DTO, 12 items had an I-CVI of less than 0.83. Each of these items was reviewed, and the experts’ comments were taken into consideration. First, the three items scoring less than 0.75 were deleted; removal of these three items was suggested because of either lack of perceived relevance of the item and/or concern for comprehension due to potential lower health literacy of patients who would respond to the measure. Next, the remaining nine items that scored 0.75 – 0.82 were revised to enhance clarity based on the experts’ feedback. Finally, the total CVI after deletion of items suggested by the experts was calculated as 0.84 (41 scoring 3 or 4 / 49 items).

Discussion

The Decisions To use Opioids (DTO) measure was developed in order to characterize and measure factors influencing patients’ motivation to use opioids for pain management. In this paper, we outline the stages of development and the measure’s content and face validity. The rigorous methods outlined in this manuscript resulted in the development of a comprehensive measure incorporating the voice of the patients as well as experts in the field to quantify motivators to use opioids for pain management. These foundational steps lay the groundwork for future internal consistency reliability analyses and construct validity testing with exploratory factor analysis (DeVellis & Thorpe, 2022; Ferketich, 1991).

The DTO is novel as it characterizes different domains of motivating factors to use opioids developed from ED patients’ own words when discussing their knowledge, attitudes, and beliefs regarding pain and opioids. Items were reviewed by content experts and ED patients for further relevance and clarity. Additionally, we incorporated comments from experts on items that did not meet our CVI score threshold in order to improve the overall measure.

Current tools to measure and identify risks for at-risk opioid use are limited to screening for symptoms of opioid use disorder, screening for at-risk use among individuals taking long-term opioids for chronic pain, or not considering patient perspectives (Punches, Ali, et al., 2021). Moreover, few have been tested in the emergency department or with patients experiencing acute pain (Punches, Ali, et al., 2021). Other measures of patients’ perceptions of pain have limited testing in the acute care setting and lack perceptions of opioid use (Block et al., 2017; Sullivan et al., 1995). Moreover, patients have expressed the problematic nature and stigma of such measures such as “catastrophizing” as a label applied to their pain (Webster et al., 2023). Our measure incorporates the beliefs and perceptions of patients experiencing acute pain, grounded in their own statements, as well as their knowledge and self-efficacy surrounding pain management and opioids.

Limitations

This study was limited to the development of the DTO measure, including face validity with ED patients as well as content validity with experts. This measure was intended for individuals with acute pain. Grounding the items to echo the voice of the participants is a strength, ensuring the measure captured the knowledge, attitudes, and beliefs motivating ED patients to take an opioid for acute pain. However, our study is limited by diversity in our sample completing face validity testing, including the use of a single ED setting and convenience sampling for the recruitment of participants.

Further psychometric testing with a large, diverse ED patient sample to complete internal consistency reliability analyses and construct validity testing is needed for validation of the measure. Additional testing will aid in determining scoring and items that are more influential in prediction of at-risk opioid use for research purposes. Additionally, the measure may be shortened to aid in clinical applicability and to facilitate discussions between patient and provider. We acknowledge the need for future investigation to determine feasibility and practicality in a setting such as the ED. Finally, the measure may be tested in other acute pain applications outside of the ED setting for greater generalizability.

Conclusions

The DTO measures motivating factors related to patient decisions to use opioids for acute pain after the ED visit. We have developed this measure to assess four primary domains of factors related to reasons for opioid use: 1) cues to action, 2) control preferences, 3) pain management literacy, and 4) risk tolerance. The DTO initially may serve as a research instrument to assess patient approach to opioids and pain as well as guide the development and testing of individualized strategies to optimize opioid use. The DTO has future potential for use by clinical staff to identify patient needs, prevention strategies surrounding pain management, and shared decision-making related to opioid use.

