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Original Contribution  |   December 2019
Adapting the Social-Ecological Framework for Chronic Pain Management and Successful Opioid Tapering
Author Notes
  • From the Solano County Health and Social Services (Drs Wu, Stacey, and Matyas and Mr Modrich); and the Primary Care Department at Touro University College of Osteopathic Medicine in Vallejo (Dr Simon and Shubrook). Conclusions presented in this paper are that of the authors and do not necessarily reflect the official views of the authors’ affiliated institutions. A version of Table 1 was used in poster presentations at the California Conference of Local Health Officers Spring meeting and the annual meeting of the American College of Preventive Medicine in May 2018.  
  • Financial Disclosures: The leadership at Partnership HealthPlan of California assisted with the initial study design, provided the necessary claims data for analysis, and supported the decision to disseminate the findings and submit for publication.  
  • Support: The study was conducted as part of Dr Wu's training in preventive medicine, which was funded by the Health Services Resources Administration Preventive Medicine Residency with Integrative Health Care Training grant and the Centers for Disease Control and Prevention Preventive Health and Health Services Block grant.  
  •  *Address correspondence to Christine A. Wu, MD, MPH, Solano County Public Health, 275 Beck Ave MS-5-240, Fairfield, CA 94533-6804. Email: cawu@solanocounty.com
     
Article Information
Pain Management/Palliative Care / Professional Issues / Opioids
Original Contribution   |   December 2019
Adapting the Social-Ecological Framework for Chronic Pain Management and Successful Opioid Tapering
The Journal of the American Osteopathic Association, December 2019, Vol. 119, 793-801. doi:https://doi.org/10.7556/jaoa.2019.132
The Journal of the American Osteopathic Association, December 2019, Vol. 119, 793-801. doi:https://doi.org/10.7556/jaoa.2019.132
Abstract

Context: In 2015, Solano County's Medi-Cal insurer implemented a new policy to taper patients using high-dose opioids (≥120-mg morphine equivalent dose) to a safer level to follow best practices to address the opioid epidemic.

Objective: To evaluate the effect of the 2015 Solano County Medi-Cal prescribing policy, gain insight into the patient experience of undergoing opioid tapering, and generate hypotheses for further study.

Methods: Using a case series approach, researchers completed medical record reviews of affiliated clinical records, Solano County Vital Statistics, and California's prescription monitoring program in 2018. After exclusions, eligible patients were asked to participate in a comprehensive qualitative interview.

Results: Medical record reviews of 38 patients found the majority were not using opioids using them at a morphine equivalent dose of 90 mg or less. The reviews also found that mental illness and obesity prevalence were higher than Solano county baseline levels. Furthermore, naloxone was not prescribed to any of the 38 patients. Researchers reached 15 of the 38 patients by phone, and ultimately 6 completed the interview process. Themes and emergent concepts from interviews identified a lack of empathetic connection with health care professionals, poor understanding of overdose risks, persistent pain, and confirmed naloxone underuse.

Conclusion: Safer prescribing policies may take multiple years to fully implement and need to be employed across the jurisdiction to minimize doctor-shopping and adverse effects on patients with chronic pain. Approaching pain management through the social-ecological model can address potential root causes of addiction and establish a framework for doctors to provide compassionate care, community leadership, and advocacy for these patients.

