Purpose
Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients’ decision-making process on postoperative opioid use.
Methods
We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.
Results
We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons “know,” thereby, reinforcing their trust in surgeons’ postoperative opioid prescribing to be in the participants’ best interest. Moreover, the positive reputation of the institution strengthened the participants’ trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as “suspicious,” and the pharmaceutical companies, that were “despised.” Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.
Conclusions
Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.
Clinical relevance
Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.
The opioid epidemic in the United States has been fueled by diverted prescription opioids from postoperative prescribing, with large quantities of excess opioids generated from outpatient surgical procedures.
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Patient-centered care remains a top health care priority, and prior research has demonstrated the importance of aligning opioid prescribing practices with patients’ needs and preferences to achieve safe, effective pain control. However, current policies and guidelines on postoperative prescribing often assume a “one-size-fits-all” approach that is not tailored to the individual patient.
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Despite the emphasis on the need for individualized pain management strategies and the common use of opioids for acute pain control, little is known about the nature and the process through which patients decide to use opioid pain medications after surgery. Wide media coverage of the opioid epidemic and related public service announcements have increased public awareness of the opioid-related harms, but we do not understand how that knowledge has influenced the way patients perceive postoperative prescribing practice. Furthermore, we lack understanding of how patients’ relationship with the surgeon influences their choice to use opioids after surgery.
In this context, we sought to investigate patients’ decision-making process on postoperative opioid use to determine the important factors that influence their choices, including the individuals involved in the care and other elements of the care pathway. Specifically, we sought to explore the role that the patient-doctor relationship plays in shaping patients’ beliefs and attitudes toward opioid use after surgery. Our findings will help frame opioid prescribing guidelines to be more patient-centered and aligned with patients’ needs in postoperative pain control.
Discussion
In our investigation, participants demonstrated the process through which they decided on future postoperative opioid use, and we found that trust plays an integral role in decision-making. Trust is an essential element in establishing treatment relationships that influences satisfaction, communication, competency, and privacy.
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It is the core attribute that describes and empowers the physician-patient therapeutic alliance, and as an instrument, it influences patients’ willingness to seek care, reveal sensitive personal information, and adhere to treatment regimens. Lack of trust, or distrust, brings forth wariness and uncertainty within patients to follow the prescribed treatment course.
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The participants evaluated and negotiated their feelings of trust toward those involved in their care to make the best decision. Trust toward the surgeon, institution, and their own protection from addiction compared to other people allowed them to perceive postoperative opioid use as safe. In our thematic analysis, we saw that the principles of bioethics would provide the framework that would help us interpret our findings.
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Under the principles of beneficence and nonmaleficence, patients believed that the prescribed pain regimen would be the most appropriate one balancing benefits and risks. However, the participants’ distrust toward the pharmaceutical companies and the opioids themselves discouraged them from using opioids after surgery as they did not abide by justice. Despite the generalized trust in surgeons, patients often expressed nuanced trust toward opioid prescribing. They wanted to discuss postoperative pain management and the benefits and risks of using opioids with their surgeons. Autonomy was reflected in patients’ wish for surgeons to trust them with opioids. Our findings highlight the importance of trust in the patient-doctor relationship for postoperative opioid prescribing.
Several studies have described trust as a central element in successful treatment relationships. For example, higher levels of trust were associated with improved adherence to colorectal screening guidelines, satisfaction with providers’ communication, and a sense of involvement in the treatment decision-making.
