Christopher J. Koenig

Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.

Approximately 10 million U.S. adults are prescribed long-term opioid therapy (LTOT) for chronic pain despite inadequate evidence of long-term benefit and growing evidence of harms (1, 2). No published studies have compared LTOT (>1 year) versus placebo, no opioid, or nonopioid therapies (2). In recent decades, a dramatic increase in the prescription of opioid medications has been accompanied by increases in opioid overdose (3); more than 33000 opioid overdose deaths occurred in 2015 (4). Higher prescribed opioid dose is associated with overdose risk (57) as well as incidence of opioid use disorder, depression, fracture, motor vehicle accident, and suicide (812). Dose reduction or discontinuation, or opioid tapering, may decrease these risks, and expert guidelines recommend tapering when risks outweigh benefits (13, 14). Opioid tapering can be challenging for both patients and clinicians. In routine practice, discontinuation of LTOT is uncommon, ranging from 8% to 35% in prior cohort studies (15, 16). In a survey of patients receiving high-dose opioid medications for chronic pain, nearly half reported wanting to cut down or stop, yet 80% were receiving high-dose opioids 1 year later (17). Among patients who had a nonfatal overdose while being prescribed LTOT, 91% continued use of opioid medications after the overdose (18). There is little evidence to guide clinicians in the process of opioid tapering, especially in primary care settings, where most opioid therapy is prescribed (19, 20). In addition, little is known about the risks and benefits of opioid tapering. Potential risks include withdrawal symptoms, increased pain, and loss to follow-up (20). However, some patients report improvements in function and quality of life after tapering (21). The effects of opioid tapering on patient outcomes have not been systematically reviewed. To address these gaps, we systematically reviewed the evidence on the effectiveness of strategies to reduce or discontinue LTOT prescribed for chronic pain and the effect of dose reduction or discontinuation of LTOT on important patient outcomes. Methods A multidisciplinary team of investigators with expertise in pain and opioid management developed 2 key questions to address the study objectives. These key questions assessed 1) the effectiveness of strategies to reduce or discontinue LTOT, and 2) the effect of dose reduction or discontinuation of LTOT on prespecified patient outcomes of pain severity, pain-related function, quality of life, opioid withdrawal symptoms, substance use, or adverse events. We followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines (22), and the protocol is registered in the PROSPERO database (CRD42015020347). Data Sources and Searches We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through 19 April 2017. We consulted with a research librarian to design a search strategy based on our key questions. We developed a MEDLINE search strategy, which was also applied to other databases, using multiple subject headings (where available) and text words for key concepts of opioids, tapering, and pain. No language or year limits were applied. Within this broader search, we identified potentially relevant systematic reviews and meta-analyses published since 2005. The full electronic search strategy for MEDLINE is presented in Appendix Table 1. We examined reference lists from all included studies and from relevant systematic reviews and published expert guidelines. We also sought input from expert contacts. Records retrieved from each search strategy were organized using the EndNote bibliographic management application (Clarivate Analytics). Appendix Table 1. Ovid MEDLINE Search Strategy Study Selection Two investigators (J.W.F. and H.R.D.) independently reviewed abstracts identified by the search strategy and, when necessary, the full text to determine inclusion. Discrepancies were resolved by consensus. We included studies that involved adults (aged 18 years) who were prescribed LTOT for chronic pain (defined as pain lasting >3 months) and that addressed at least 1 key question. Studies that did not report pain duration were included if the average duration of opioid therapy was more than 3 months. We did not require interventions to involve explicit goals or mandatory conditions of opioid dose reduction. Eligible study designs included randomized trials, cohort studies, casecontrol studies, and case series. We excluded case reports and cross-sectional studies, as well as studies that did not describe the clinical intervention or report patient-level data. We also excluded studies that were not published in English; involved nonhuman participants; addressed only acute, surgical, postoperative, obstetric, or cancer pain; involved only palliative or hospice care; evaluated