The opioid epidemic has caused an unprecedented death toll nationally, surpassing prior leading causes of death for nearly all age groups.1 The epidemic is a major contributor to the decline in US life expectancies for the second year in a row.2 In 2016, the Centers for Disease Control and Prevention (CDC) released recommendations to improve the safety of opioids when prescribed for chronic pain, which is defined as the experience of pain for 3 months or more or beyond the normal time for tissue healing.3 These guidelines included informing prescribers to exercise extreme caution when prescribing above a morphine equivalent dose (MED) of 90 mg.3 The MED is a person's total daily intake of all opioid medications and helps indicate potential risk for serious complications of opioid overdose. 
In March 2015, as part of their Managing Pain Safely (MPS) program, Solano County's Medi-Cal insurer Partnership HealthPlan of California (Partnership), implemented a new policy that asked primary care health care professionals (HCPs) to taper down the doses for patients who used high-dose opioids (HDOs; MED ≥120 mg) to a “safer” level or to discontinuation.4 Prior to the release of the CDC's 2016 guidelines, studies had shown evidence of benefit with using an MED of 120 mg as an indication for HCPs to increase monitoring of patients.5 However, opioid tapering protocols are varied,6 and pressures to adopt new policies quickly may have unforeseen consequences on the health and well-being of people targeted to benefit from such reforms. The primary objective of this study was to evaluate the effect of this prescribing policy, with secondary aims to gain insight into the patient experience of undergoing opioid tapering and to generate hypotheses for further study. 
Methods
Study Design
Researchers selected a case series approach to evaluate the MPS program. This study design is useful for characterization of a known study population and aids in analyzing specific aspects of health care systems, discovering novel effects, and generating testable hypotheses.7,8 The study was approved by Touro University's institutional review board in Vallejo, California, which is the board used for Solano County Public Health research endeavors. 
Study Population
Partnership data identified 16,322 adult Medi-Cal patients capitated to Solano County Family Health Services on March 1, 2015. A total of 252 patients were identified as being at highest risk: 206 patients who used opioids for 3 consecutive months or more and 46 patients who used HDOs (MED≥120 mg). Researchers followed up with these patients for successful program completion for approximately 30 months. Of the 46 patients using HDOs, initial medical record reviews found that 3 patients had died of non–opioid-related causes, another 3 patients had cancer or another ineligibility-for-weaning diagnosis, and 2 did not have accessible records in the county or state systems. Researchers performed comprehensive medical record reviews for all eligible patients and used claims data, county and associated health systems’ electronic health records, Solano County Vital Statistics, and the state's prescription monitoring program, the Controlled Substances Utilization Review and Evaluation System (CURES). Researchers also calculated each patient's MED per CDC guidelines.3 To validate information gathered by medical record reviews, researchers attempted to contact all eligible patients to offer participation in the interview portion of the study and used the inclusion criteria of speaking English and being older than 18 years. If patients had cancer, were receiving palliative care, or if they could not be reached by phone after a specified, approved calling protocol, they were excluded. 
Data Collection
For the in-depth, semistructured interviews, researchers developed 36 open-ended, conditional, or Likert-style questions for either in-person or telephone administration. For consistency, throughout the first 3 months of 2018, the primary investigator (C.A.W.) conducted, recorded, and transcribed all interviews, which were approximately 45 minutes each. Interviews were conducted to validate information gleaned from medical record reviews and to obtain additional information not available in medical records. Researchers obtained free and informed consent from all study participants and provided copies of study information and a $25 gift card incentive after completion of the interview. 
Data Analysis
Medical record reviews were conducted and verified by the primary investigator with help from 2 team members (A.J.S. and M.A.M.). For the qualitative analyses of interviews, in keeping with the Straussian grounded theory approach9 and accepted qualitative research methods,10,11 a team of 3 interdisciplinary team members (C.A.W., A.J.S., and M.A.M.) each coded transcriptions independently. These initial codes were then classified under broader indicators in an iterative process to identify recurring themes. Observations were then reclassified under recurrent themes. To further inform developing theories, the primary investigator conducted key informant interviews with pain specialists outside of Solano County to maintain interview participant confidentiality. 
Results
Medical Record Review
Table 1 shows basic demographics, significant comorbidities, and opioid therapy status of the 38 patient records included in the study. The mean (SD) age was 46 (10) years, ranging from 28 to 64, with more men (21 [55%]) than women (17 [45%]). Regarding race and ethnicity, 18 were white (47%), 13 were African American (34%), and 5 were Hispanic (13%). Six (16%) had a normal body mass index (BMI) (<25 kg/m2), and 21 (58%) had a BMI greater than or equal to 30. Of the patients with a BMI greater than or equal to 30, 15 patients (42%) had obesity (BMI, 30 to <40), and 6 (16%) had morbid obesity (BMI, ≥40). Twenty-five (76%) also had mental health diagnoses (ie, depression and anxiety) that required pharmaceutical or behavioral health treatment. 
Table.
Characteristics of Patients Using High-Dose Opioids and Interviewed Participants (N=38)a
Characteristics All Patients Interviewed Participants
Total Number in High-Dose Opioid Group From Claims Data 46 (100) NA
Total Number Excluded for Death, Cancer, or Lost to Follow-up 8 NA
No. of Patients Evaluated 38 6
Mean Age, y, (range) 46 (28-64) 55.8 (53-61)
Gender
 Male 21 (55) 4 (66)
 Female 17 (45) 2 (33)
Race/Ethnicity
 White 18 (47) 2 (33)
 African American 13 (34) 2 (33)
 Hispanic 5 (13) 2 (33)
 Unknownb 2 (5) 0
Status of Opioid Therapy
 Ongoing opioid use 9 (24) 3 (50)c
 Active tapering documented on CURESd 11 (29) 3 (50)c
 Discontinuation of opioids, no patient activity report, or MED ≤90 18 (47) 3 (50)
Comorbidities
 BMIe kg/m2
  Normal weight, <25 6 (16) 1 (16.7)
  Overweight, ≥25 to <30 9 (25) 1 (16.7)
  Obese, ≥30 to <40 15 (42) 3 (50)
  Morbidly obese, ≥40 6 (16) 1 (16.7)
  Unknownb 2 0
 Mental health diagnosesf
  Mental health diagnoses noted 25 (76) 5 (83.3)
  No mental health diagnoses noted 8 (24) 1 (16.7)
  Unknowna 5 0

