A Qualitative Study of Patient Protection Against Postoperative Opioid Addiction – A Thematic Analysis of Self-Agency

Abstract

Background

Opioids are commonly used following outpatient surgery. However, we understand little about patients’ perspectives and how patients decide on postoperative opioid use. This study seeks to investigate aspects of patients’ thought processes that most impact their decisions.

Methods

We conducted semi-structured interviews with 30 adults undergoing minor elective hand surgery at one tertiary hospital. Narratives were content-coded to arrive at our thematic analysis. We incorporated Bandura’s concept of self-agency to interpret the data and develop a conceptual framework that best explained the implicit theory within participants’ responses.

Results

We found 6 themes under two domains of self-agency. Participants actively sought out protective mechanisms supporting their decision on opioid use, but sometimes did so unconsciously. They would avoid opioids postoperatively because they were “tough” and wanted to evade the risk of addiction as “good citizens.” They conveyed a nuanced safety against addiction because they were “not the kind” to become addicted and because they trusted the surgeons’ prescribing. However, participants felt discouraged by the stigma associated with opioids. Both intentionally and unintentionally, participants integrated a strong sense of self in their decision-making processes.

Conclusions

A robust understanding of how patients choose to take opioids for postoperative pain control is imperative to develop patient-centered strategies to treat the opioid epidemic. Effective opioid reduction policies should consider patients as active agents who negotiate various internal and external influences in their decision-making processes. Surgeons must incorporate patients’ individual goals and perspectives regarding postoperative opioid use to minimize opioid-related harm after surgery.

Postoperative opioid prescribing has been a substantial contributor to the opioid epidemic in the United States, with more than 70,000 opioid-related deaths in 2017 alone.^1,2 The surgical community has established postoperative prescribing guidelines aimed at minimizing prescription sizes and curbing consumption³ on state and federal levels.⁴ These policies have led to a moderate decrease in postoperative opioid prescribing in a few states; implementation of prescribing limits in Massachusetts was associated with a mean of 38 oral morphine equivalents whereas there was not a statistically significant reduction observed in Connecticut.^5-8 Moreover, opioid-related morbidity and mortality remain at alarming levels as the Center for Disease Control reports 47,852 opioid related deaths for 2019.^9-11

To reduce opioid prescribing rates and related harms simultaneously, experts call for patient-centered care plans for pain management because a uniform restriction on prescribing will not solve the epidemic.¹² This recommendation echoes the transition to a model of shared decision-making with open communication, promoting patients’ choice.¹³ However, with regards to opioid prescribing, we do not understand how patients think of postoperative pain control and how they decide on opioid use. More specifically, it is unknown as to what factors patients consider important and how they integrate internal and external influences to make the choice to use opioids. In other words, the intersection of patients’ viewpoints, senses of self, and newly formed opioid reduction policies has yet to be examined. Self-agency, as defined by Albert Bandura, is the proactive commitment to advocate for oneself to accomplish self-set goals, operating through conscious and unconscious mechanisms.¹⁴ Using Bandura’s theory of self-agency can provide a conceptual framework that will help us better understand patient’s decision-making processes for postoperative opioid analgesia.

Given our current limited understanding in how patients choose to take opioids postoperatively, we aim to understand how patients view opioid prescribing after minor procedures. We explore how patients are active players negotiating between internal and external influences in their decisions to take opioids after surgery. Findings from this study will help frame opioid reduction policies from a patient-centered outlook to tailor opioid prescribing toward patients’ needs and preferences regarding postoperative analgesia.

METHODS

Participants/Cohort Selection

We recruited adult patients scheduled to undergo minor elective hand surgery at one tertiary hospital because these procedures are associated with less pain and variable opioid prescribing pattern. Patients were excluded if they had a concomitant diagnosis of substance use disorder or could not sign their own consent. Interviews were conducted in person preoperatively to accurately capture patients’ decision-making process. This study was approved by the study center’s Institutional Review Board (HUM00141703). Written informed consent was obtained.