References

  1. Beatty PC, & Willis GB (2007). Research synthesis: The practice of cognitive interviewing. Public Opinion Quarterly, 71(2), 287–311. [Google Scholar]
  2. Beauchamp GA, Nelson LS, Perrone J, & Lyons MS (2020). A theoretical framework and nomenclature to characterize the iatrogenic contribution of therapeutic opioid exposure to opioid induced hyperalgesia, physical dependence, and opioid use disorder. The American Journal of Drug and Alcohol Abuse, 46(6), 671–683. [DOI] [PubMed] [Google Scholar]
  3. Block PR, Thorn BE, Kapoor S, & White J (2017). Pain Catastrophizing, rather than Vital Signs, Associated with Pain Intensity in Patients Presenting to the Emergency Department for Pain. Pain Management Nursing, 18(2), 102–109. 10.1016/j.pmn.2016.12.001 [DOI] [PubMed] [Google Scholar]
  4. Blomqvist K (2003). Older people in persistent pain: Nursing and paramedical staff perceptions and pain management. Journal of Advanced Nursing, 41(6), 575–584. [DOI] [PubMed] [Google Scholar]
  5. Butler MM, Ancona RM, Beauchamp GA, Yamin CK, Winstanley EL, Hart KW, Ruffner AH, Ryan SW, Ryan RJ, & Lindsell CJ (2016). Emergency department prescription opioids as an initial exposure preceding addiction. Annals of Emergency Medicine, 68(2), 202–208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. CDC. (2024, April 23). Understanding the Opioid Overdose Epidemic. Overdose Prevention. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html [Google Scholar]
  7. Creswell JW, & Clark VLP (2017). Designing and conducting mixed methods research. Sage publications. [Google Scholar]
  8. DeVellis RF, & Thorpe CT (2022). Scale development: Theory and applications (5th ed.). Sage publications. [Google Scholar]
  9. Dowell D (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022. MMWR. Recommendations and Reports, 71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Dueñas M, Ojeda B, Salazar A, Mico JA, & Failde I (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 457–467. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Ferketich S (1991). Focus on psychometrics. Aspects of item analysis. Research in Nursing & Health, 14(2), 165–168. 10.1002/nur.4770140211 [DOI] [PubMed] [Google Scholar]
  12. Food and Drug Administration. (2019). FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. FDA Drug Safety Communication. [Google Scholar]
  13. Gaskin DJ, & Richard P (2012). The Economic Costs of Pain in the United States. The Journal of Pain, 13(8), 715–724. 10.1016/j.jpain.2012.03.009 [DOI] [PubMed] [Google Scholar]
  14. Han B, Compton WM, Blanco C, Crane E, Lee J, & Jones CM (2017). Prescription opioid use, misuse, and use disorders in US adults: 2015 National Survey on Drug Use and Health. Annals of Internal Medicine, 167(5), 293–301. [DOI] [PubMed] [Google Scholar]
  15. Henschke N, Kamper SJ, & Maher CG (2015). The epidemiology and economic consequences of pain. Mayo Clinic Proceedings, 90(1), 139–147. [DOI] [PubMed] [Google Scholar]
  16. Lincoln Y, & Guba E (1985). Naturalistic Inquiry Vol. 75 Sage. Beverly Hills, CA. [Google Scholar]
  17. Lynn MR (1986). Determination and quantification of content validity. Nursing Research, 35(6), 382–386. [PubMed] [Google Scholar]
  18. Nahin RL (2015). Estimates of pain prevalence and severity in adults: United States, 2012. The Journal of Pain, 16(8), 769–780. 10.1016/j.jpain.2015.05.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Oliver JE, & Carlson C (2020). Misperceptions about the ‘Opioid Epidemic:’ Exploring the Facts. Pain Management Nursing, 21(1), 100–109. 10.1016/j.pmn.2019.05.004 [DOI] [PubMed] [Google Scholar]
  20. Peterson CH, Peterson NA, & Powell KG (2017). Cognitive interviewing for item development: Validity evidence based on content and response processes. Measurement and Evaluation in Counseling and Development, 50(4), 217–223. [Google Scholar]
