**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Communicating about Opioids for Chronic Pain; What Really Happens in Clinic Visits**

**Presenter: Marianne S. Matthias, Ph.D.**

**April 1, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**robin.masheb@yale.edu**.*

Robin Masheb: Good morning everyone. This is Robin Masheb. I'm director of education at the Prime Center and will be hosting our monthly pain call entitled Spotlight on Pain Management. Today's session is Communicating about Opioids for Chronic Pain; What Really Happens in Clinic Visits. I would like to introduce our presenter for today, Dr. Marianne Matthias. Dr. Matthias has been with the Indianapolis VA since 2007 and has a faculty appointment at Indiana University. She currently has a VA HSR&D Career Development Award focused on chronic pain, self-management, communication, and decision making. We will be holding questions for the end of the talk. At the end of the hour there will be a feedback form to fill out immediately following today's session. Please stick around for a minute or two to complete this short form as it is critically important to help us provide you with great programming. Dr. Bob Kerns, director of the Prime Center will unfortunately not be on our call today. Now I'm going to turn this over to our presenter, Dr. Marianne Matthias. 

Dr. Marianne Matthias: Thank you Robin and thanks Heidi too and thanks everybody for tuning in today. Before we get started I believe Heidi's going to put up a poll question just so we can get a senses of who our audience is today. So when that comes up if you could check the appropriate--yeah, here it is. So if you could mark the appropriate category for what your role is in the VA whether it's student, trainee, or fellow, clinician, researcher, a manager or policy maker, or other. 

Moderator: And you can actually click on more than one if you had a dual role so feel free if you need to click two. Please go ahead. And it looks like we're seeing most of our audience of clinicians about 53 percent of the audience are clinicians, 25 percent research, about 20 percent managers, about 20 percent other, and five percent student, trainee, or fellow. Thank you everyone for filling that out. 

Dr. Marianne Matthias: Yes thanks. That's helpful. Alright, so as many of you do realize pain is a significant problem. It's common and it's costly with over a 100 million Americans suffering and over 600 billion dollars a year in healthcare costs and lost worker productivity as a result. In addition, communication is often difficult in chronic pain management. Research has described a burdened physician/patient relationship with power struggles and mistrust. Patients describe feeling as though their doctor doesn't believe their pain and some of them feel like they've been treated as if they're drug seekers. Physicians describe situations with sometimes hostile patients demanding medications. These communication problems negative affect both patients and physicians. for example, in one study patients with back pain and who also disagreed with their doctor on the cause and treatment plan for their pain experience less satisfaction and lower SF-36 scores for mental health, social function, and vitality compared to the patients who had agreed with their doctors. 

Other work has described patients as feeling burdened and depressed when physicians didn't believe their pain complaints. They characterize this kind of communication as strenuous, complicated, and heavy. So research indicates that there is an emotional toll for patients like this. But it's not just patients who experience the emotional toll of poor communication about chronic pain. Providers also experience this. In one study providers describe caring for patients with chronic pain as a thankless task in which they are confronted with failure every day. In a VA study almost three-quarters of providers described chronic pain as a major source of frustration. In some qualitative work that we did here at our VA a few years ago providers used words like frustrating, overwhelming, and ungratifying to describe caring for patients with chronic pain. Providers described feeling guilty when they couldn't do much to relieve a patient's pain. One physician even said that the frustration and lack of self-efficacy that he felt in treating chronic made him feel unsuccessful as a doctor. 

So why is communication difficult? The literature describes a number of reasons why this is so difficult. A major reason is because pain is subjective so there's no way for the physician to measure it short of asking the patient and different patients have different perceptions of pain. And this also means that trust plays a large role in pain assessment. In addition, there's clinical uncertainty in pain management. With open questions about what treatments are the safest and most effective. Sometimes after negative experiences with pain management providers develop negative attitudes toward patients with pain. And this is often exacerbated by a lack of specific training and pain management for providers. And of course, many pain treatments are controversial, especially opioids. 

So in fact, in the study that we did a few years ago that I described earlier issues with opioids emerged with providers during these interviews. Providers described feeling a lot of pressure from patients to prescribe opioids. They also cited feeling guilty if they said no to opioids and some were afraid of being fired, which then is reflected on their performance appraisals. One provider described patients' demands for opioids like this. It was like you go to McDonald's drive-thru and you order what you want and they should give it to you. 