Interviews

We conducted semi-structured interviews with 30 patients (2/2019–11/2019) to obtain a robust understanding of patients’ decision-making processes regarding postoperative opioid use. A preliminary interview guide was constructed from literature review and expert consultation on important factors related to the choice to take opioids for pain control, including amount of pain relief, side effects, risk of addiction, cost, trust in prescriber, and stigma associated with opioid use.^15-22 We conducted five pilot interviews and revised the interview guide based on content and face validity.

Data Processing and Analysis

Interviews were transcribed verbatim. Coding of the data was completed through an iterative and team approach. First, three investigators independently content-coded the transcripts. We then met to discuss our emergent codes and collectively developed a working codebook. We tested this codebook on three interviews and then met again to revise the codebook to enhance the trustworthiness and credibility of data analysis. NVivo 12 (QSR International, Doncaster, Victoria) was used for storage and coding of the data. Through thematic analysis, we developed a conceptual framework that explained the inherent theory in the data.²³ We followed the Standards for Reporting Qualitative Research guidelines in our explanation of the methods.²⁴

Because our patterned results demonstrated that participants described self-agency, we referred to the self-agency scholarship to interpret our findings on participants’ beliefs, preferences, and thought processes regarding the choice to use opioids postoperatively. Bandura explains that to exercise self-agency is to make deliberate actions to influence one’s life. Self-agents navigate through a complex world with challenges and hazards while making judgments about their own capabilities, anticipating the most-likely consequences of the choice-options in the social and cultural environment. This process of selecting, constructing, regulating, and evaluating courses of action happens both consciously and unconsciously.¹⁴

RESULTS

Based on Bandura’s theory on self-agency,¹⁴ we developed a conceptual framework that best explained the inherent theory in participants’ responses (Figure 1). Throughout our data, we found that participants made a proactive commitment to bring forth their desired outcome: achieving adequate pain control while minimizing the risk of addiction. They consciously thought about how their decisions to use opioids postoperatively would influence their life and future. However, participants revealed that they were not always aware of their deliberate integration of a strong sense of self into their decision-making. Thus, we arrived at two domains of self-agency, “intentional” and “unintentional” via our thematic analysis. Under each domain, we found three themes that were most pervasive in our data (Table 1).

Figure 1.

Conceptual Framework of Self-Agency

This conceptual framework was devised to help explain the inherent theory in participants’ responses we found via thematic analysis: how patients intentionally and unintentionally incorporate a strong sense of self into their decision-making regarding postoperative opioid use.

Table 1.

Thematic Analysis Results – Definitions

Domain/Theme	Definitions
Intentional	Consciously incorporating various internal and external factors of influence into decision-making process
“We are tough people”	Participants reported that they have confidence in their ability to control pain after surgery with minimal opioid use.
“That’s not where I want to go”	Participants expressed their awareness of the risk of addiction with opioid use and that they would avoid addiction to opioids above everything else.
“I want to be a good citizen”	In regards to misuse and abuse of prescription opioids, participants explained that they want to do what is considered right by their moral standards and limit their opioid use.
Unintentional	Unconsciously integrating various internal and external factors of influence into decision-making process
“I am not that kind of person”	On the topic of being exposed to the risk of opioid addiction, participants conveyed that addiction happens to certain types of people, of which they were not.
“Whatever they [physicians] give me is fine”	Participants expressed complete trust in their physicians and believed that an opioid prescription was a surrogate for necessity.
“Like you are a junkie”	Participants felt stigmatized for using opioids, even if they needed them.

Intentional

“We are tough people”

Participants reported high levels of confidence in their ability to control pain after surgery. They strongly believed that they had high pain tolerance, which influenced their decision for using opioids postoperatively.