only illicit or nonmedical use of opioid medications; or addressed only reduction of interventional pain techniques. Data Extraction and Quality Assessment We developed an instrument for data extraction based on prior systematic reviews conducted by the investigators. Three investigators piloted the data extraction instrument using a randomly chosen study, and the results were returned to the pool for formal review. These investigators discussed difficulties with the extraction instrument and reached consensus on minor modifications. Using the finalized instrument, 2 investigators independently extracted data on design, patient sample, setting, interventions, measures, and results from each study. When dose information was not provided by the study, we used a standard algorithm for calculating morphine-equivalent doses (MEDs) of opioid medications (23). Two reviewers independently assessed study quality (risk of bias in individual studies) using criteria developed by the U.S. Preventive Services Task Force (USPSTF), which facilitate rating of study quality as good, fair, or poor (Appendix Table 2). The investigators were blinded to each others ratings, and discrepancies were resolved by consensus or by a third reviewer, if necessary. We did not exclude studies on the basis of quality. Appendix Table 2. USPSTF Quality Rating Criteria for RCTs and Cohort Studies Data Synthesis We assessed the overall quality of the evidence using a method developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group (24). GRADE provides explicit criteria that address study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect to rate the quality of evidence across studies. This method rates the quality of the evidence from high (very confident that the true effect lies close to that of the estimate of effect) to very low (very little confidence in the effect estimate) (Appendix Table 3). All authors iteratively discussed GRADE assessments to achieve consensus. We present systematic review results organized by key question. We did not attempt meta-analyses because of heterogeneity across studies and methodological limitations of the studies. Appendix Table 3. GRADE Criteria for Assessing Quality of Evidence* Role of the Funding Source The Veterans Health Administrations Substance Use Disorder Quality Enhancement Research Initiative funded the study through its Locally Initiated Projects program (QLP 59-046). The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. Results Database searches identified 3522 abstracts, from which 74 studies met criteria for full-text review. Seventeen additional articles were identified from reference lists and expert contacts. Of these 91 studies, 68 articles representing 67 studies met inclusion criteria (2592) (Appendix Figure). These studies included 11 randomized controlled trials, 8 controlled observational studies, and 48 uncontrolled observational studies. Studies presented data on 12546 patients (range, 5 to 1457 patients); 10 studies conducted at a single center (32, 33, 36, 4448, 70, 80) and 2 studies each at 3 centers (37, 49, 50, 52, 63, 64) may have included data on individual participants in more than 1 study. We categorized studies into 8 mutually exclusive intervention types: interdisciplinary pain programs, buprenorphine-assisted dose reduction, behavioral interventions, detoxification, ketamine-assisted dose reduction, acupuncture, other outpatient programs, and other interventional programs (Table 1). Interventions occurred in outpatient settings, inpatient settings, or both in 42, 15, and 10 studies, respectively; 5 studies were conducted in primary care settings. Among 48 studies reporting baseline opioid dose for participants receiving LTOT, the mean daily dose ranged from 29 to 556 mg MED. Study interventions had an objective of opioid discontinuation or dose reduction in 43 and 12 studies, respectively; 12 studies reported on this outcome in secondary or exploratory analyses. Table 1. Effectiveness of Strategies to Reduce or Discontinue LTOT (n= 67 studies) Appendix Figure. Study flow diagram. All included studies assessed the effectiveness of strategies to reduce or discontinue LTOT (key question 1). Study quality as assessed by the USPSTF criteria was good for 3 studies, fair for 13 studies, and poor for 51 studies. The GRADE quality of evidence to address the effectiveness of strategies to reduce or discontinue LTOT was very low (Table 2; Appendix Table 4). In the remainder of this section, we highlight results from good- and fair-quality studies. Descriptions of all included studies are available in Appendix Table 5. Table 2. Summary of Findings and Quality-of-Evidence Assessment Appendix Table 4. Derivation of GRADE Score* Appendix Table 5. Characteristics of Studies Evaluating the Effectiveness of Strategies to Reduce or Discontinue LTOT for Chronic Pain Thirty-on