a Data are given as No. (%) unless otherwise indicated. Percentages may not always add up to 100% due to rounding.

b Data on race and comorbidities are limited by availability of records in Solano County Family Health primary care clinic and associated electronic health records.

c All 3 interview participants who are still using opioids are actively tapering, as confirmed with CURES search.

d CURES (controlled substances utilization review and evaluation system) is the prescription monitoring program in California.

e Percentage calculations for body mass index (BMI) used a denominator of 36 because of missing data for 2 patients.

f Percentage calculations for mental health diagnoses (consisting of depression and/ or anxiety, requiring medical intervention) used a denominator of 33 because of missing data for 5 patients.

Abbreviation: MED, morphine equivalent dose.

Table.
Characteristics of Patients Using High-Dose Opioids and Interviewed Participants (N=38)a
Characteristics All Patients Interviewed Participants
Total Number in High-Dose Opioid Group From Claims Data 46 (100) NA
Total Number Excluded for Death, Cancer, or Lost to Follow-up 8 NA
No. of Patients Evaluated 38 6
Mean Age, y, (range) 46 (28-64) 55.8 (53-61)
Gender
 Male 21 (55) 4 (66)
 Female 17 (45) 2 (33)
Race/Ethnicity
 White 18 (47) 2 (33)
 African American 13 (34) 2 (33)
 Hispanic 5 (13) 2 (33)
 Unknownb 2 (5) 0
Status of Opioid Therapy
 Ongoing opioid use 9 (24) 3 (50)c
 Active tapering documented on CURESd 11 (29) 3 (50)c
 Discontinuation of opioids, no patient activity report, or MED ≤90 18 (47) 3 (50)
Comorbidities
 BMIe kg/m2
  Normal weight, <25 6 (16) 1 (16.7)
  Overweight, ≥25 to <30 9 (25) 1 (16.7)
  Obese, ≥30 to <40 15 (42) 3 (50)
  Morbidly obese, ≥40 6 (16) 1 (16.7)
  Unknownb 2 0
 Mental health diagnosesf
  Mental health diagnoses noted 25 (76) 5 (83.3)
  No mental health diagnoses noted 8 (24) 1 (16.7)
  Unknowna 5 0

a Data are given as No. (%) unless otherwise indicated. Percentages may not always add up to 100% due to rounding.

