Table 3.
Characteristics of 48 Discussions about Opioid Analgesics
| Category | n (%) | Examples | |
|---|---|---|---|
| Empathy | |||
| Provider verbally acknowledged pain | 20 (42%) | D: I mean, I’m sorry that all these things hurt. | |
| P: mhm | |||
| D: um And we’ll try to work on pain medicine and maybe, eventually other things- | |||
| P: mhm | |||
| D: to get better, better improvement like if we can get your knee really treated properly then maybe, I know- | |||
| P: I’ll dance again. | |||
| _______ | |||
| P: I still need me some. Can I get a few? | |||
| D: What do you use the Vicoden for? | |||
| P, For my legs and stuff | |||
| D: Oh, for your arthritis and your knees….You’ve been evaluated and you have bad osteoarthritis in the knee – | |||
| P: Yeah, that’s why | |||
| D: And that is painful and I know you can’t take Motrin so. | |||
| P: No, that pill is bad for my kidneys. | |||
| D: Right, so the Vicoden is fine. | |||
| P: Yeah, they help me. | |||
| D: Alright | |||
| Provider did not verbally acknowledge pain (‘missed opportunity for empathy’) | 28 (58%) | P: I mean it wakes me up in the middle of the night cryin’ it hurts so bad. | |
| PC: she walk in I help her put her underwear on and stuff, she can’t take a shower it hurts so bad sometimes and stuff. | |||
| D: Well, um yeah, I’m gonna send you to the bone doctors and and we’ll be able to get the Oxycontin based on this new diagnosis, now that we have the MRI resolved. | |||
| P: OK | |||
| _______ | |||
| P: The pain in the shoe is killing me. It won’t leave me alone. | |||
| D: Say Ahh. | |||
| P: Ahh. | |||
| D: Lift up your tongue…When was your last dentist appointment? | |||
| Concern about Opioid Use | |||
| Provider verbalized concern about opioids or suggests reduction in use | 22 (46%) | D: And now I also want you to think about coming, backing off that a little bit if you can. | |
| P: Yeah well I can't do everything all at once. | |||
| D: No I know but it's just a long-term goal, okay? | |||
| P: That's a long-term goal. | |||
| ________ | |||
| P:“I can’t just stop takin’ ‘em.” | |||
| D: “Why?” | |||
| P: “What do you want me to do, go crazy?” | |||
| D: “You could slow down. Say go from four to three.” | |||
| ________ | |||
| D: My feeling is- | |||
| P: you know how I feel. | |||
| D: you know how I feel | |||
| P: Yeah, I know how you feel. | |||
| D: And you know why I feel that way. | |||
| P: That’s how I’m gonna get drugs, okay. | |||
| D: And you know it’s not that I don’t trust you, it’s your illness that I’m concerned about and we know that when people start to use again, that they take poor, worse care, I should say, of their HIV and I don’t want that. | |||
| Alternative Treatments | |||
| % Provider suggested an alternative therapy | 23 (48%) | D: I will give you some ibuprofen … if that’s not controlling it then you need to let me know, we can switch around to another and you can try something else and see if that works better … | |
| ______ | |||
| D: So, well you’re gonna see a neurologist…We can start you on something. What you are describing sounds somewhat like neuropathy. We can start you on some Neurontin if you want. | |||
| P: What’s that? | |||
| D: That’s something that works on neuropathy, it works on the nerves actually. It’s a medication. | |||
| P: What about my shoulder? | |||
| D: You can have some Naprosyn for it and some patches, like lidocaine on top if you want. | |||
| P: What’s that? | |||
| D: That’s just to numb it. You know like they give you something to numb your tooth and that’s the same thing. You can try that. Let’s start with that. Let’s try that and then I would want to get an MRI of your shoulder. | |||
| Conflict | |||
| Conflict or difference of opinion regarding pain treatment | 12 (25%) | P: You know, I don't even want to come here anymore. I wanna – I wanna – I wanna change it. I wanna – I'm tired of this thing‥…Now all of a sudden I'm not on medications? I been with you for the – for ten years -- | |
| D: [Name of patient], you haven't been on meds – I haven’t given you any meds. | |||
| P: Ma'am, no, that's a lie, that's not true Miss [name of doctor]. I'm not an idiot and I'm and then -- | |||
| D: Well I don't know how you got them -- | |||
| P: And then you people keep treating me like an idiot here. | |||
| D: Because – look, look, look -- | |||
| P: Now they keep telling me, "Oh, you don't take Oxycontin." "What do you mean?" I been Oxycontin, I'm on Oxycontin for two years because you didn't give it to me for two prescriptions of fifteen days, all of a sudden now I never take that medication. The other medication is no good, it doesn't work. My feet are still inflamed, I'm sick of feeling like that. You know, come on, this is ridiculous. I need to get to a place where I need to get my stuff taken care of. I can't keep like this because everybody wants to change me, or cuz you feel I'm doin' drugs or whatever you don't want to give me medications. I don't want to hear that. It's not fair to me. | |||
| D: Okay. There are two different issues here, [name of patient]. | |||
| P: No there's not. There's no different issues. | |||
| Prescribing Opiods | |||
| Prescribe opioid, sometimes reluctantly or for a limited time | 24 (50%) | D: I’ll give you a little bit of oxycodone but you need to get off that, okay? | |
| ________ | |||
| D: One more month of Vicodins, all right? And then, …you know I don't want you to be in pain, right? I am just very wary of you getting back up on your Vicodins again. | |||
| Changing Topic | |||
| End discussion by changing topic, sometimes abruptly | 36 (75%) | P:“The end of the night, where I sleep, my back hurt me real bad…that’s when I take the Percocet and…” | |
| D:“Let me ask a quick question for ya” | |||
| P:“Uh Huh” | |||
| D:“When was the last time you had a flu shot? | |||
| _________ | |||
| D: I want you to consider going to the pain thing. | |||
| P: Uh uh. I just want my regular prescription what you all been giving me every month. And I -- | |||
| D: Your last hepatitis C viral load was 1,560,000. | |||
| Shifting Decision Making | |||
| Defer decision making to other care providers | 5 (10%) | D: Yeah – we don't give – I told you they don't pay for Oxycontin and we don't give Oxycontin anymore. | |
| P: Ma'am I'll pay for it myself. I don't need you guys to pay for it. | |||
| D: No, I can't – I – you know, that goes through Dr. [name of doctor] to – the neurologist. | |||
| P: No, other people take it – I don't understand what the problem is. | |||
| __________ | |||
| P: When they gonna be able to, I can’t get me no Vicoden. | |||
| D: What do you use – | |||
| P: I used to get ‘em until what happened. | |||
| D: Well we deferred the prescription of pain medications to the primary doctors – | |||
| P: Them guys full of shit | |||
| D: And we’ll concentrate on the HIV. | |||
P=Patient; D=Doctor: PC=Patient’s Companion