So communication problems related to opioids are further exacerbated by the dramatic increases in opioid prescriptions in recent years accompanied by similar increases in misuse. And to complicate matters more the long term benefits of opioids have not been well studied and some observational study raise questions about these benefits. 

Alright, I just lost my slides Heidi. 

Moderator: I think we all did. Give me just a second and I will pull those right back up. 

Dr. Marianne Matthias: Oh great. 

Moderator: It should take just a moment to load here. 

Dr. Marianne Matthias: Alright, I see them. Does everybody else? 

Moderator: There we go. Yep. They should be up for everyone now. 

Dr. Marianne Matthias: Okay. All right. So while high quality patient provider communication is always important I would argue that it's especially important when managing opioids with patients. This is because opioid management really is rooted in communication from making decisions about opioid treatments including whether to initiate opioid therapy in the first place, changes in dose, tapering of opioids to discussions of risks and benefits of opioids, and of course, opioid monitoring strategies such urine drug testing. All of these things require effective communication. 

There we go, we lost the slides again. They're back. 

So to kind of sum up the background communicating about chronic pain in primary care can be challenging and this is especially true if opioids are involved. These challenges have been expressed in a number of interview studies some of which I shared with you in these last few minutes. However, there is very little research that has studied the actual clinical communication between patients with chronic pain and their providers. So what really happens in these clinic visits? This is a large gap in our knowledge about this since interview accounts are limited by a respondents own individual perspectives and opinions, and they're also subject to recall bias. 

So we undertook a pilot study to help address this research gap and better understand the communication and behaviors related to chronic pain. So we did this pilot study at RVA in Indianapolis and the participants were primary care providers and their patients. And the patients had inclusion criteria which included a diagnosis of chronic pain, which we identified by ICD-9 codes and they had to have at least moderately severe pain at their last primary care visit. And this was defined as at least four on a zero to ten scale with zero being no pain. And just logistically they had to have an appointment with their PCP during the study period. 

So what we did was we audio recorded these regularly scheduled primary care visits and we told the study--we told the patients that the study was about communication but we didn't tell them that we were interested in pain because we wanted any discussions about pain to emerge naturally. The PCPs knew the study was about pain just to help us facilitate appropriate recruitment. And after the clinic visits patients were interviewed and we asked some questions about their doctor, about their pain, and about their pain treatment. So for data analysis we had two sources to analyze. We had the patient provider communication from the clinic visits and then the patient interviews themselves. And we used an immersion crystallization approach to qualitative data analysis. And I'm not going to go into a lot of detail on what that involves right now. 

So we had five PCPs who participated. They were physicians, three were female, and they had between six and 23 years of practice experience. 40 patients participated but pain didn't come up in ten appointments so we dropped these from our subsequent analysis. Four were women, seven were African American. And the age range of our patients were 27 to 70 with a mean of 57. The average duration of the patient provider relationship was four years. The longest was 16 years. And we also captured a few first visits. Of the 30 that we retained for analysis, 17 had low back pain, and another 13 had arthritis. 

So we can find the results of our analysis in terms of two questions that are listed here. And the first one is how do doctors and patients communicate about opioids? And the reference for each of these questions is listed underneath in case you're interested in reading more about it than what I'm going to give you today. The second question then is what influences these communication patterns and patient's interpretations of physicians opioid prescribing decisions? I should note before I go on that if you recall from the inclusion criteria we didn't specifically choose participants based on whether they were taking opioids. And the original purpose of the study was simply to better understand clinical communication about chronic pain in general. However, the issue of opioids was such a pervasive theme that this really ended up dominating our inductive analysis. So that's why I'm reporting to you today about the conversations about opioids. 

So let's talk about the first question first and that is how physicians and their patients communicate about opioids. So just in general sometimes the mention of opioids was very brief. The physician might has the patient if he or she needed their opioid renewed. The patient would say yes and there would be no further discussion. There were other more extensive discussions about opioids and these can be characterized by three patterns of responses related to the uncertainties about opioids. And the first pattern was providing reassurance. The second pattern was deciding avoid opioids. And the third pattern was gathering additional information. So I'll detail each of these responses. 

When the patient or physician brought up an issue about opioids it was almost always related to misuse or addiction and the response was often one of reassurance. It was usually the physician who brought up these issues. For example, one patient in his interview described how he had reassured his doctor about his opioid use. He told me--he being the physician--that the prescribed opioid was addictive and he would only give me so many pills at a time. And I told him you don't have to worry about it because I'm not going to take anymore than I have to. 