b Data on race and comorbidities are limited by availability of records in Solano County Family Health primary care clinic and associated electronic health records.

c All 3 interview participants who are still using opioids are actively tapering, as confirmed with CURES search.

d CURES (controlled substances utilization review and evaluation system) is the prescription monitoring program in California.

e Percentage calculations for body mass index (BMI) used a denominator of 36 because of missing data for 2 patients.

f Percentage calculations for mental health diagnoses (consisting of depression and/ or anxiety, requiring medical intervention) used a denominator of 33 because of missing data for 5 patients.

Abbreviation: MED, morphine equivalent dose.

×
Partnership claims data on the 38 patients after 18 months showed more than 50% no longer made claims for opioids. Subsequent comprehensive medical record review at 30 months showed that 74% (28/38) were managed by pain (25/28) or addiction (3/28) specialists; 29 (76%) were either not using opioids, using them at an MED of 90 mg or less, or actively tapering; 6 patients (16%) remained using HDOs without signs of tapering. Issues with concomitant dangerous coprescriptions, doctor-shopping, or other concerns were evident for 2 of these 6 patients. Additionally, medical record reviews did not show that naloxone was ever prescribed to any of the 38 patients. 
Interview
Enrollment for the interview portion of the study was attempted for the 38 patients. Researchers were not able to reach 12 patients because of incorrect contact information, and 11 patients did not respond to phone queries. Fifteen patients (39%) were reached by phone: 10 agreed to participate in the interview, but only 6 patients completed the interview process. Patients who were not interested in participating or did not complete the interview process were either not using opioids, were using them at an MED of 90 mg or less, or were actively tapering. 
The 6 interviewed participants consisted of 4 men and 2 women, with an age range of 53 to 61 years. Two identified as white, 2 as African American, and 2 as Hispanic. Their comorbid distributions were similar to the rest of the 38 patients (Table). Five of the 6 interviewed participants had chronic pain managed by pain specialists, and 3 were not using HDOs. Of these 3 participants not using HDOs, 2 had persistent pain and 1 had episodic pain. Two of these 3 participants continued to access the emergency department (ED) for opioids and retained unused opioids; both indicated a poor connection with their health care professional. 
The 3 interviewed participants with ongoing HDO use were actively tapering. Each reported persistent pain, withdrawal symptoms, and decreased quality of life. The interviewed participants expressed concerns of not being able to enjoy participating in life because of pain and were frustrated with the US Food and Drug Administration's laws, which they felt did not consider the patients as individuals. Of the 6 interviewed participants, 2 were self-motivated to wean. One interviewed participant that was self-motivated to wean had completely tapered all opioids but continued to experience severe pain as her condition progressed. The other participant had requested a referral to a pain specialist to completely taper opioids and was making progress, although he experienced increased pain, too. Despite these issues, both expressed immense gratitude to their pain specialists. 
Two of the interviewed participants had personal knowledge or history of how to purchase illegal opioids from the street. One described what he did to convince a physician to accept him as a patient with chronic pain: “I had no choice. I…bought some oxy's on the street…I showed him the next time I saw him.” The other related a story of a friend who died from heroin use during prescription opioid tapering. Five of the 6 interviewed participants had previously been coprescribed dangerous medication combinations, such as benzodiazepines and/ or muscle relaxants while taking opioids. None of the 6 interviewed participants had heard of naloxone or been prescribed naloxone when using an opioid, which confirmed the medical record review finding. Figure 1 depicts how emergent themes, observations, and concepts may influence each other. 
Figure 1.
Themes of communication, education, and management influence the emergent concepts of a lack of empathetic connection between patients with chronic pain and their HCP and the underuse of naloxone. Observations pertaining to each theme surround each cogwheel and affect the patient-HCP relationship. Abbreviations: HCP, health care professional; OUD, opioid use disorder; QOL, quality of life.
Figure 1.
Themes of communication, education, and management influence the emergent concepts of a lack of empathetic connection between patients with chronic pain and their HCP and the underuse of naloxone. Observations pertaining to each theme surround each cogwheel and affect the patient-HCP relationship. Abbreviations: HCP, health care professional; OUD, opioid use disorder; QOL, quality of life.
