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Discussion
Patient needs for pain relief, an explanation of their symptoms and help to improve or maintain their quality of life were often unmet amongst those we interviewed. All GPs expressed dissatisfaction with some aspect of their approach to chronic pain management, be it with their own consultation skills, the limitations of the drugs they were prescribing, or the constraints of the clinical environment. The accounts in this study have highlighted problematic long-term prescribing, but we recognise that there will be many clinical encounters involving the non-problematic management of patients well controlled on a stable opioid prescription that is appropriate to their condition. We encountered a now-familiar story of dissatisfaction on both sides – patients experiencing repeated consultations that did not meet their needs, and GPs describing frustration with this state of affairs and yet with no clear idea of how to break out of it.
The resulting transaction was an impasse with the features of failure of satisfactory management of a long-term condition. The most striking manifestation of this failure was that both patients and clinicians recognised that they did not share a mutually-agreed plan of action, instead negotiating change through a series of short-term, often emotionally-charged consultations.
Three other themes in the clinical encounter confirm this formulation. First is an awareness of failure to resolve the tension between patient-centredness and evidence-based practice, generating uncertainty about responsibility for day-to-day symptom management. Second is ambivalence about the place of relational continuity – valued in one way to maintain consistency but also seen as contributing to the nature of the impasse. And finally there is an awareness of the lack of mutuality in the relationship – things not being understood, or if understood then not said: this is an important deficit given the centrality of trust to long-term care.
Given these circumstances, the continued prescription of an opioid can seem like the least-worst option for both parties, but becomes the main – if unintended – mechanism for preventing resolution. It creates an atmosphere of pseudo-mutuality and pseudo-control for both parties – the patient has got what they requested and the doctor has acted in role. The medication can reduce symptoms of distress and anxiety, at least transiently. And the act of giving and receiving the prescription can look like active engagement with the main dilemma but is in fact a form of avoidance, one of a number of strategies employed as means of not getting uncomfortable uncertainties and differences of opinion into the open.
Strengths and Limitations
We studied a sample of patients which may be atypical (more women; mainly prescribed strong opioids) although we did achieve some balance in trajectories. An alternative of asking GPs to select patients could have resulted in a different selection bias. There was likely under-representation of patients from black and minority ethnic groups. We also studied self-selected GPs who may have had greater interest in this issue, although our invitation specifically sought GPs with a range of interests and only a minority in our sample self-declared interests in pain. We studied GPs and patients in one geographical area within the UK National Health Service; however, similar concerns about prescribing decisions and actions are emerging elsewhere in other healthcare systems. Our understanding of prescribing trajectories was based upon subjective accounts of diagnoses and opioid prescription strength and duration, with discrepancies between prescription records and what patients reported taking, although this is common for many prescribed medications.
Comparisons With Existing Literature
Our patient accounts are broadly consistent with those in a recent meta-ethnography of qualitative studies, particularly in the 'adversarial struggle' patients faced in constructing explanations for their symptoms and negotiating the healthcare system. Similarly, GPs would recognise such experiences and have further concerns around adverse effects, addiction, misuse and probity of prescribing. Variations in reported practice have been linked to training in pain management and experience, including adverse events.
Esquibel and Borkan also compared the experiences of primary care physicians and patients in one US Family Care Center, separately interviewing each in 21 dyads. There were many similarities to our findings, such as challenges in legitimising non-objective pain and physician feelings of inadequacy as care providers in treating pain. However, the problems we uncovered with the lack of management plans and discontinuity were less apparent, probably because all patients held contracts for opioid treatment of chronic pain and the physicians knew and nominated each patient interviewed.
Implications for Research and Practice
Our findings suggest that GPs would be receptive to guidance on and support with the management of chronic, non-cancer pain and opioid prescribing. The content of educational interventions should draw upon existing good practice guidance, and preventive strategies suggested by our study. These include: early recognition of at-risk patients who might benefit from more anticipatory and structured management; checking patient expectations of opioid therapy and advising on their limited benefit in chronic pain; and reconsidering strategies of prescribing opioids to establish false therapeutic relationships.
For those already prescribed opioids, our findings indicate the need for a systematic approach to each patient that is not negotiated 'on the hoof' during individual consultations. A first step in primary care is practice-level reviewing of prescribing and potential non-pharmacological approaches to chronic pain management; a plan can then be formulated that is not over-influenced by the short-term consultation-by-consultation approach. Consistency in delivering this plan requires clear communication, including agreement of a shared aim within the general practice team and informational continuity for individual patients. At the same time, it cannot be assumed that relational continuity will work in the patient's best interests, given the risks of perpetuation of ineffective clinical strategies. Therefore, practices should consider matching patients with more problematic issues to GPs with greater skills in pain management. Subsequent consultations require open and explicit discussions of the element of management plans that is doctor-driven, including the possibility of non-negotiated reduction or stopping of opioids, to establish the boundaries of clinical responsibility for prescribing and reduce some of the mistrust due to lack of openness about plans.
General practice strategies to prevent or manage problematic opioid prescribing also need support from commissioned specialist services which should include non-drug interventions. There are transferable elements of collaborative care approaches, effective for other long term conditions, which enable active communication between GPs and specialists to monitor and plan patient care. However, there is a need for rigorously developed and evaluated interventions to change GPs' chronic pain management and prescribing behaviours.
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