So in these clinic visits and the visits themselves too we sometimes heard candid discussions about opioids like the following example. So the physician says I'm hoping we can help you cut back on this other stuff, this crap that were having to give you, because they're not controlling, that Methadone is not good period. It's not as dangerous as some drugs. It's just the side effects and dealing with, you know, possible addiction and what not. Yes, exactly. Then the patient goes on to reassure his doctor. And he says, I think I'm doing pretty good. I don’t have to double up on the Methadone every night. I'm not abusing or anything. 

The second pattern that we observed was just deciding to avoid opioids altogether. In interviews patients shared in some cases that they were afraid of getting addicted and this led to want to just stay away from opioids. For example, one patient told us they said, we'll give you those pills. And I said, those are addictive. I don’t want that. And another patient said, I'm trying to stay off narcotics. I don’t want to get addicted. Interestingly we also heard a lot of patient/physician concordance on the issue of avoiding opioids. For example, one physician said to his patient the more you can stay off these medicines--one patient after another are on narcotics and once they're on you can't get them off. She didn't respond in that clinic visit but in her interview she did express the desire to avoid opioids saying I'm really happy not taking narcotics. 

The next example related to avoiding opioids is a case where the physician wanted to discontinue the patient's opioids and explore alternative treatments. So the patient expresses agreement although the physician didn't bring up concerns about addiction, it's clear from the interview that's followed, that addiction was certainly a concern that the patient had. So here's what happened in the clinic visit. The physician says I'm going to give you no Hydrocodone refills because my goal is after your injection you're not going to be having much pain. Yeah, I don't I think I'm going to need anything. The physician replies, I think your potentially going to have chronic back issues. If you can help you with a couple of things, one, weight loss, two, strengthening your back with physical therapy, I think it's going to help you in the long run. The patient's concordance was evident in his interview as were his concerns related to addiction. He said in the interview, I don’t take Hydrocodone unless I have to because I don’t want to get hooked on anything. 

The final pattern that we observed was gathering additional information. So sometimes patients and their physicians reacted to the uncertainty about opioids by having extended conversations to gather more information. Sometimes the information in addition to the conversation included things like requests for urine drug screens. And sometimes included pretty candid discussions about opioid misuse that explored issues of trust. This is especially the case when patients had a history of substance use disorder. 

So in the follow example the physician had a candid discussion about the possibility of opioid misuse with the patient who had a history of cocaine use. The doctor opened up the topic with a request for a urine drug screen before diving into the patient's history. So the physicians says have you been using cocaine recently? No. When was the last use? I don’t remember. Approximate...? Maybe a year, year and a half. Nothing since then...? No. Can I do a urine drug screen today? I got a ride. I can come back today. I just got to go out there and tell them. Will it be clean? Can I come tomorrow? Will it be clean tomorrow? Will it be clean tomorrow? Yeah. Okay. My general approach to patients that have had a positive urine drug screen, which I think yours was in '09, I require them to go through substance abuse treatment. Well, I'm not going to do that because I don’t think it's necessary. I've been going to substance abuse treatments all my life. Uh-huh. And you test me. I think you tested me last time for drugs. Well, it seems like you've been doing pretty well. Why don't we check it tomorrow? If it's positive obviously we'll put a stop to it. But I'm okay renewing your Hydrocodone today. 

So ultimately the doctor gave the patient the benefit of the doubt and renewed his Hydrocodone in spite of his worries about opioid misuse. He even praised the patient saying he had been doing pretty well with his substance use. So when I first read this transcript it appear tense to me. And so what I did was I went back and I listened to the audio. And interestingly, when you listen to this portion of the audio it doesn't reveal any sign of a heated discussion. The tone of voice, everything about the conversation sounds exactly like the rest of the clinic visit. So nobody verbally appeared to be getting upset. And then it was interesting that later on in the visit they actually shared laughter together about the patient's weight. The patient sort of elaborated on this idea a little bit more in his interview when he acknowledged that he and his doctor have had disagreements but he put it in perspective saying I feel I've got more rapport with him over time. We've had our differences and now we have a better relationship. But everything is rocky sometimes when you're dealing with people. 

So to sum up this part of the findings, we found three ways that through communication patients and their physicians handled the uncertainty about opioids and these patterns were reassurance, avoidance, and gathering more information. We also saw that patients and their doctors often shared concerns about opioids and that these concerns especially for patients most commonly were related to fears of addiction or abuse. And this is especially true with patients who had a history of substance use disorder. Not insignificantly, we saw more agreement than disagreement between patients and their doctors. 

