Table 4

Themes and Findings From Clinician Interviews

ThemesFindingsExample Quotes
Inheriting patients on chronic opioidsClinicians feel frustrated after inheriting patients with chronic pain on opioids.“Her pain doctor got fired or, you know, loss of license (I can’t remember what happened) so she came to me very angry, very difficult conversation wanting to be on the same huge doses.”
Clinicians feel pressured to manage inappropriate amounts or types of chronic opioids.“I get a call from the case manager who says would you be willing to consider the following: Would you be willing to consider prescribing her methadone as a pain management medication and not as methadone maintenance for her substance abuse disorder…. Looking back now it’s one of these …what the heck was I thinking kind of thing…. I sort of felt like I was getting stiff-armed into things.”
Primary care often becomes the default chronic pain medication manager.“She is seeing a psychiatrist, a pain specialist, an orthopedist, and a rheumatologist. She’s got all of these people involved in her care but, for some reason, I’m the person who stuck with her pain med management and nobody is super-eager to touch that.”
Co-occurring health problemsExtent or complexity of medical comorbidities often takes priority.“He’s kind of a mess…. Bad asthma. Bad COPD. Bad heart. He’s been in the hospital more than he’s been out and was diagnosed with leukemia about six months ago. I told him, you know, your pain pills are the least of my concerns; whatever it takes to get you through the day.”
Patients with chronic pain often have complex social situations.“She’s someone I’ve been trying to wean but her social situation is just a disaster. She’s leaving an abusive relationship. I think she’s actually homeless right now.”
Contraindication of nonopioid pain medications limits pain management strategies.“I will say that the older ones …have crappy kidneys and contraindications to a lot of other things that you could actually put them on to help with their pain.”
Access to adjunctive pain management strategies is limited.“She’s stable and is a single mom working and has limited access to adjunctive therapies and physical therapies. I’m a little stuck on her.”
Benefits of opioids for chronic pain managementChronic opioids are necessary to sustain functional capacity and quality of life.“I feel like a change is not indicated at this time because she needs the medication in order to do her job and go to work and help her family, and it is working for her. She is overall low-risk for abuse. I don’t feel compelled to make a change for her.”
Chronic opioids help manage chronic diseases.“She’s got chronic pancreatitis and without this dose she can’t eat and she gets malnourished and gets really sick.”
Challenges with weaningClinicians lack time to manage chronic opioids.“It might be different if I were a chronic pain management doctor and I was seeing 20 patients a day every day and just doing this.”
Lack of control over other sources of opioids undermines weaning attempts.“The amount of narcotics she gets in the hospital blows us out of the water. The problem is she is on around-the-clock high-dose IV-pain medicine when she goes to the hospital.”
Clinicians have a hard time justifying weaning stable patients receiving long-term opioid pain management.“It’s very hard with patients who have been on them [a long time] to get them off…. Five to seven years ago, [when many of my patients started on opioid], this wasn’t even part of the cultural discussion. It was like patients just came in and demanded these medications, they could be downright hostile with you. Now, I could tell them we’re going to wean down, but it would be a really ugly fight.”