Liebschutz Jane M, Lange Allison V, Heymann Orlaith D, Lasser Karen E, Corey Pamela, Shanahan Christopher W, Kopinski Hannah S, Husain Jawad M, Cushman Phoebe A, Parker Victoria A
Visiting Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Associate Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts.
Resident, Department of Internal Medicine, UTSouthwestern Medical Center, San Antonio, Texas.
J Opioid Manag. 2018 May/Jun;14(3):191-202. doi: 10.5055/jom.2018.0449.
One approach to potential misuse of prescription opioids by patients with chronic pain is team-based collaborative primary care, with primary care visits complemented by frequent visits with nurse care managers (NCMs) specializing in addiction care. However, little is known about the communication strategies NCMs employ in these visits. This study aimed to describe strategies NCMs used with patients when discussing aberrancies encountered during opioid monitoring.
Observational study of NCM-patient interactions. Patients' primary care providers had been randomized to the treatment arm of a study evaluating an intervention, of which NCM visits were part, to change opioid prescribing patterns. The overall intervention was found to be successful.
Four primary care settings.
Two NCMs and 41 patients.
Forty one interactions between two NCMs and 41 unique patients were directly observed, and the detailed field notes coded for strategies using conventional content analysis.
Five themes describing strategies that NCMs use to navigate aberrant patient behavior emerged: (1) NCM develops therapeutic relationship with patient; (2) NCM encourages adherence to monitoring strategies by contextualizing intensive opioid management for patient; (3) NCM inquires into discrepancies between patient's narrative and objective data to further understand aberrancy; (4) NCM assesses patient's medication use and pain to obtain more information about aberrancy and determine risk for opioid misuse; and (5) NCM educates patient and makes recommendations to guide appropriate medication use.
These findings provide a potential model for the replication of intensive care management strategies utilizing NCMs in primary care.
慢性疼痛患者潜在滥用处方阿片类药物的一种应对方法是基于团队的协作式初级保健，即初级保健就诊辅以由专门从事成瘾护理的护士护理经理（NCM）进行的频繁就诊。然而，对于NCM在这些就诊中采用的沟通策略知之甚少。本研究旨在描述NCM在讨论阿片类药物监测期间遇到的异常情况时与患者使用的策略。
对NCM与患者互动的观察性研究。患者的初级保健提供者已被随机分配到一项评估干预措施的研究的治疗组，NCM就诊是该干预措施的一部分，目的是改变阿片类药物的处方模式。结果发现总体干预是成功的。
四个初级保健机构。
两名NCM和41名患者。
直接观察了两名NCM与41名不同患者之间的41次互动，并使用传统内容分析法对策略的详细现场记录进行编码。
出现了五个描述NCM用于应对异常患者行为的策略的主题：（1）NCM与患者建立治疗关系；（2）NCM通过为患者将强化阿片类药物管理情境化来鼓励其坚持监测策略；（3）NCM探究患者叙述与客观数据之间的差异以进一步了解异常情况；（4）NCM评估患者的用药情况和疼痛程度以获取更多关于异常情况的信息并确定阿片类药物滥用风险；（5）NCM对患者进行教育并提出建议以指导合理用药。
这些发现为在初级保健中利用NCM复制重症护理管理策略提供了一个潜在模型。