So moving onto the second question that our findings answer, how does the patient physician relationship influence communication about opioids? So an interesting pattern that we saw in our data was that patients sometimes exhibited very different responses to virtually identical physician behaviors and physician decisions about opioids including requests for urine drug screens, decreasing opioids, or saying no to opioids. So what we wanted to do was figure out what was driving these different patient reactions. 

So one of the things we looked at to better understand these different reactions was the patient accounts of conflicts with prior physicians. This came up during the interviews and in all cases in this study the conflicts that patients described were with physicians that they were no longer seeing. And these conflicts were related primarily to two concerns. First, perceptions that the previous provider didn't care about or didn't believe their pain. And second, they were related to disagreements over opioids including the belief that the physician was withholding opioids or belief that the patient was drug seeking. Now these ideas aren't new and they've been explored in prior research, some of which I shared with you at the beginning of this seminar. So I'm not going to say anything more about this here. The reason I present this to you is because it really serves as a nice way to contrast with the rest of our patients who were actually the majority in our study. 

So most patients in our study describe believing that their doctors listened to them and that they demonstrated genuine concern for them. For example, people said things like, I feel he's concerned about my health. Not only does she listen but she shows her concern. She knew I used to drink. When she asked me how my drinking was she told me she was proud of the fact that I had stayed two years sober. Patients like these describe trusting their doctor's treatment decisions even if they were cautious about prescribing opioids. For example, another patient in his interview told us that his Hydrocodone wasn't really helping his pain but also said he would not ask his doctor for additional medication. He explained that this is because he trusts his doctor. He said to us I had 26 open prescriptions, five psyche medications, so she balances. What will not affect the other medications? 

In another example, a patient had asked his doctor for an opioid refill which the doctor granted immediately. So that's what we captured on the audio for the clinic visit. And it wasn't really that interesting. But then during the patient's interview we learned more about his history with the doctor as it related to opioids. So what happened was in a previous appointment the doctor had reduced his Hydrocodone because of concerns about liver toxicity. The patient said that as a result he has more pain now but he also believes that his doctor acted in his best interest. When we asked him how satisfied was he with this doctor's pain management he told us this. I'm satisfied because he looks out for me because he was giving strong medication but he was more concerned about my liver. I could see he was really concern so he cut the Hydrocodone back. And as long as it helps me out there's some pain you're going to have to endure. But when he said he was concerned about my liver I am as well. So after a while I adjust my mind down to what I'm getting now. He was concerned about me. So he brought up how it causes liver problems and so forth. So he emphasized many times in the short passage the concern. 

Another patient credited his doctor with helping him to overcome his addiction to marijuana. Recently he had gone to the ER and he had gotten additional Hydrocodone. When his doctor found about this he decreased the patient's Hydrocodone dose. The patient reacted in a way that might be surprising to some. First, this is what he said in his interview. I was a little upset at first but I kind of understood what he did because I've been coming into the emergency room for other issues. And the other doctors were giving me stuff and they weren't notifying him. I don’t feel it is punishment. But he just wanted to make sure I wasn't getting over indulged in, you know, what I was using. So I was glad he did what he did. You got to keep me in check sometimes. Even in his clinic visit the patient was positive about what had happened. The physician says how are you and he replies I'm doing well. Well, I say that. I'm getting by, getting by. Yeah, well, you know, it's obvious the muscle relaxers are helpful. When you knocked it down to 20 on the pain killers it didn't quite get me through, not even one day. You know, I'm trying to hold off and use them only when needed but there's some days when you just--you almost need more. I found myself taking more of the muscle relaxers because I didn't have the pain killers. But other than that, I'm not feeling too bad. 

He further explained his relationship with his doctor in his interview emphasizing that his doctor's actions were keeping me healthy. He takes me off of Hydrocodone for a while or limits me to fewer amounts so I don’t get too addicted. I don’t take them as prescribed. I only take them when I need them. So there's days when I won't take any. I'll wait until I absolutely can't take the pain anymore, and then I'll take it. And he understands that. They're keeping me healthy. I know there's a lot of people out there that abuse. 