“I think I was tough or [other] patients are weak… If I set my mind to doing it, I can do it.” (Interview 11)

“Some people could barely handle a sliver in their finger. Some people [pointing at herself] can handle delivering a 10-pound baby.” (Interview 25)

Some participants referred to using mindfulness to manage pain, that they would “suck it up and deal with it” or try to take their minds off the pain. Participants considered their body as an object that they can control, simply by their decision to regard it that way.

“You learn to just ignore it… It’s almost like trying to compartmentalize it…Yes, something hurts, and you just say no, it’s over there. And focus on something else or whatever you’ve got to do.” (Interview 29)

“When you can get into the pain, be present with it instead of resisting and fighting it and take a deep breath, you can get through it. I’ve taught myself to tolerate it. I’ve had six surgeries on my right leg, so I know pain.” (Interview 16)

Many participants expressed high self-efficacy regarding pain control based on previous experiences. They believed that they would be able to “push through” after the upcoming minor elective procedure because they had successfully dealt with pain after much “bigger surgeries” in the past (Table 2).

Table 2.

Thematic Analysis of Intentional Self-agency and Decision to Use Opioids

Theme	Exemplar
“We are tough people”	People need to understand that there’s not a magic pill for your discomfort and I hate to boil it down to something as simple as you’ve got to toughen up a little bit, but that’s kind of my view (Interview 7)
	Based on my own experiences, I have a relatively high pain threshold. Being a mechanic, when you hurt yourself, you live through pain… So these sorts of things, I’ve just learned to become accustomed to, I think… In the end, I think I would endure a little bit of pain just to not take a medication. (Interview 12)
	I just pretty much just deal with the pain… I still have that half a bottle of Oxycodone that’s hanging out at my house. In case I need it. But will probably will never be touched because I probably won’t need it… If I was okay with the shoulder surgery, I’m like alright, it’s going to be fine. (Interview 24)
“That’s not where I want to go”	What I see is people that normally don’t have like addictive traits or don’t become addicted to things like cigarettes or alcohol and things, people that don’t become addicted to that can become addicted to this and not even know. That’s what I’m reading about in the press and the media, how addictive these medications really can be without a person actually knowing. They can sneak up on you, I guess. (Interview 12)
	I’d rather take something else [other than opioids] if it’s available. Just because of the fact, that I just know that there’s a very good chance… you never know. I do know other people that have had surgeries and they did have a problem getting off of them. (Interview 19)
	[working as a paramedic] I’ve administered Narcan. How they sit right up and talk to you, it’s like wow, is that a miracle drug or what? It’s crazy. But, yeah. I’ve seen what it [opioids] does to people and what it does to families, and I don’t want any part of that, I really don’t. (Interview 28)
“I want to be a good citizen”	When I go to the doctor for pain, I ask “what can I do to change my lifestyle to positively impact this, to mitigate this problem?” That’s always my first go to… Before we get to the question about opioids, for me the first question is always what lifestyle changes should I be making so that never even has to be a consideration… I don’t know how many people start there…that’s where we need to start. (Interview 10)
	I think a lot of that other stuff is choices. You don' go out somewhere, say, "Hey, I'm going to look for some cancer today." Yeah, but you can go out and look for opioid pills. It's your choice, right? Right. Where a disease is not your choice. Nobody wants to have those… You can either choose to take that or you can choose to look for some other way to tolerate the pain or the problem that you have… We have to make better choices. (Interview 25)
	I think I’m pretty smart, I’m an educated woman. You know, I have a college degree. I’ve been a teacher. I wasn’t brought up to use drugs unless you-drugs prescriptions-unless you needed them… doctors [will] look at me and my history and say ‘This is a person we don’t have to worry about.’ (Interview 27)

“That’s not where I want to go”

Participants often portrayed direct aversion to opioid addiction. They explained that they know about the dangers of opioid medications from the media, and that they do not want to become addicted.