Discussion
To evaluate the MPS opioid policy, we considered the definitions for successful and unsuccessful tapering. We defined successful tapering as no longer taking opioids and not having pain on most days. Unsuccessful tapering could result in 1 of 3 potential pathways: (1) tapered off of opioids but have continued pain; (2) continued access to prescribed opioids through doctor-shopping; or (3) continued access to nonprescribed opioids through illicit drugs. 
From our data collected from the 6 interviewed participants, we determined that none of the participants' had been successfully tapered. Two of the interviewed participants that had been tapered off opioids continued to have pain. The other 4 who were compliant with opioid tapering endured persistent pain that affected their quality of life. Two of these participants also accessed opioids through doctor-shopping. Furthermore, 2 participants had access to illicit drugs, but none of the 6 interviewed reported using street drugs to control their pain. Claims data and medical record reviews indicated that a large portion of patients who had used HDOs appeared to be not using opioids or tapering use to a safe level, but interview data revealed that many of these patients may still have been in pain. Based on interview data, we cannot consider any of the interviewed participants as having successfully tapered. Our findings support the idea that claims data have limitations12; they cannot divulge subjective experiences, doctor-shopping, or access to illegal opioids. Apparent successful policies based solely on claims data may need reevaluation in light of the interview data we obtained. 
This study's findings indicate that implementing safe prescribing policies requires multiple years and needs to be applied across the jurisdiction to be fully effective. Solano County Family Health Services opioid prescribing policies were implemented in 2013 and across EDs and clinics insured by Partnership in 2014-2015, mainly targeting HCPs. Primary care HCPs mostly referred HDO users to pain specialists. However, 2 pain specialists interviewed by the principle investigator said that Solano County pain specialists did not start tapering the opioid doses of patients until 2016-2017 (M. Ali and W. Longton, written communication, August 2017), possibly when the specialty was under “immense pressure” to align with CDC guidelines. 
Reports have suggested that the rise in heroin use may be caused by initial prescription opioid addiction.13,14 Our study did not find that patients who used HDOs transitioned to heroin or illegal opioids, despite 4 interviewed participants reporting a physical addiction to opioids during the tapering process and 2 having access to illegal opioids. As stated within those reports, observational studies cannot claim causality, only that for heroin users, prior misuse of prescription opioids is a strong risk factor for subsequent heroin use, much like polysubstance abuse.1,14,15 Further research into what additional characteristics are risk factors for transitioning to heroin use should be conducted. Additionally, there is a difference between physical dependence and mental addiction to opioids. Although interviewed participants stated that they had a physical addiction to opioids, they did not have a mental addiction and never misused their prescription opioids. However, 4 of the 6 interviewed participants were prescribed benzodiazepines and/or muscle relaxants while taking opioids, a potentially deadly combination.16 Patients using HDOs should be considered at increased risk of overdose, and HCPs should coprescribe naloxone with HDO prescriptions, even during tapering. 
We found that the lack of an empathetic connection between HCPs and patients was detrimental to the patients’ care. In 2011, the National Academies Press stated that a patient's reporting of pain to HCPs often required “validation [to be] accepted as real and treated with concern.”17 Inopportunely, the continued rise of opioid-related overdose deaths altered the focus on improving the management of pain and added to the growing distrust between patients and HCPs when dealing with the way pain is perceived and managed.17,18 