So patient interpreted similar physician decisions about limiting or denying opioids very differently. Some, a minority in our study, saw these decisions as representative of mistrust or punishment. This contrasts then with others, the majority in our case, who believe that these actions stemmed from their doctor's genuine concern for their health. So in addition patients who believe their doctors are looking out for their best interest described making appropriate adjustments that in some cases allow them to adapt to lower opioid doses. This included things like adjusting expectations for pain levels and degree of pain relief and being willing to accept a little more pain. In some cases this also included patients describing how they learn to modify their activities to help minimize their pain. 

So the results of this study suggest that the nature and the history of the patient/physician relationship influences how patients interpret their physician's decisions about opioid prescribing. In many cases these patients who are positive about decisions to limit or just deny opioids had had a long history with their doctors, some even having confronted use disorders with their doctor's help. These findings then underscore the critical role of the patient physician relationship in pain management especially when opioids a involved. So patients in this study were more accepting of limitations placed on opioids when they believe that their doctors really cared about them. The results of this study echo much of the literature on communication, the patient/provider relationship and chronic pain. Our findings support the idea of creating and sustaining a therapeutic alliance with patients one in which patients and physicians have shared goals as well as mutual liking and trust. Having a strong therapeutic alliance can lead to more positive responses from patients when limiting or when just saying no to opioids. This happens in part by shifting the focus from the patient and whether or not this patient is trustworthy to the benefits and harms of the opioids themselves. In short, it puts the opioids on trial rather than the patient. This type of framing then reinforces the therapeutic alliance and emphasizes concern for the patient. And we found that this was critically important for patients in our study. 

There's some final observations I want to make about our data. So first there overall were not a large number of pain discussions. If you remember I said early on that 10 of 40 didn't talk about pain at all. And this despite having an inclusion criterion of pain greater than or equal to four at the last PCP appointment. And in addition to those 10, some discussions of pain just weren't very substantive often involving a brief request for renewal followed by an affirmative answer and then they move onto other things. Now it's interesting that there hasn't been much work that's been done actually listening to and observing communication in the clinic about opioids. But there was a recent study by Steven Henry and Susan Eggly that was published in JGIM. And they found something a little bit different. They found that about one-third of clinic time in their study was spent discussing pain. There were quite a few differences though from our study. And the most important difference is that their study took place in a resident clinic and many patients were seeing the physician for the first time. Obviously this would require a more extensive history taking which could account, at least in part, for the greater discussion of pain in the Henry and Eggly study. 

For our study there are some possible explanations of the relatively low number of pain discussions. First, patient and physician perceptions of the difficulty of these conversations may have led to them avoiding talking about pain when possible especially for physicians they might have just avoided asking the patient about pain unless the patient brought it up. The other thing that was happening in these visits was the visits that we recorded were really dominated by discussions of conditions, most commonly diabetes and hypertension. Obviously, as you know, because poor management of conditions like these can lead to serious complications physicians likely prioritize these discussions. And this may have resulted in crowding out some of the pain discussions. 

Another important observation was that conflict was relatively infrequent in our sample. This really could be for a number of reasons. The most obvious one is just simply selection bias. And I think it's highly unlikely that patients who are particularly difficult or physicians who feel like they have a particularly difficult time with their patients with pain would say yes to be in a study like this to have their clinic visits recorded. So I think that that is just an inherent limitation in this kind of work is that you're not necessarily going to be able to capture those types of patients and those types of patient/physician relationships. 

We went into the study maybe a little naively not thinking about that but really wanting to learn more about this difficult communication that is so often talked about interview studies of patient provider communication, about chronic pain, and for much of this audience is comprised of clinicians and just the anecdotal reports from clinicians are pretty plentiful about this difficult communication. So we really went into the study wanting to be able to see these conversations and be able to study them and learn more about them. And at first we were disappointed that we weren't able to capture that. But in the end I think what we found was very interesting and we found that we had a lot to learn from conversations about pain and opioids that go well. And in fact, maybe we can learn more about conversations that go well than we can learn from the conversations that don't because we have a good general sense of what conversations don't go well, how they don't go well, and even why they don’t go well. But I was not able to share with you all of the examples in this presentation but we observed some pretty skillful navigating on the part of the physicians where they really were able to diffuse potential conflict in a very skillful way. And I think that looking at things like this, learning what goes right in conversations that are potentially very difficult is just as important as learning what can go wrong. And when we learn what can go right and we see how these physicians skillfully diffuse these situations it can really provide us with a lot of good information for a well targeted communication intervention. 

