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Associated with Expectations of Opioid Prescriptions for Acute Pain Control J Am Board Fam Med: first published as 10.3122/jabfm.2020.06.200096 on 20 November 2020. Downloaded from ORIGINAL RESEARCH Patient “Catastrophizing” Associated with Expectations of Opioid Prescriptions for Acute Pain Control Eriko Onishi, MD, MCR, Jennifer Lucas, PhD, Tetsuro Maeno, MD, PhD, and Steffani R. Bailey, PhD Background: The prescription of opioids for acute pain may be a driving factor in chronic opioid abuse. We examined patients’ characteristics associated with the expectation of the receipt of opioid prescriptions for acute pain control. Methods: A 1-time survey was administered to adult patients at family medicine clinics in the Pacific Northwest between November 2018 and January 2019. Logistic regression modeled adjusted odds of expecting an opioid prescription in ≥ 3 of the 4 dispositional acute pain scenarios by patient demo- graphics, opioid use, past-week pain intensity and duration, past-week anxiety, and pain catastrophizing. Results: The survey was completed by 108 patients (62% female, 48% between 30 and 49 years of age, 75% non-Hispanic Whites). Most patients (71%) expected an opioid prescription in ≥ 1 of the 4 scenarios; 26% expected a prescription in ≥ 3 scenarios. Patients with higher levels of pain catastroph- izing had more than 3 times greater odds of expecting opioids than those with lower pain catastrophiz- ing (OR, 3.73; P = .032; 95% CI, 1.12-12.46); no other characteristics were statistically significant. Conclusion: Higher pain catastrophizing was associated with increased odds of expecting opioids in dispositional acute pain scenarios in outpatient settings. Future studies can determine whether copyright. addressing pain catastrophizing reduces expectations of opioid prescribing for acute pain control. The finding that most patients expected opioid prescriptions in acute pain scenarios needs further explora- tion into other potential factors associated with these expectations. Evidence-based guidelines for con- dition-specific acute pain management are warranted for appropriate opioid prescribing and to guide treatment expectations. ( J Am Board Fam Med 2020;33:858–870.) Keywords: Acute Pain, Catastrophization, Family Physicians, Logistic Models, Opioid-Related Disorders, Opioids, Outpatients, Pain Management, Physician’s Practice Patterns, Surveys and Questionnaires http://www.jabfm.org/ Introduction use. Increasingly, studies suggest that opioid expo- The opioid epidemic in the United States has sure for acute pain control (ie, sudden onset of pain resulted in increased efforts to reduce chronic opioid that lasts no longer than 90 days1) could be a leading cause of chronic opioid abuse.2,3 Systematic reviews largely agree that opioids have greater short-term an- on 26 September 2021 by guest. Protected This article was externally peer reviewed. algesic efficacy than placebos4; thus, opioids are rou- Submitted 11 March 2020; revised 17 June 2020; accepted 18 June 2020. tinely used for acute pain management in many US From the Department of Family Medicine, Oregon health care settings.1,3 In 2000, the Joint Commission Health & Science University, Portland (EO, JL, SRB); Department of Primary Care and Medical Education, introduced standards for organizations to improve University of Tsukuba, Tsukuba, Japan (TM). care for patients with pain, which included emphasiz- Funding: None. ing the need for organizations to perform systematic Conflict of interest: None. Author contributions: EO, TM, and SRB developed the assessments using quantitative measure for pain (eg, survey. EO conceived of the manuscript concept. EO con- place pain on a 10-point score).5 These standards may ducted analysis of the outcome supervised by JL. EO, JL, TM, and SRB drafted the manuscript and contributed to the manuscript revisions. Corresponding author: Eriko Onishi, MD, MCR, Department 3181 SW Sam Jackson Park Road, OR 97239 (E-mail: of Family Medicine, Oregon Health & Science University, [email protected]). 858 JABFM November–December 2020 Vol. 33 No. 6 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2020.06.200096 on 20 November 2020. Downloaded from have resulted in increasing opioid prescriptions in the waiting rooms at 2 family medicine clinics in US health care system.5 Recently, with increasing Portland, Oregon: Clinic A serves a high proportion knowledge of the highly addictive properties of of patients with private insurance, and Clinic B, opioids and significantly increased mobility and mor- which is a federally qualified health center (FQHC), tality from opioid use, prescribing patterns of opioids primarily serves Medicaid-insured or uninsured have been changing as general guidelines are being patients. developed to encourage limiting opioid prescription for both chronic (ie, pain that persists or recurs for Recruitment Methods and Inclusion Criteria more than 3 months1,6) and acute pain.1,7 Adult patients were recruited from the waiting Studies have examined patient factors associated rooms of 2 