A 2016 study19 identified patient-perceived barriers to successful opioid tapering, including a low perceived risk of overdose, immediate risk of increased pain, and skepticism of nonopioid pain management strategies. Furthermore, a growing body of evidence20-24 linked adverse childhood experiences (ACEs) to addiction and a cascade of poor health outcomes, including obesity, depression, anxiety, heart disease, cancer, and stroke. One study21 found that men with 6 or more ACEs had a 4600% higher risk of becoming an injection drug user than men with no ACEs. The cohort of HDO users in this study was found to have above-baseline prevalence of obesity and mental health diagnoses. Although the current study did not inquire about ACEs, a Suboxone (Indivior) clinic in Shasta County, another Partnership-insured county, screened for ACEs and found similarly high levels of ACEs among their clients.25 Based on the findings from the Suboxone clinic in Shasta County,25 it is likely that the population of low-income patients with chronic pain who used HDOs in Solano also had higher than average ACEs and could benefit from trauma-informed care. This kind of care involves actively listening and acting on each complaint, even complaints that are not life-threatening. Acting on each complaint does not necessarily require prescribing more medications, but rather forging a compassionate relationship that supports the entire person's well-being,17,26 especially during the tapering process. Promoting resilience by establishing relationships with caring health care professionals is vital for children and adults with ACEs.25 
Adapting the Bronfenbrenner social-ecological model27 to the care of patients with chronic pain ensures that a comprehensive approach is taken (Figure 2). This framework examines how individual, interpersonal, organizational, societal, and environmental factors affect human development and what can be addressed on each of these levels. Findings from the current study stress the importance for HCPs to recognize that individuals with longstanding chronic pain present with many personal factors, possibly including ACEs, personal biases, or history of being stigmatized as a patient using HDOs; they may even have vulnerabilities and predispositions embedded in their genetic makeup.28 Health care professionals can help patients with chronic pain start the healing process by recognizing the importance of empathetic connections because caring interpersonal relationships can help build resilience.25 
Figure 2.
Applying the socio-ecological model to the opioid epidemic—how providers can help start the healing process for patients with chronic pain. The provider's actions within each ring—recognizing the individual and interpersonal factors, influencing organizational policies, and shaping legal and societal factors—can allow for better care of patients with chronic pain. This model is not all-inclusive; it may be further adapted for use. Adapted from the Bronfenbrenner's ecological model of human development, 1977. Abbreviations: ACEs, adverse childhood experiences; CURES, controlled substances utilization review and evaluation system.
Figure 2.
Applying the socio-ecological model to the opioid epidemic—how providers can help start the healing process for patients with chronic pain. The provider's actions within each ring—recognizing the individual and interpersonal factors, influencing organizational policies, and shaping legal and societal factors—can allow for better care of patients with chronic pain. This model is not all-inclusive; it may be further adapted for use. Adapted from the Bronfenbrenner's ecological model of human development, 1977. Abbreviations: ACEs, adverse childhood experiences; CURES, controlled substances utilization review and evaluation system.
Health care professionals should also recognize that their own organization or clinic policies affect patients taking HDOs. For example, policies that cancel appointments when patients are late, including for pain medication refills, may adversely affect vulnerable populations with transportation and mobility issues. Health care professionals should also recognize the high potential for dangerous drug interactions to inadvertently occur because many commonly prescribed noncontrolled substances like antidepressants or beta-blockers are metabolized by the same cytochrome P450 isoenzymes as common opioids.29 By understanding potential drug interactions, HCPs can help establish a medication reconciliation policy to help capture information on the controlled substances that patients may not readily report. In California, checking CURES is mandated only when an HCP prescribes a controlled substance and only when the prescription is for longer than 7 days; ED physicians may be exempt if they prescribe a less-than-7-day supply.30 This study found that patients did go to the ED to get opioid prescriptions and did not readily tell their HCP. Health care professionals can also help alter environmental factors and public policies that adversely affect these patients, offer guidance through interagency community work, shed light on potential issues with health care laws, and bring about positive changes for patients. 
Limitations and Future Studies
This study's design as a case series was limiting because no sampling was involved. Interviewed participants self-selected, and those who were compliant with opioid tapering and without pain or those who continued to access illicit opioids after opioid tapering may have chosen not to respond to queries. Another limitation of this study was the small number of participants that were all from a single payer in a single health system, which limited generalizability. Furthermore, interviews were subject to responder bias, and medical record reviews were limited by the completeness and accuracy of documentation. 