You know, in addition, something that we got out of this was as researchers we talk a lot about the importance of the patient provider relationship. As a researcher studying chronic pain I've talked and written about this a lot. But in this study patients themselves let us know that this relationship is absolutely critical and, importantly, patients and their physicians can get a lot more accomplished if the patient really believes that their doctor is looking out for their best interest. 

So let me share some limitations with you. Obviously I already discussed one, and that was the issue of selection bias. And that’s certainly a limitation. In addition, this was a select sample at one VA medical center. Because this is qualitative research our purpose was never to generalize. What we wanted to do was gain a richer, more detailed understanding about patients and their doctors actually communicating about chronic pain. And we feel like we were able to do this. Another limitation is that for most of the relationships that we witness between patients and physicians, these were long term relationships. Chronic pain is obviously a long term condition and we only captured on visit in the context of relationships that for some patients span 16 years. And we were, as you saw from some of the interview data I presented, we were able to fill in some of the gaps with the interviews where the patients gave us additional insight into what had happened previously either in a previous appointment or in ER or things like that. But still, we only saw a very small glimpse of a very long, in many case, patient provider relationship. 

So having said that it really is going to be important for longitudinal research so that we can better understand pain communication patterns over time. And chronic pain by definition is not managed in one visit. And so it's really hard to capture, to gain a real understanding of how pain is managed and how patients and their providers communicate about this management in one visit. Another thing that for future research to do is try to understand what factors influence the present and the extent of pain discussions because, as I said, they--we were surprised that there weren't more and extensive pain discussions. And these factors could include things like pain intensity or psychiatric comorbidities, whether there's a pain exacerbation at the time. The patient/provider relationship clearly could be a factor based upon our data from this study. And, of course, there could be others too and you all might have ideas about that as well.

So I just want to acknowledge our study team and the funding and also just disclose that we don't have any conflicts of interest. And I thank you again all for attending and I can take questions now. 

Robin: Thanks Matthias. This is Robin. We have a few questions here for you. Can you hear me? 

Dr. Marianne Matthias: Yes I can. 

Robin: Were the patient's on opioids, chronic users, that is 90 days or more...?

Dr. Marianne Matthias: Most of them I believe were. The one thing--because we didn't select based upon whether patients were taking opioids, we didn't--that wasn't one of the criteria we used to select them. But based upon our data most of them were. There might be a few exceptions. 

Robin: Another question for you is whether you think that video recordings as opposed to just the audio recordings would have been helpful to you in understanding more what was going on? 

Dr. Marianne Matthias: Yeah, that's a very good question and we've certainly talked about using video in other studies as well because you do--you are privy to the non-verbal channel which you don't get all of with the audio. You only get the paralinguistic cues, tone of voice and things like that, from the audio. So yeah, we--the issue with the video was there's logistical issues, of course, but the other thing is that we were really striving to be as unobtrusive as possible especially because we were anticipating the potential at least to capture some contentious interactions. So we didn't want to have distractions that might interfere with the natural course of conversations. And another factor related to that was we actually struggled a little bit with whether or not the research assistant who was collecting the data should be in the room with the recorder or wait outside. Because if she's in the room she's going to be able to capture a lot of nuances that in audio alone can't. But we made the decision to have the RA wait outside the room for the same reason that we didn’t want the presence of another person to be distracting or to alter the natural course of conversation. The digital audio recorder is so small and it just sits on a desk and it's easily forgotten about. So those were--and this was a pilot study as well. So those were several of the reasons why we opted for audio recording. But I agree that, you know, if you use video it opens up a whole new channel for analysis. 

Robin: Did any of the physicians make decisions to prescribe or not prescribe that were due to plan restrictions or restrictions of the facility? 

Dr. Marianne Matthias: Not that I'm aware of. I don’t recall seeing anything like that in the data that was more logistically based. And again, that's not to say it didn't happen because, as I said, we only captured one visit and that could have happened in a prior or a subsequent visit. But we didn't really capture any of that. 

Robin: And were you able to get an idea of non-opioid treatment options being discussed, any complimentary medicine options? 

Dr. Marianne Matthias: Interestingly not really. There were--there's one clinic visit, one audio recording that I can think of where it was discussed a little bit. It was actually I didn't present that part of the quote but it was the quote where the doctor said he wanted to get his patient off this crap that he's on when he was referring to opioids in that way. And he elaborated on finding--maybe exploring physical therapy and other alternative treatments. But, and definitely nothing was mentioned related to CAM for pain. 

