Communication between nurse care managers and patients who take opioids for chronic pain: Strategies for exploring aberrant behavior

Jane M. Liebschutz, MD, MPH; Allison V. Lange, MD; Orlaith D. Heymann, MA; Karen E. Lasser, MD, MPH; Pamela Corey, MSN, EdD, RN, CHSE; Christopher W. Shanahan, MD, MPH; Hannah S. Kopinski, BA; Jawad M. Husain, MD; Phoebe A. Cushman, MD, MS; Victoria A. Parker, EdM, DBA

doi:10.5055/jom.2018.0449

Authors

Jane M. Liebschutz, MD, MPH
Allison V. Lange, MD
Orlaith D. Heymann, MA
Karen E. Lasser, MD, MPH
Pamela Corey, MSN, EdD, RN, CHSE
Christopher W. Shanahan, MD, MPH
Hannah S. Kopinski, BA
Jawad M. Husain, MD
Phoebe A. Cushman, MD, MS
Victoria A. Parker, EdM, DBA

DOI:

https://doi.org/10.5055/jom.2018.0449

Keywords:

opioids, chronic pain, primary care, nurse care manager

Abstract

Objective: 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.

Design: 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.

Setting: Four primary care settings.

Participants: Two NCMs and 41 patients.

Main outcome measure: 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.

Results: 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.

Conclusions: These findings provide a potential model for the replication of intensive care management strategies utilizing NCMs in primary care.

Author Biographies

Jane M. Liebschutz, MD, MPH

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

Allison V. Lange, MD

Resident, Department of Internal Medicine, UTSouthwestern Medical Center, San Antonio, Texas

Orlaith D. Heymann, MA

Doctoral Student, Department of Sociology, University of Cincinnati, Cincinnati, Ohio

Karen E. Lasser, MD, MPH

Associate Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts; Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts

Pamela Corey, MSN, EdD, RN, CHSE

Nurse Educator, Department of Nursing, Boston Medical Center, Boston, Massachusetts

Christopher W. Shanahan, MD, MPH

Assistant Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts

Hannah S. Kopinski, BA

Medical Student, New York University, New York, New York

Jawad M. Husain, MD

Resident, Department of Psychiatry, Boston Medical Center, Boston, Massachusetts

Phoebe A. Cushman, MD, MS

Assistant Professor of Medicine, Division of General Internal Medicine, UMass Memorial Health Care, Worcester, Massachusetts

Victoria A. Parker, EdM, DBA

Associate Professor of Management, Department of Management, Peter T. Paul College of Business and Economics, University of New Hampshire, Durham, New Hampshire

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