Passing the Baton: A Grounded Practical Theory of Handoff Communication Between Multidisciplinary Providers in Two Department of Veterans Affairs Outpatient Settings

ABSTRACTBACKGROUNDHandoffs are communication processes that enact the transfer of responsibility between providers across clinical settings. Prior research on handoff communication has focused on inpatient settings between provider teams and has emphasized patient safety. This study examines handoff communication within multidisciplinary provider teams in two outpatient settings.OBJECTIVETo conduct an exploratory study that describes handoff communication among multidisciplinary providers, to develop a theory-driven descriptive framework for outpatient handoffs, and to evaluate the strengths and weaknesses of different handoff types.DESIGN & SETTINGQualitative, in-depth, semi-structured interviews with 31 primary care, mental health, and social work providers in two Department of Veterans Affairs (VA) Medical Center outpatient clinics.APPROACHAudio-recorded interviews were transcribed and analyzed using Grounded Practical Theory to develop a theoretical model of and a descriptive framework for handoff communication among multidisciplinary providers.RESULTSMultidisciplinary providers reported that handoff decisions across settings were made spontaneously and without clear guidelines. Two situated values, clinic efficiency and patient-centeredness, shaped multidisciplinary providers’ handoff decisions. Providers reported three handoff techniques along a continuum: the electronic handoff, which was the most clinically efficient; the provider-to-provider handoff, which balanced clinic efficiency and patient-centeredness; and the collaborative handoff, which was the most patient-centered. Providers described handoff choice as a practical response to manage constituent features of clinic efficiency (time, space, medium of communication) and patient-centeredness (information continuity, management continuity, relational continuity, and social interaction). We present a theoretical and descriptive framework to help providers evaluate differential handoff use, reflect on situated values guiding clinic communication, and guide future research.CONCLUSIONSHandoff communication reflected multidisciplinary providers’ efforts to balance clinic efficiency with patient-centeredness within the constraints of day-to-day clinical practice. Evaluating the strengths and weaknesses among alternative handoff options may enhance multidisciplinary provider handoff decision-making and may contribute to increased coordination and continuity of care across outpatient settings.

Managing Patient-centered Communication across the Type 2 Diabetes Illness Trajectory: A Grounded Practical Theory of Interactional Sensitivity

This article uses the theoretical and methodological framework of Grounded Practical Theory (GPT) to provide a lens for analyzing and interpreting discourse as a situated form of social action in routine Type 2 diabetes visits. Drawing on a total data-set of 400 audio-recorded routine visits, we randomly selected 55 visits for qualitative analysis. In this article, we use Conversation Analysis to document communication techniques, which we in turn use as evidence to ground our claims within the GPT framework. We use two single cases of interaction to analyze communication techniques physicians use when recommending a change from oral medication to insulin. We argue treatment intensification is a key moment in health communication to reflect about patient centeredness because physicians can find themselves in an interactional dilemma: while insulin may effectively help control unstable disease, an insulin recommendation may simultaneously counter patient values and treatment preferences. Our analysis suggests that physicians use what we call interactional sensitivity to balance medical need and patient preferences when making medical decisions by tailoring their communication according to the local situation and the patients larger illness trajectory. We propose that interactional sensitivity is a type of communication work and a quality of patient-centered communication characterized by the theoretical relationship between tailoring communication to the contingencies of the local interaction and the global illness trajectory. Overall, this article contributes to health communication scholarship by proposing a normative model for reflecting on how physicians negotiate challenging interactions with patients during routine chronic illness visits.

Negotiating complementary and alternative medicine use in primary care visits with older patients

OBJECTIVE To empirically investigate the ways in which patients and providers discuss Complementary and Alternative Medicine (CAM) treatment in primary care visits. METHODS Audio recordings from visits between 256 adult patients aged 50 years and older and 28 primary care physicians were transcribed and analyzed using discourse analysis, an empirical sociolinguistic methodology focusing on how language is used to negotiate meaning. RESULTS Discussion about CAM occurred 128 times in 82 of 256 visits (32.0%). The most frequently discussed CAM modalities were non-vitamin, non-mineral supplements and massage. Three physician-patient interactions were analyzed turn-by-turn to demonstrate negotiations about CAM use. Patients raised CAM discussions to seek physician expertise about treatments, and physicians adopted a range of responses along a continuum that included encouragement, neutrality, and discouragement. Despite differential knowledge about CAM treatments, physicians helped patients assess the risks and benefits of CAM treatments and made recommendations based on patient preferences for treatment. CONCLUSION Regardless of a physicians stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions. PRACTICE IMPLICATIONS Providers do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use.