Robin: This is an interesting question because it sounded like the physicians all had somewhat long relationships with their patients but the biggest challenges of the therapeutic alliance is the new patient who comes in demanding opioids. Are there any insights that you have from your research to share with from with everyone? 

Dr. Marianne Matthias: Yeah and we did have a couple of first visits, and those in many cases were the same patients that complained about their previous physicians which makes sense. And you know, I'm not sure I have any real insight to share related to that. You know, a lot of time it is the patients that are more demanding and more difficult that tend to do more of the changing from provider to provider. You know, a common complaint we hear anecdotally is that patients will--that physicians often inherit patients who are already on opioids, maybe even high doses of opioids and they're not sure what to do with that. So I mean just the best insight I have from the research I've done from this study as well as from other studies is really that the emphasis of concern for the patient as a person and for the patient and his or her health. You know, if you're talking about opioids, like I said a little bit earlier, make it clear you're putting the opioids on trial. You're not putting the patient on trial. And it just--it seems like from the work that we've done that visible demonstration of genuine concern for the patient can cover a multitude of mistakes or not even mistakes but just difficult situations or difficult decisions a physician might have to make. So that's the biggest take away that I can emphasize from this is I know that all you clinicians out there are concerned about your patients but I would encourage you to really emphasize that in a very clear communicative way. 

Robin: Great! I have a couple of comments and maybe to reflect your thoughts these are perhaps ideas for you in terms of extending your line of research. There are many side effects with long term opioid use. I wonder why addiction seems to be the main concern expressed by physicians. Interviews with the physicians would be interesting. 

Dr. Marianne Matthias: Yeah. That really is an excellent point. And I would say--and I may not have made this very clear from this particular presentation--but really addiction was primarily the biggest concern for the patients. it's not that physicians didn't talk about it. So don't get me wrong there. But physicians did express concern over other things. And I didn't present all the data here either. But liver toxicity was a big issue that physicians expressed concern about as well. But I think with the environment right now surround opioids that especially patients are more cognizant of addiction issues. So I think that those are likely to come up more. But we did hear some other concerns come up from the physicians. And I agree that physician interviews would be helpful for this. And we actually intended to--and we did. We interviewed three of the five physicians. One physician left the VA before we were able to do that interview and another physician simply wasn't able to, so. Because we really didn't get--we only had five physicians anyway. Since we didn’t get all of their interviews we didn't really do a lot of analysis on those interviews. 

Robin: Great! Here's kind of another idea for you. Have you thought about examining how patients' chronic pain--with chronic pain are prepared for procedures that may exacerbate management? 

Dr. Marianne Matthias: No. And that's an interesting question. It's not something that we have really ever considered but I think it's an excellent idea. 

Robin: Here's another interesting one. Are there any plans to do a similar study with individuals that have established comorbid, opioid, opiate dependence and chronic pain management issues? 

Dr. Marianne Matthias: Can you say that one again? 

Robin: Sure. Are there plans to do a similar study with individuals that you know going into the study have comorbid, opiate dependence, and chronic pain? 

Dr. Marianne Matthias: Yeah, you know, that's an interesting question as well. And I think it's an important one. We're actually tossing around what we want to do next right now. And I'm not sure if we're going to take an observational approach like we did here or if we're going to combine what we learned here with what we've learned from some other studies in some other areas and actually try to pilot an intervention that might help to improve some communication. So we're--that's definitely a consideration but we haven’t made any decisions yet on what the next study is going to be. 

Robin: Okay, great. Maybe you could just also talk about your feelings about the diversity of the sample that you studied. 

Dr. Marianne Matthias: Yeah. I mean it's a VA sample and as we all know it's not the most diverse sample that we could have. So it is what it is. And we can't do much about it. But because this is a qualitative study it's less concerning to me for this particular study because, as I said we weren't interested in trying to make generalizations or to say that most discussions about opioids, in most discussions about opioids there's a high degree of concordance. We're not trying to claim anything like that based on the data. We were really more interested in learning what people really talk about because most of the published literature is secondhand interview accounts. And those are really limiting. So we wanted to learn the kinds of things people talk about, how they talk about them, and how it sort of unfolds from that perspective. So I agree that diversity would not be a characteristic of this sample but fortunately for this study I don’t think it influences what we were trying to do with the data. 

Robin: Here's an interesting question, maybe you can share something that you might have learned about talking with patients about risks for opioid use without the patient walking away with that feeling that they're being suspected or accused of misuse. 