“I think that they’re not good, there’s a problem in our country… it’s like smoking cigarettes, once you have one, you got to just keep smoking ‘em and addiction is not, I want nothing to do with addiction… You know, you hear about all these people that are addicted to it and they’re dying, and it’s like no that’s not for me, that’s not where I want to go.” (Interview 1)

"I see stuff on TV like how people get addicted to drugs really quick, like just from surgeries… I’m scared… I probably won’t take it [opioids] if it’s prescribed to me.” (Interview 15)

Facing the fact that every opioid use carries a risk of addiction, participants recognized that opioid addiction is a systemic social problem. This led them to make a preemptive action to “avoid things that would be addictive.”

“I have zero desire to try them. People start with them, with no thought that they could become addicted… one day leads into the next. And at some point, it evolved into somebody that relies on them. That, that makes me nervous… the best way, if you really don’t want to happen, just abstain from it.” (Interview 10)

Participants also noted that witnessing how opioid addiction “ruined” people influenced them to decide against opioid use. While many mentioned the media coverage of the opioid epidemic, some shared stories from their personal lives.

“I don’t want to take the risk of depending on it every day and make it a crutch… My dad, I’ve seen how he got messed up on medications and it ruined him. So that was a big learning lesson for me.” (Interview 6)

“Don’t want to use them at all. Don’t want anything to do with them, I’ve seen the devastation that it’s caused so many people. It’s terrible. I see it on a weekly basis, people that have been addicted… Good people are being destroyed by it…. I’d rather take the pain.” (Interview 16)

Participants were aware that opioid addiction can “sneak up” on people who have no intention of abusing drugs, that “it could happen to anyone.” They expressed that they want to avoid opioids at all costs to prevent any exposure to addiction (Table 2).

“I want to be a good citizen”

Participants asserted that they want to act in accordance with their perception of a societal code of ethics. Participants stated that they want to “follow the rules.”

“My friends, they always took their medicines all the time…I don’t want to do that…if I have pain, I am going to take the lower one…I want to be a good citizen.” (Interview 2)

“I tend to be a rule follower… I am very thoughtful about why we have different rules in place. And trying very hard to adhere to them for the common good. I mean many rules exist not just so that you keep yourself safe, but so others are respected or their safety is maintained. So I’m acutely aware of that. Umm, yeah that plays a part [in my decision against opioids].” (Interview 10)

In their decision to “do the right thing,” participants regarded opioid addiction as “wrong” and ethically unacceptable. By incorporating a sense of moral agency, they deliberately made the choice to limit their postoperative opioid use (Table 2).

Unintentional

“I’m not that kind of person”

Participants conveyed that their inherent personality traits protected them from opioid addiction. They expressed that “other” people were getting addicted to opioids, implying a subconscious separation of self from “others” and thus they are not at risk to become addicted to opioids.

“I’ve heard stories… People are going to heroin and things like that after they can’t get pain meds… I don’t think that I have an addictive personality, and I don’t think that’s something I’d ever have to worry about.” (Interview 24)

“Addictive people will find ways to kill themselves, that’s just the way it goes.” (Interview 18)

“Some people are- have addictive personalities and they’re going to find something to get addicted to. There are just some people… you know, they are users.” (Interview 22)

Participants expressed that addiction could never happen to them because they were not “users” or “criminals.” Through not having an “addictive personality,” participants felt protected against addiction and that it would be safe to take opioids postoperatively (Table 3).