The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter

BackgroundShared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.MethodsBased on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.ResultsThree iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.ConclusionsThe process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Performance of an online translation tool when applied to patient educational material

BACKGROUND Language barriers may prevent clinicians from tailoring patient educational material to the needs of individuals with limited English proficiency. Online translation tools could fill this gap, but their accuracy is unknown. We evaluated the accuracy of an online translation tool for patient educational material. METHODS We selected 45 sentences from a pamphlet available in both English and Spanish, and translated it into Spanish using GoogleTranslate™ (GT). Three bilingual Spanish speakers then performed a blinded evaluation on these 45 sentences, comparing GT-translated sentences to those translated professionally, along four domains: fluency (grammatical correctness), adequacy (information preservation), meaning (connotation maintenance), and severity (perceived dangerousness of an error if present). In addition, evaluators indicated whether they had a preference for either the GT-translated or professionally translated sentences. RESULTS The GT-translated sentences had significantly lower fluency scores compared to the professional translation (3.4 vs. 4.7, P < 0.001), but similar adequacy (4.2 vs. 4.5, P = 0.19) and meaning (4.5 vs. 4.8, P = 0.29) scores. The GT-translated sentences were more likely to have any error (39% vs. 22%, P = 0.05), but not statistically more likely to have a severe error (4% vs. 2%, P = 0.61). Evaluators preferred the professional translation for complex sentences, but not for simple ones. DISCUSSION When applied to patient educational material, GT performed comparably to professional human translation in terms of preserving information and meaning, though it was slightly worse in preserving grammar. In situations where professional human translations are unavailable or impractical, online translation may someday fill an important niche.

Veterans’ Perspectives on the Psychosocial Impact of Killing in War

Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It describes the consequences that veterans identify as most relevant in their lives, including postwar changes in emotions, cognitions, relationships, and identity. Furthermore, it illustrates the linked psychological and social dimensions of those consequences—namely, how the impact of killing in war is rooted in the unique perspectives, actions, and experiences of individual veterans, as well as the social worlds they confront upon returning from war. We found that, for many veterans, killing provokes a moral conflict with a lasting impact on their sense of self, spirituality, and relationships with others. In working with combat veterans, mental health professionals should be sensitive to the complexities of discussing killing and attuned to the psychosocial challenges veterans may face after taking a life in war.

The Process of Interactional Sensitivity Coding in Health Care: Conceptually and Operationally Defining Patient-Centered Communication

This study aimed to develop a process for measuring sensitivity in provider–patient interactions to better understand patient-centered communication. The authors developed the Process of Interactional Sensitivity Coding in Healthcare (PISCH) by incorporating a multimethod investigation into conversations between physicians and their patients with type 2 diabetes. The PISCH was then applied and assessed for its reliability across the unitization of interactions, the activities that were reflected, and the characteristics of patient-centered interactional sensitivity that were observed within each unit. In most cases, the PISCH resulted in reliable analysis of the interactions, but a few key areas (shared decision making, enabling self-management, and responding to emotion) were not reliably assessed. Implications of the test of this coding scheme include the expansion of the theoretical notion of interactional sensitivity to the health care context, rigorous implementation of a multimethod measurement development that relied on qualitative and quantitative assessments, and important future questions about the role of communication concepts in future interpersonal research.

Multitasking and Silent Electronic Health Record Use in Ambulatory Visits

Author(s): Ratanawongsa, Neda; Matta, George Y; Lyles, Courtney R; Koenig, Christopher J; Barton, Jennifer L; Yu, Kaylin; Schillinger, Dean

How does culture influence preventive service utilisation among Asian Indians living in the USA? A qualitative study

Asian Indians are one of the fastest growing immigrant groups in the USA and are at high risk for preventable chronic diseases, such as diabetes and cardiovascular disease. We describe the cultural practices of Asian Indians living in the USA to build a theory of health seeking behaviour for preventive healthcare services. We conducted in-depth qualitative, semi-structured interviews with 21 Asian Indians seen at two outpatient clinics in the San Francisco Bay Area. Using the Constructionist Grounded Theory, we show that participants typically use primary healthcare services for urgent health problems and had been unfamiliar with routine care for disease prevention when immigrating to the USA. Participants deviated from this pattern during culturally significant life course events, such as marriage or childbirth and in response to the concerns of family members, local social network members, and primary care service providers during medical visits for urgent illnesses.