Dr. Marianne Matthias: Yeah. And that's so important. And I think that that's come up in many studies, and in some of them I talked about at the beginning. And you know, it definitely came up in this one too. And I would just go back again to say that I think one of the most important things is to make it clear that it's the opioid that's on trial, not the patient. And you know, that can be difficult to navigate especially--it can be difficult to navigate depending on the type of relationship the provider and the patient have, the type of--whether there's a substance abuse history with the patient. You know, there's a--it's simple to say. It's harder to actually do and I recognize that and I don’t want to over simplify it. But I do this it is critical any way possible to just really try to make that clear that it's really the opioid we're concerned about. 

Robin: Could you also maybe talk about sex differences that you--you probably didn't have enough patients to analyze of this, but whether you had any thoughts about particular challenges that women had in terms of obtaining treatment for their chronic pain? 

Dr. Marianne Matthias: Yeah, that is an excellent question. And you know, there's more and more research on disparities and pain management between women and men as well as blacks and whites. And unfortunately from this study, this study doesn't get us any closer to understanding that. But it's absolutely an important question to be asking in our future research. 

Robin: Oh, somebody just asked if they can get CEU credits or points for this training. Maybe Heidi can help us with that question. 

Moderator: Actually we're not offering CEU credits for this. This is the one I spoke with you and Bob about a couple months ago. And at this point we are not going to be offering CEU credits for the Spotlight on Pain Management series. 

Robin: This question is can you share the "good communication skills?" Maybe in the Power Point--I'm not sure I understand that question. 

Dr. Marianne Matthias: The question might be referring to some of the things I described where--that I didn't share in this particular presentation where we did observe some very skillful communication on behalf of the providers in terms of diffusing potentially contentious situations and things like that. So that might be what that's referring to. And what I would suggest is that I believe it's in the--can I--I can still navigate through these slides, right? 

Moderator: Yes you can. 

Dr. Marianne Matthias: Yeah. So if I go back there's two references I have early on of papers that we've published with this data. And so if I can get to that I can show you where you can go to get a little bit more detail because obviously I'm not able to go into all of the detail here. But here--and I believe it's--if the question is how I understand it I believe it's that first article, the one in patient education and counseling, 2013, that is going to point that person who asked the question toward the answer a little bit more specifically than I go into right now. 

Robin: Okay. I'm just waiting for a little bit more explanation. Thinking about possible interventions what is your feeling the big payoff may be, patient or provider facing interventions, and why? 

Dr. Marianne Matthias: Patient or provider what? 

Robin: Facing interventions...

Dr. Marianne Matthias: Yeah. 

Robin: I'm just seeing who you were thinking about who the target is provider or patient or a maybe a combination. 

Dr. Marianne Matthias: Yeah, that is an excellent question and that's a question that we have talked about many, many, many times. And I think it would be so cool to design a study where we actually tested that and we compared intervening with the patient versus intervening with the provider versus perhaps intervening with both versus a control. I think pragmatically where I am in my thinking about interventions is more on the patient side and a lot of that is for logistical reasons. Providers, I mean a lot of you are clinicians on this call. Providers are so busy. And I think asking them to do even one extra thing sometimes is very difficult. And I think that there have been some studies that have shown that brief interventions with patients can ensure decision making, for example, can really make a difference. So in terms of feasibility my inclination right now is leaning more toward the patient side. Now, you know, granted if you can intervene with providers you get a bigger bang for your buck, right, because providers have so many patients if you can influence one provider, you then in turn affect a lot of patients. So I'm not against provider interventions but I think there's challenges to both. There's pros and cons to both and it's--I don’t really have a good answer for which one is better at this point. 

Robin: Here's a question about a provider intervention. Can you tell us a little bit what's been done in terms of motivational interviewing in the pain context? 

Dr. Marianne Matthias: That's a really good question. And that's one that I really don't know a lot about. So I really can't elaborate on that at this time. 

Robin: I think we're out of question. Thank you so much Dr. Matthias for preparing and presenting. We very much appreciate it. Our audience had some really great questions and the clinical material is so helpful to explain your research. Just one more reminder to hold on another minute or two for the feedback form. Our next cyber seminar will be Tuesday May 6th by Dr. Kelly Allen. We will be sending registration information out to everyone around the 15th of the month. I want to thank everyone for joining at this HSR&D cyber seminar and we hope to see you at a future session. 

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