A Human Factors Approach towards Designing Apps to Support Opioid Tapering for Chronic Noncancer Pain in Primary Care Settings
TimeWednesday, April 141:10pm - 1:30pm EDT
LocationPatient Safety Research and Initiatives
Chronic pain, or pain that lasts for more than six months, is widely prevalent, with a 2014 survey estimating approximately 25.3 million adults in the U.S. experiencing daily pain. Although opioid medications can provide pain relief, over-prescribing of opioids has contributed to the current opioid epidemic. Several US-based agencies such as the Centers for Disease Control, U.S. Department of Veterans Affairs/Department of Defense, U.S. Department of Health and Human Services, have provided guidelines to assist with tapering opioid medications. However, these guidelines are complex and can be difficult to operationalize and implement. Further, it is important to consider the perspectives of patients and providers when designing safe and effective opioid tapering plans. The objective of our study was to uncover information needs of important stakeholder groups in tapering opioid medication.
Participants: Convenience sampling was used to recruit four patients with chronic noncancer pain (gender: 3 male, 1 female; race: 3 Caucasian, 1 African American; age: 58-76 years old, mean 68.1 education: high school to advanced degree), four family members of patients with chronic noncancer pain (all female; race: 3 Caucasian, 1 African American; age: 50-76 years, mean 66.5 years; education: some college to advanced degree), four primary care providers (all female; limited experience in prescribing and managing pain medications), and four pain specialists (all male; experience: 13-21 years; all estimated more than 50% of their patients were prescribed opioid medication).
Instruments: We conducted semi-structured interviews. Interview topics differed by the participant type. Patients and family members of patients were requested to describe the nature of their pain, experiences managing pain and familiarity with opioid tapering, and technology use in tracking pain. Primary care providers and pain specialists were requested to describe their information needs in understanding pain symptoms, etiology, and treatment, planning and executing plans to taper opioid and non-opioid medications, and design features for technology to support opioid tapering.
Procedure: Remote interviews lasting no more than an hour were conducted by interviewers skilled in human factors or implementation science. Interviews were audio recorded and extensive notes were used to capture participant responses.
Data analysis: An inductive approach was used by researchers with training in human factors or implementation science to thematically analyze interviews.
Patients with chronic noncancer pain: Patients’ pain had varying etiologies ranging from spinal surgeries, Lyme disease, and chronic malnutrition. Regardless of the pain etiology, pain broadly impacted patients’ activities of daily living, functioning, and health. Because of the relatively long durations of having experienced pain, patients no longer tracked daily pain scores; instead, patients reported tracking their range of motion and functionality. Some patients relied on their caregivers to track appointments and medications.
Patients did not expect be pain-free. Instead, pain management goals ranged from experiencing minimal pain, enjoyment of hobbies, and taking fewer medications to manage pain. All four patients were familiar with the concept of opioid tapering. However, opioid tapering was perceived to be mentally challenging, and having adversely impacted functionality and social relationships. Patients also desired more frequent contact with providers during tapering, and expressed the need to identify evidence-based guidelines about pain management and opioid tapering.
Family members of patients with chronic noncancer pain: Family members reported providing many forms of support to patients, including encouraging exercise, scheduling and accompanying the patient to appointments, monitoring the patient on a day-to-day basis, providing emotional support, and being an advocate for best care in emergent situations. A variety of technologies (patient portals, apps, after-visit summaries) and methods (participating in patient appointments) were used to access medication information about the patient, but family members reported being overwhelmed by tracking appointments and relevant medical information. Family members were also not generally aware about what to expect during opioid tapering and desired access to information about withdrawal symptoms.
Primary care providers: Primary care providers used different strategies to manage pain depending on pain etiology (e.g., opioids, non-opioids, non-medication approaches). Patients prescribed long-term high dose opioids are generally considered high-need patients because providers invest considerable mental effort in interacting and managing them. These patients make multiple appointments, are seen more frequently than patients with other conditions, and require intensive monitoring and management, continuous education, and discussion around opioids. These patients are also perceived as “difficult” because they often have psychological co-morbidities (substance abuse and dependence, inflating pain symptoms, lying, drug-seeking behavior) that adversely affects the patient-provider interaction.
Participants had considerable regret around prescribing long-acting opioids in the past and contributing to the current opioid epidemic, and were frustrated about the lack of standard opioid prescribing and tapering practices in their practice sites. Participants indicated they prioritized maintaining long-term relationships with their patients and struggled with initiating conversations about opioid tapering with patients because tapering conversations can quickly turn contentious and fracture this relationship. Primary care physician participants discussed a number of challenges with tapering, mainly related to patient/caregiver resistance to tapering, personal life challenges for patients (e.g., depression/anxiety, lack of access to treatment), and challenges specifically for patients with drug-seeking behavior. In addition, participants were also generally unfamiliar with detailed guidelines on safe opioid tapering. Patients were perceived to fear several things: uncontrolled pain and uncomfortable withdrawal during tapering, being abandoned by their providers if they do poorly on the taper, changing their treatment when the medication regimen was perceived as working, or providers “giving up” on a good outcome for the patient’s condition if they were taking their medications away. Patient’s families were also perceived to be fearful about the implications of changing the patient’s treatment.
Pain specialists: Primary care physician participants discussed a number of challenges with tapering, mainly related to patient/caregiver resistance to tapering, personal life challenges for patients (e.g., depression/anxiety, lack of access to treatment), and challenges specifically for patients with drug-seeking behavior. Patients were perceived to fear several things: uncontrolled pain and uncomfortable withdrawal during tapering, being abandoned by their providers if they do poorly on the taper, changing their treatment when the medication regimen was perceived as working, or providers “giving up” on a good outcome for the patient’s condition if they were taking their medications away. Patient’s families were also fearful about the implications of changing the patient’s treatment. Similar to findings from primary care physicians, a patient’s disposition and willingness to taper is seen to be critical to success (e.g., patient-initiated taper discussion, a patient’s looking for alternative treatments, patients who take ownership of their condition and want to do something about it, highly motivated). Other factors include access to multimodal pain treatments, patients who have been on opioids long-term, the ability to discuss tapering over multiple visits, and a strong support system. Pain specialists also believe that provider-initiated tapers were generally unsuccessful.
Based on these findings, we have designed two apps to support opioid tapering. A patient-facing app enables patients to record pain intensity and pain behavior, visualize pain trends, access information about what to expect during a taper, and track appointments and medications relevant to the taper. A provider-facing app enables providers to design a safe plan to taper opioid medications based on guidelines by the U.S. Department of Veterans Affairs/ Department of Defense, the Centers for Disease Control, and the U.S. Department of Health and Human Services, and choose medication and non-medication options to proactively manage pain and withdrawal symptoms during the taper process. These applications are in the process of being deployed in a large healthcare system in the mid-Atlantic region.