Table 3:

Thematic Analysis of Unintentional Self-Agency and Decision to Use Opioids

Theme	Exemplar
“I am not that kind of person”	I’m not that kind of person, you know, using the drugs. (Interview 14)
	I imagine for some people, they like that buzz and they’re just going to tell the doctor they need more. (Interview 19)
	You have to know you. You have to know if you gain dependence on things, and some people are more prone to become dependent on things. (Interview 22)
	I think a lot of people that are abusing the opioids are not taking them because of a physical ailment. They just want to feel good. And that’s an easy way to feel good. (Interview 27)
“Whatever they [physicians] give me is fine”	If the doctor gave me that for my pain, it’s ok. (Interview 2)
	Her [the surgeon] I trust… I’m not going to second guess [the surgeon]. (Interview 3)
	If he [the physician] says that’s the way it’s going to be [about prescribing opioids], then I’ll try that. I’ll try it (Interview 18)
	I’d take them. Whatever he tells me to do is what I’m gonna do. (Interview 21)
“Like you are a junkie”	I feel a stigma everyday…. it’s definitely praised if you are like I’m going to be tough and I’m not going to take any narcotic…like that’s praised. There’s definitely a stigma of anyone who has a narcotic on their chart. I can see that from both ends, as a patient as well as a provider, so that’s something I worry about as a patient, for sure. (Interview 11)
	I went to this doctor. He was new to town, I liked him, he was just starting his practice…And then he began doing addiction medicine. And I stuck with him because I liked him. I had no addiction problems, but he was my doctor. But then I was concerned about the stigma because I was being treated by him. But I still stuck with him until I tried to make an appointment, and they were insisting that I get drug tested. And I said no, I can no longer be treated by this doctor because I can’t be associated with this practice. (Interview 16)
	You are, as an honest patient, as a patient who is not an abuser and never has been, you are kind of made to feel a little bit like if the word painkiller comes up, it’s almost like it’s now so hyper reactive that everybody looks at you like you’re a junkie. (Interview 18)

“Whatever they [physicians] give me is fine”

Participants trusted that their physicians would prescribe specific medications because they were necessary, and thus they would not become addicted. Participants believed physicians would do what was in their best interest.

“I think, according to the surgeon’s experiences…whether because I trust him, he knows, according to his experience with patients. If he prescribes, then he knows that I am really in pain.” (Interview 14)

“Yeah, I figure if he does this on a daily basis, and he thinks that it’s something I’ll need them [opioids] for, then he’ll prescribe them.” (Interview 19)

“He’s a doctor, so I’m assuming [he] wouldn’t just give me something to give it to me. [He] would give it to me just because I need it. I trust doctors, I’m pretty sure he’s good.” (Interview 15)

Participants’ trust in the physician provided a foundation where whatever the physician prescribed should be taken. More specifically, an opioid prescription reaffirmed that the patient would need the opioid postoperatively (Table 3).

“Like you are a junkie”

Despite the trust in their physicians, participants found stigma associated with opioid use as a barrier to use them postoperatively.

“But just for the fact that I know I just don’t want it around. Not that I don’t trust myself, but the fact that I don’t want a prescription out there when I know I have to work. I just don’t want the prescription out there for people to question whether I took it or not.” (Interview 11)

“I feel like you get tracked. Right, like they track your ID, when you get doses [of opioids]. So that’s a deterrent for me, just because I have a federal job. I feel extra nervous about things being associated with me…I don’t want anyone to think I’m abusing these pills.” (Interview 26)

Their fear of being misjudged was substantial. Participants were concerned that even “legitimate” opioid use would lead to negative perceptions that would adversely affect their reputation (Table 3).

DISCUSSION

In our investigation, participants demonstrated the ways they make the decision to use opioids postoperatively by integrating their personal beliefs, previous experiences, and preferences both consciously and unconsciously. The participants incorporated internal and external factors of influence, exercising self-agency in the decision-making about future opioid use. Patients acted as purposive beings on choosing the course of action rather than simply undergoing events as they happen. Self-agents reflect upon their values, strengths, weaknesses, and surroundings, and govern their actions to increase the probability of their desired outcome.¹⁴ In our study, participants decided that their ultimate goal is to avoid opioid addiction as witnessed from the media and their peers. To achieve that outcome, they chose to minimize their opioid use as a form of self-regulation. They made that decision by reflecting on their confidence in managing pain, personal moral standards, and the stigma associated with opioid use in current social climate. Considering the possible scenario of requiring opioid analgesia, participants legitimized their use by reflecting on their self-image as a non-addict and deferring the responsibility to the surgeon. Participants intentionally and unintentionally accounted for factors of influence within themselves and the environment and incorporated them into their decision-making processes.^14,25,26 As such, patients are active agents protecting themselves against opioid addiction, and policies should recognize this to effectively reduce opioid-related harms.

