Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Center for Pharmaceutical Policy and Prescribing, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2024 Mar 4;7(3):e241342. doi: 10.1001/jamanetworkopen.2024.1342.
Guidelines recommend deprescribing opioids in older adults due to risk of adverse effects, yet little is known about patient-clinician opioid deprescribing conversations.
To understand the experiences of older adults and primary care practitioners (PCPs) with using opioids for chronic pain and discussing opioid deprescribing.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study conducted semistructured individual qualitative interviews with 18 PCPs and 29 adults 65 years or older prescribed opioids between September 15, 2022, and April 26, 2023, at a Boston-based academic medical center. The PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using and discussing opioid medications with PCPs.
Shared and conflicting themes between patients and PCPs regarding perceptions of opioid prescribing and barriers to deprescribing.
In total, 18 PCPs (12 [67%] younger that 50 years; 10 [56%] female; and 14 [78%] based at an academic practice) and 29 patients (mean [SD] age, 72 [5] years; 19 [66%] female) participated. Participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged in both patient and PCP interviews: opioids were used as a last resort, opioids were used to improve function and quality of life, and trust was vital in a clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and PCPs focusing on adverse drug events. Both groups felt deprescribing conversations were often unsuccessful but had conflicting views on barriers to successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred, and many patients had prior negative experiences tapering. The PCPs described gaps in knowledge on how to taper, a lack of clinical access to monitor patients during tapering, and concerns about patient resistance.
In this qualitative study, PCPs and older adults receiving long-term opioid therapy viewed the use of opioids as a beneficial last resort for treating chronic pain but expressed dissonant views on the risks associated with opioids, which made deprescribing conversations challenging. Interventions, such as conversation aids, are needed to support collaborative discussion about deprescribing opioids.
由于不良反应的风险，指南建议为老年人减少阿片类药物的使用，但对于老年人和初级保健医生（PCP）使用阿片类药物治疗慢性疼痛和讨论减少阿片类药物使用的情况知之甚少。
了解老年人和初级保健医生（PCP）使用阿片类药物治疗慢性疼痛以及讨论减少阿片类药物使用的经验。
设计、地点和参与者：这是一项定性研究，于 2022 年 9 月 15 日至 2023 年 4 月 26 日在波士顿的一家学术医疗中心对 18 名 PCP 和 29 名 65 岁或以上服用阿片类药物的成年人进行了半结构式个体定性访谈。PCP 被要求描述他们为老年人开阿片类药物和减少阿片类药物使用的经验。患者被要求描述他们与 PCP 就阿片类药物使用进行讨论的经历。
患者和 PCP 对阿片类药物处方和减少阿片类药物使用的障碍的看法，存在共同和冲突的主题。
共有 18 名 PCP（12 名[67%]年龄小于 50 岁；10 名[56%]为女性；14 名[78%]在学术机构工作）和 29 名患者（平均[标准差]年龄，72[5]岁；19 名[66%]为女性）参与了研究。参与者表示，PCP 和患者之间关于慢性疼痛使用阿片类药物的讨论通常具有挑战性，并且关于阿片类药物风险和减少阿片类药物使用的讨论并不常见。患者和 PCP 的访谈中都出现了与慢性疼痛使用阿片类药物相关的三个常见主题：阿片类药物是最后的治疗手段；阿片类药物用于改善功能和生活质量；在医患关系中信任至关重要。患者和 PCP 对阿片类药物的风险表达了相互冲突的观点，患者关注成瘾，而 PCP 关注药物不良反应。两组都认为减少阿片类药物使用的对话往往不成功，但对成功对话的障碍有不同的看法。患者认为减少阿片类药物使用通常是不必要的，除非出现不良反应，而且许多患者以前在减少药物剂量时都有过负面经历。PCP 描述了在如何减少剂量方面知识的差距，在减少剂量期间缺乏临床途径来监测患者，以及对患者抵制的担忧。
在这项定性研究中，接受长期阿片类药物治疗的 PCP 和老年人将阿片类药物作为治疗慢性疼痛的有益的最后手段，但对与阿片类药物相关的风险表达了不同的看法，这使得减少阿片类药物使用的讨论具有挑战性。需要干预措施，如对话辅助工具，以支持关于减少阿片类药物使用的协作讨论。