  21. Punches BE, Ali AA, Brown JL, Freiermuth CE, Clark AK, & Lyons MS (2021). Opioid-Related Risk Screening Measures for the Emergency Care Setting. Advanced Emergency Nursing Journal, 43(4), 331–343. [DOI] [PubMed] [Google Scholar]
  22. Punches BE, Ancona RM, Freiermuth CE, Brown JL, & Lyons MS (2021). Incidence of opioid use disorder in the year after discharge from an emergency department encounter. Journal of the American College of Emergency Physicians Open, 2(3), e12476. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Punches BE, Brown JL, Soliman S, Johnson KD, Freiermuth CE, Walker Q, Omololu SO, & Lyons MS (2022). Patient Pain Experiences and the Emergency Department Encounter: A Qualitative Analysis. Pain Management Nursing. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Punches BE, Brown JL, Taul NK, Sall HA, Bakas T, Gillespie GL, Martin-Boone JE, Boyer EW, & Lyons MS (2023). Patient motivators to use opioids for acute pain after emergency care. Frontiers in Pain Research, 4. https://www.frontiersin.org/articles/10.3389/fpain.2023.1151704 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Punches BE, Stolz U, Freiermuth CE, Ancona RM, McLean SA, House SL, Beaudoin FL, An X, Stevens JS, Zeng D, Neylan TC, Clifford GD, Jovanovic T, Linnstaedt SD, Germine LT, Bollen KA, Rauch SL, Haran JP, Storrow AB, … Lyons MS (2022). Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study. PLOS ONE, 17(9), e0273378. 10.1371/journal.pone.0273378 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Rikard SM (2023). Chronic Pain Among Adults—United States, 2019–2021. MMWR. Morbidity and Mortality Weekly Report, 72. 10.15585/mmwr.mm7215a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Schwaller F, & Fitzgerald M (2014). The consequences of pain in early life: Injury-induced plasticity in developing pain pathways. European Journal of Neuroscience, 39(3), 344–352. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Smith AM, Chambers WA, Smith WC, Hannaford PC, & Penny K (2001). The impact of chronic pain in the community. Family Practice, 18(3), 292–299. [DOI] [PubMed] [Google Scholar]
  29. Smith, & Hillner BE (2019). The Cost of Pain. JAMA Network Open, 2(4), e191532. 10.1001/jamanetworkopen.2019.1532 [DOI] [PubMed] [Google Scholar]
  30. Stumbo SP, Yarborough BJH, McCarty D, Weisner C, & Green CA (2017). Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement. Journal of Substance Abuse Treatment, 73, 47–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Sullivan MJL, Bishop SR, & Pivik J (1995). The Pain Catastrophizing Scale: Development and validation. Psychological Assessment, 7(4), 524–532. 10.1037/1040-3590.7.4.524 [DOI] [Google Scholar]
  32. Turner HN, Oliver J, Compton P, Matteliano D, Sowicz TJ, Strobbe S, St. Marie B, & Wilson M (2022). Pain Management and Risks Associated With Substance Use: Practice Recommendations. Pain Management Nursing, 23(2), 91–108. 10.1016/j.pmn.2021.11.002 [DOI] [PubMed] [Google Scholar]
  33. US Department of Health and Human Services. (2019). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. Washington, DC: US Department of Health and Human Services. [Google Scholar]
  34. Webster F, Connoy L, Longo R, Ahuja D, Amtmann D, Anderson A, Ashton-James CE, Boyd H, Chambers CT, Cook KF, Cowan P, Crombez G, Feinstein AB, Fuqua A, Gilam G, Jordan I, Mackey SC, Martins E, Martire LM, … Darnall BD (2023). Patient Responses to the Term Pain Catastrophizing: Thematic Analysis of Cross-sectional International Data. The Journal of Pain, 24(2), 356–367. 10.1016/j.jpain.2022.10.001 [DOI] [PMC free article] [PubMed] [Google Scholar]

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