Many experts, including the Opioids After Surgery Workgroup from the American College of Surgeons, advocate for tailoring opioid prescribing to individual patient’s needs and preferences.^27,28 Despite an established need for a patient-centered approach, studies often focus on achieving quantitative outcome results that do not explain patients’ choices. A study found that a decision-aid with information on anticipated amount of pain and risks/benefits of opioid medications brought forth a reduction in the number of pills prescribed despite a wide interquartile range. The study did not investigate how and why patients decided on the number of pills they would like to be prescribed, which would likely further reduce opioid consumption.²⁹ In a qualitative analysis of patients’ perspectives on tapering chronic opioid therapy, patients often used “othering” mechanism to protect themselves against risk of overdose when they decided against tapering.³⁰ Our study focusing on acute postoperative opioid analgesia corroborates this finding in that patients defended their choice to use opioids by this socio-structural concept. Qualitative research provides an opportunity to gain valuable insight into how patients make decisions as demonstrated with our study,³¹ which can act as the foundation to develop patient-centered plans for postoperative pain management.

In efforts to treat the opioid epidemic, medical professionals have sought ways to decrease prescription opioids being diverted into the community.^1,3,5,7 As of December 2019, 36 states have implemented opioid reduction policies to minimize opioid prescriptions for acute pain management.^8,32,33 These guidelines have led to a reduction in postoperative opioid prescribing and subsequent decrease in opioid-related mortality.³⁴ However, experts share a concern that policies decreasing postoperative opioid prescribing will have limited effectiveness because they impose a uniform restriction despite the fact that pain is subjective and there is no “one size fits all” model of pain management.^12,27 To move the needle further, policies need to recognize patients as an important stakeholder in efforts to address the opioid crisis. Our findings show that patients have unconscious and conscious mechanisms involving personal and societal factors of influence that they utilize to protect themselves against opioid addiction. Through harnessing these mechanisms of self-agency within policies, we can develop patient-centered strategies that safely reduce postoperative opioid prescribing without affecting patient satisfaction with pain control.

Our study is limited in a few ways. First, because we found emergent themes in participants’ responses, it is possible that there are other factors that influence patients’ decision-making process on opioid use. As an inherent nature of qualitative studies, our finding of 6 major themes pervasive in our data is by no means a complete survey of all possible factors a patient may consider. However, our explorative investigation provides an in-depth understanding of how patients view and decide on postoperative opioid use and an opportunity to appreciate patients as individual self-agents. Second, our study sustains the inherent selection bias from interviewing patients who volunteered to participate in research. Additionally, the participants were recruited from an institution with a multi-disciplinary team actively working to prevent opioid-related harms in the state.³⁵ With the presence of such efforts in the region, our study participants may have greater knowledge of opioid-related morbidity and thus a more negative stance against opioid use than an average patient undergoing elective surgery. Nevertheless, our findings on how patients act as self-agents making deliberate actions to bring forth the desired outcome is still valid and offers an important opportunity to understand patients as individual human beings exercising control over their actions and outcomes.³¹

This study on how patients perceive postoperative use of opioids and how they choose to take opioid analgesics provides a robust, holistic insight of the process and the inherent framework through which patients make their decisions. We found that patients purposefully integrate their beliefs of self, society, and multiple personal and environmental influences. Our study results further emphasize the need to focus on patients’ individual goals and perspectives regarding postoperative opioid use. Policy makers should recognize patients as self-agents and use a tailored patient-centered approach to implement strategies to reduce opioid-related harms after surgery.