Future studies should test the emergent concepts identified: (1) whether naloxone can be used as a tool to start the conversation, improve safety, and enhance empathetic connections; (2) whether motivational interviewing techniques can maximize understanding of the risks of overdose before tapering begins; and (3) whether applying a trauma-informed lens through the socio-ecological framework can improve patient outcomes regarding pain, tapering, and addiction. 
Conclusions
Health care professionals, trained to assess the legitimacy of patient complaints, often regard opioid tapering symptoms, like sleep disturbances, as non–life-threatening and less important to address. Yet, such grievances are often the center of one's sense of well-being. As pressures to adhere to the MED recommendations mount, a transformation in how we care for patients is critically needed. We propose that HCPs refocus on compassionately treating patients with chronic pain, empowering them in their own healing, and helping them build resilience. 
Acknowledgments
We acknowledge Robert Moore, MD, MPH, Mark Netherda, MD, and Danielle Carter, MPH, of Partnership HealthPlan of California for their assistance with data gathering, the conceptual design, and providing participant incentives. 
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De Bellis MD, Zisk A. The biological effects of childhood trauma. Child Adolesc Psychiatr Clin N Am. 2014;23(2):185-222. doi: 10.1016/j.chc.2014.01.002 [CrossRef] [PubMed]
Holmquist GL. Opioid metabolism and effects of cytochrome P450. Pain Med. 2009;10(suppl 1):S20-S29. doi: 10.1111/j.1526-4637.2009.00596.x [CrossRef]
mandatory use CURES. Medical Board of California website. http://www.mbc.ca.gov/Licensees/Prescribing/CURES/Mandatory_Use.aspx. Accessed June 6, 2018.
Figure 1.
Themes of communication, education, and management influence the emergent concepts of a lack of empathetic connection between patients with chronic pain and their HCP and the underuse of naloxone. Observations pertaining to each theme surround each cogwheel and affect the patient-HCP relationship. Abbreviations: HCP, health care professional; OUD, opioid use disorder; QOL, quality of life.
Figure 1.
Themes of communication, education, and management influence the emergent concepts of a lack of empathetic connection between patients with chronic pain and their HCP and the underuse of naloxone. Observations pertaining to each theme surround each cogwheel and affect the patient-HCP relationship. Abbreviations: HCP, health care professional; OUD, opioid use disorder; QOL, quality of life.
Figure 2.
Applying the socio-ecological model to the opioid epidemic—how providers can help start the healing process for patients with chronic pain. The provider's actions within each ring—recognizing the individual and interpersonal factors, influencing organizational policies, and shaping legal and societal factors—can allow for better care of patients with chronic pain. This model is not all-inclusive; it may be further adapted for use. Adapted from the Bronfenbrenner's ecological model of human development, 1977. Abbreviations: ACEs, adverse childhood experiences; CURES, controlled substances utilization review and evaluation system.
Figure 2.
Applying the socio-ecological model to the opioid epidemic—how providers can help start the healing process for patients with chronic pain. The provider's actions within each ring—recognizing the individual and interpersonal factors, influencing organizational policies, and shaping legal and societal factors—can allow for better care of patients with chronic pain. This model is not all-inclusive; it may be further adapted for use. Adapted from the Bronfenbrenner's ecological model of human development, 1977. Abbreviations: ACEs, adverse childhood experiences; CURES, controlled substances utilization review and evaluation system.
Table.
Characteristics of Patients Using High-Dose Opioids and Interviewed Participants (N=38)a
Characteristics All Patients Interviewed Participants
Total Number in High-Dose Opioid Group From Claims Data 46 (100) NA
Total Number Excluded for Death, Cancer, or Lost to Follow-up 8 NA
No. of Patients Evaluated 38 6
Mean Age, y, (range) 46 (28-64) 55.8 (53-61)
Gender
 Male 21 (55) 4 (66)
 Female 17 (45) 2 (33)
Race/Ethnicity
 White 18 (47) 2 (33)
 African American 13 (34) 2 (33)
 Hispanic 5 (13) 2 (33)
 Unknownb 2 (5) 0
Status of Opioid Therapy
 Ongoing opioid use 9 (24) 3 (50)c
 Active tapering documented on CURESd 11 (29) 3 (50)c
 Discontinuation of opioids, no patient activity report, or MED ≤90 18 (47) 3 (50)
Comorbidities
 BMIe kg/m2
  Normal weight, <25 6 (16) 1 (16.7)
  Overweight, ≥25 to <30 9 (25) 1 (16.7)
  Obese, ≥30 to <40 15 (42) 3 (50)
  Morbidly obese, ≥40 6 (16) 1 (16.7)
  Unknownb 2 0
 Mental health diagnosesf
  Mental health diagnoses noted 25 (76) 5 (83.3)
  No mental health diagnoses noted 8 (24) 1 (16.7)
  Unknowna 5 0