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However, when it comes to opioid prescribing and use for acute pain control after surgery, there is little evidence on how trust plays a role in decision-making for postoperative pain control. Furthermore, although it is widely accepted that a patient-centered approach for effective pain management while minimizing risks is required, there is not a good understanding of how patient-doctor relationships and trust between them can have an influence on the patients’ perception of opioids and, ultimately, their choice of drug for postoperative pain control. In our qualitative investigation, we identified that patients not only factor their trust in the surgeon into their decision-making process but also include how they feel about the medical institution, pharmaceutical companies, the medication itself, and others’ opioid use. It may seem incongruent that the patients would take opioid medications, which they distrust, just because they were prescribed by the surgeons, who they trust. However, this relationship actually highlights the importance of trust in the patient-doctor relationship and how much it can influence the patients’ decision-making process. Our findings demonstrate the complex nature of patients’ decision-making process regarding postoperative opioid use and emphasize the importance of harnessing the trust in the doctor-patient relationship to develop patient-centered strategies to reduce opioid-related harms.
Current guidelines on postoperative opioid prescribing impose a rather uniform restriction on the size of opioid prescriptions, which can harm the therapeutic alliance and reduce patients’ trust in the provider.
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It has been demonstrated that for patients on long-term opioid therapy for pain, implementation of policies restricting the prescription sizes leads to lower levels of rapport and trust in the patient-doctor relationship.
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We found that even in the case of short-term opioid use, some patients may feel stigmatized and misjudged that the surgeons do not trust them and assume that they will abuse the medications. In fact, patients expressed a strong desire for honest discussions with their surgeons about postoperative pain management and the risks and benefits of using opioids for pain management, to develop informed trust in the care that they were prescribed.
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Policies based on “one-size-fits-all” models may invoke distrust in the patient-surgeon relationship and lead to suboptimal outcomes.
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To effectively reduce opioid-related morbidity and mortality while providing adequate pain control, strategies that encourage informed communications to strengthen the patient-doctor relationship through building trust are required.
Our study has a few limitations. Owing to the inherent nature of qualitative research and thematic analysis, our findings of 6 major themes may not be applicable to all patient populations. There may be other ways patients perceive and make decisions on postoperative opioid use based on their trust and distrust in the surgical and pharmaceutical providers. Nevertheless, our investigation provides insight into understanding how patients process various factors that influence their postoperative pain decisions. Second, our study participants were recruited from patients who received care at a tertiary care institution with an excellent reputation.
43University of Michigan Hospitals - Michigan medicine
US News and World Report.
Therefore, it is possible that our participants placed greater levels of trust in the institution and the surgeons affiliated with the system and were more likely to participate in the study. However, our thematic analysis results demonstrating that the concept of trust and distrust governs patients’ decision-making process on opioid use is still valid and thus offers an opportunity to approach postoperative pain management from a patient-centered perspective. Third, our study participants were those who underwent outpatient, elective hand surgeries and may not have expected to receive many opioid medications, if any were to be prescribed. This may have resulted in selection bias. Lastly, qualitative research carries an inherent risk of subjective bias by the investigators, especially in coding and thematic analysis. We have mitigated this bias by having 3 investigators perform the coding independently and discuss to agree on a codebook before the full thematic analysis was performed.
From a qualitative approach, we found that patients form their preferences based on the inherent trust and distrust toward those involved in their care, including themselves. Our findings emphasize the importance of harnessing trust and patient-doctor relationships in our approach to postoperative opioid prescribing while minimizing the opioid-related harms. Surgeons should seek to build informed trust with their patients through effective communications that strengthen the therapeutic alliance for postoperative pain control.
Article info
Publication history
Published online: December 13, 2021
Accepted:
October 27,
2021
Received:
November 12,
2020
Footnotes
Drs Cho, Billig, and Haase received the American Foundation for Surgery of the Hand Clinical Research Grant (Award 1919). Dr Cho received a surgical scientist training grant in health services and translational research (5-T32-GM008616-16A1) from the National Institutes of Health Ruth L. Kirschstein National Research Service Award. Dr Waljee received funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse (R01 DA042859). Dr Chung received funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and is a Consultant to Axogen and Integra. No benefits in any form have been received or will be received by the other authors related directly or indirectly to the subject of this article.
Copyright
© 2022 by the American Society for Surgery of the Hand. All rights reserved.