Narratives Are Useful Strategies for Overcoming Challenges in Risk Communication

The opioid overdose epidemic is an ongoing public health crisis in the United States, initially fueled, in part, by prescription opioid use for pain management. The Centers for Disease Control and Prevention reported more than 14 000 deaths caused by overdoses involving prescription opioids in 2019, making up more than 28% of all opioid overdose deaths.¹ Prescription opioids are still commonly used, either alone or in combination with other pain management drugs, for the treatment of acute pain. The current standard for communicating risk is not always effective at impacting an individual’s decision-making regarding prescribed opioid use, raising the need to evaluate additional communication strategies.

In “A Multicentered Randomized Controlled Trial Comparing the Effectiveness of Pain Treatment Communication Tools in Emergency Department Patients with Back Pain or Kidney Stone Pain,” Meisel et al. (p. S45) sought to evaluate effective means of communicating benefits and risks of opioid use for managing acute kidney stone or back pain in an emergency department. Participants were presented with either a personalized probabilistic risk tool (PRT), the PRT plus video narratives of real patients, or standard written instructions on analgesics. The study found that patients presented with the narrative and PRT had a lower preference for opioids than patients receiving written instructions. However, communication type did not affect patterns in opioid use up to 90 days after the emergency department visit. Patients rated as high risk in the group receiving narratives and PRTs were more likely to recall their individual risks. Furthermore, the narrative group reported higher initial satisfaction with their treatment and higher scores on the American Pain Society questionnaire asking about participation in decision-making regarding pain treatment. Together, these findings demonstrate that communication strategies involving narratives have the potential to be effective tools in a patient’s decision-making regarding pain management.

OVERCOMING CHALLENGES IN RISK COMMUNICATION

Several findings from this study stood out and are further discussed here. First, narratives are a useful strategy for overcoming challenges in risk communication. Second, patients presented with narratives reported increased scores in one measure of shared decision-making, which may have implications for their healing process and future experiences with decisions regarding health care. Finally, a greater understanding of risk using narratives may not change patients’ patterns of opioid use and is worth further exploration.

Effective communication on the risks and benefits of treatments is vital for decision-making in clinical settings; yet, it remains a challenge. Narratives are known to be powerful communication tools³ and represent a useful strategy for risk communication. The narratives used in this study ranged from individual experiences with opioid use after surgery and individuals’ decision-making processes regarding opioid use to the experiences of grieving parents after the death of a child because of an opioid overdose. Matching a real person to the benefits and risks associated with opioid use may help humanize the experience and add an element of emotion that is not obtained from a fact sheet. In addition, video narratives may appeal to different learning styles and reach people with low literacy, as noted in the study. Expanding the narratives to include a large variety of experiences, backgrounds, and languages that match those of the participants has been shown to be particularly persuasive^2,3 and may have a greater impact on recall and understanding of the risks associated with opioid use.

Effective communication through narratives may be particularly useful by improving the patient experience in a clinical setting through increased participation in medical decision-making. The use of PRTs demonstrated that risks change depending on background and circumstances and can be influenced by factors not necessarily known to the provider, such as trauma and family history. Clear communication between providers and patients regarding patients’ health allows both parties to understand the factors that play into the patients’ risks and decide the best treatment plan. Shared decision-making between patients and providers can also impact their adherence to prescribed treatments.⁴ The benefits of shared decision-making may extend beyond treatment adherence and result in increased trust in clinicians regarding future health decisions.⁵ It is important to note that although there was an increase in decision-making scores on the American Pain Society questionnaire, no statistically significant differences were found between groups in an additional measure of shared decision-making (collaboRATE).

Although the use of narratives resulted in a decrease in opioid preference, they had no effect on opioid use over time. If the goal of narrative use and PRTs is to decrease long-term opioid use, a single presentation of the narratives and PRTs may not be effective. Communication on the risks and decisions in pain management at time points beyond the initial visit to the emergency department may have an impact on patients’ using opioids for prolonged periods of time. A second question is whether the use of multiple pain management pharmacotherapies plays into outcomes such as patient satisfaction and long-term opioid use. The study noted that the patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) alone, opioids alone, NSAIDs and opioids, or no pain medication. It would be interesting to determine if there were differences in risk recall, opioid use, and patient satisfaction between the opioid-alone and the opioid and NSAIDs group.

NARRATIVES AND CANCER

Expanding the use of narratives across pain conditions to facilitate shared decision-making may prove useful in cancer-related pain. The experiences of a patient with cancer with pain vary, depending on factors such as disease stage and treatment; thus, practices in prescribing opioids to these patients should also differ. Opioids may be beneficial for acute pain related to surgery or cancer progression; however, patients may be weaned off of opioids if the treatment is successful. In addition, opioids are not recommended for patients with chemotherapy-induced peripheral neuropathy.⁶ A greater understanding of the risks associated with opioid use through narratives that match the conditions seen in patients with cancer could help these patients understand when opioid use is appropriate and work with their providers to assess the best strategies to manage their pain. There is also a risk of underprescribing opioids for patients experiencing pain during end-stage cancer. Research has shown that opioid prescriptions from 2007 to 2017 among patients with cancer within 1 month of hospice care or death decreased; yet, pain-related emergency visits increased, suggesting that the opioids are not being replaced with other effective forms of pain management.⁷ Incorporating narrative tools that facilitate feelings of shared decision-making into end-of-life care may allow patients to effectively advocate for better pain management strategies. Future research should examine whether the use of narratives across different cancer pain states impacts opioid-prescribing practices and provides better outcomes for pain management.