a Data are given as No. (%) unless otherwise indicated. Percentages may not always add up to 100% due to rounding.

b Data on race and comorbidities are limited by availability of records in Solano County Family Health primary care clinic and associated electronic health records.

c All 3 interview participants who are still using opioids are actively tapering, as confirmed with CURES search.

d CURES (controlled substances utilization review and evaluation system) is the prescription monitoring program in California.

e Percentage calculations for body mass index (BMI) used a denominator of 36 because of missing data for 2 patients.

f Percentage calculations for mental health diagnoses (consisting of depression and/ or anxiety, requiring medical intervention) used a denominator of 33 because of missing data for 5 patients.

Abbreviation: MED, morphine equivalent dose.

Table.
Characteristics of Patients Using High-Dose Opioids and Interviewed Participants (N=38)a
Characteristics All Patients Interviewed Participants
Total Number in High-Dose Opioid Group From Claims Data 46 (100) NA
Total Number Excluded for Death, Cancer, or Lost to Follow-up 8 NA
No. of Patients Evaluated 38 6
Mean Age, y, (range) 46 (28-64) 55.8 (53-61)
Gender
 Male 21 (55) 4 (66)
 Female 17 (45) 2 (33)
Race/Ethnicity
 White 18 (47) 2 (33)
 African American 13 (34) 2 (33)
 Hispanic 5 (13) 2 (33)
 Unknownb 2 (5) 0
Status of Opioid Therapy
 Ongoing opioid use 9 (24) 3 (50)c
 Active tapering documented on CURESd 11 (29) 3 (50)c
 Discontinuation of opioids, no patient activity report, or MED ≤90 18 (47) 3 (50)
Comorbidities
 BMIe kg/m2
  Normal weight, <25 6 (16) 1 (16.7)
  Overweight, ≥25 to <30 9 (25) 1 (16.7)
  Obese, ≥30 to <40 15 (42) 3 (50)
  Morbidly obese, ≥40 6 (16) 1 (16.7)
  Unknownb 2 0
 Mental health diagnosesf
  Mental health diagnoses noted 25 (76) 5 (83.3)
  No mental health diagnoses noted 8 (24) 1 (16.7)
  Unknowna 5 0

a Data are given as No. (%) unless otherwise indicated. Percentages may not always add up to 100% due to rounding.

b Data on race and comorbidities are limited by availability of records in Solano County Family Health primary care clinic and associated electronic health records.

c All 3 interview participants who are still using opioids are actively tapering, as confirmed with CURES search.

d CURES (controlled substances utilization review and evaluation system) is the prescription monitoring program in California.

e Percentage calculations for body mass index (BMI) used a denominator of 36 because of missing data for 2 patients.

f Percentage calculations for mental health diagnoses (consisting of depression and/ or anxiety, requiring medical intervention) used a denominator of 33 because of missing data for 5 patients.

Abbreviation: MED, morphine equivalent dose.

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