clinics. The principal investigator visited with receipt of opioids for chronic pain in outpatient each clinic waiting room multiple times between settings and postsurgical opioid use; however, to our November 2018 and January 2019. Visits to the clin- knowledge, none have examined the patient charac- ics varied in length and occurred at varying times of teristics associated with the expectation of provision the day depending on the investigator’s schedule. of opioids for acute pain control in outpatient set- Patients in the waiting room were approached to ask – tings.8 11 Several studies on postsurgical acute and if they would be willing to complete a survey on chronic pain showed that increased anxiety and opioid use and pain. Patients were verbally assessed depression are associated with increased opioid for study eligibility, which included being a patient at requirement and patients who were anxious had sig- the clinic for a scheduled appointment or an accom- nificantly higher pain scores compared with less anx- panying family member who identified as being a – ious patients.12 17 Pain catastrophizing, a cascade of patient of the clinic, at least 18 years of age, could negative thoughts and emotions in response to actual read and write English, and who could provide verbal or anticipated pain,18 is shown to predict delayed consent; there were no other inclusion or exclusion opioid cessation after surgery19 as well as predict acute criteria for participation. – copyright. postoperative pain and chronic postsurgical pain.16,20 23 Pain catastrophizing has been associated with long- Survey Creation Process term opioid use,24 opioid craving,25 and opioid mis- The study team created the original survey. The use26 in outpatient settings. One study among a chronic survey was piloted with 10 randomly recruited indi- pain population found a significant relationship viduals (patients or family members who were visit- between pain intensity and opioid prescriptions that ing the lobby of the health center in which one of was much stronger in women, especially those with the study clinics was located). Verbal feedback was high levels of pain catastrophizing.18 Demographic solicited after completion of the survey and used to develop the final version. characteristicshavebeenfoundtobeassociatedwith http://www.jabfm.org/ acute and chronic postsurgical pain intensity and opioid use, as well as in chronic opioid use in primary care set- Survey Measures – tings, including age,9,27,28 gender,15,29 31 race,9 socioe- After providing verbal consent, participants com- conomic status,10,17,32 and education level.14 pleted a 21-question article survey in writing. The current study examines patients’ expectations (Appendix Table 1 includes survey items analyzed of receipt of an opioid prescription for acute pain con- in this article). It took an average of 10 to 15 minutes trol and patient characteristics associated with these to complete the survey; patients either completed the on 26 September 2021 by guest. Protected expectations. Understanding the factors associated survey while in the waiting room or while in the ex- with expectations of opioids among patients, especially amination room and returned the survey to the prin- for acute pain relief in outpatient settings, could aid in cipal investigator before leaving the clinic. The providing patient-centered health care and education following items are included in the current analysis. with the goal of reducing unnecessary opioid exposure. Demographics Participant demographic information including: age Methods (18to29years,30to39years,40to49years,50to Study Design and Settings 59 years, 60 to 69 years, 70 to 79 years, and > 80 years This cross-sectional study utilized a 1-time survey old), gender (male, female, prefer not to describe, with a convenience sample of patients in clinic prefer not to answer), ethnicity (Hispanic, non- doi: 10.3122/jabfm.2020.06.200096 Patient “Catastrophizing” and Expectations of Opioid Prescriptions 859 J Am Board Fam Med: first published as 10.3122/jabfm.2020.06.200096 on 20 November 2020. Downloaded from Table 1. Patient Demographics (n = 108) † ‡ Total* Clinic A Clinic B N (%) N (%) N (%) P Value§ Gender 108 54 (50.00) 54 (50.00) .47 Female 67 (62.04) 35 (32.41) 32 (29.63) Male 40 (37.04) 18 (16.67) 22 (20.37) Other 1 (0.93) 1 (0.93) 0 Age, years 108 54 (50.00) 54 (50.00) .41 18 to 29 11 (10.19) 7 (6.48) 4 (3.70) 30 to 39 28 (25.93) 15 (13.89) 13 (12.04) 40 to 49 24 (22.22) 15 (13.89) 9 (8.33) 50 to 59 17 (15.74) 8 (7.41) 9 (8.33) 60 to 69 19 (17.59) 6 (5.56) 13 (12.04) 70 to 79 6 (5.56) 2 (1.85) 4 (3.70) ≥ 80 3 (2.78) 1 (0.93) 2 (1.85) Ethnicity 104 54 (51.92) 50 (48.08) .80 Hispanic 6 (5.77) 3 (2.88) 3 (2.88) Non-Hispanic 95 (91.35) 50 (48.08) 45 (43.27) Prefer not to answer 3 (2.88) 1 (0.96) 2 (1.92) Race 107 53 (49.53) 54 (50.47) .45 Black 9 (8.41) 4 (3.74) 5 (4.67) White 80 (74.77) 39 (36.45) 41 (38.32) Asian 7 (6.54) 5 (4.67) 2 (1.87) Native American 2 (1.87) 2 (1.87) 0 Pacific Islander 0 0 0 Other 7 (6.54) 2 (1.87) 5 (4.67) copyright.
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