It seems more folks are starting to see that our current medical system and its methods have made doctors and patients into adversaries. Both initially assume the other isn’t truthful, is either maximizing (patient) or minimizing (doctors) pain.
It’s become a contest: patients want the pain relief opioids provide and doctors want to avoid prescribing them. Both parties have valid reasons for their views and both have valid reasons to distrust the other, a sorry situation for all fo us.
Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care – PubMed – free full-text /25261714/ – Dec 2014
Findings revealed that patients’ narratives focus on suffering from chronic pain, with emphasis on the role of opioid therapy for pain relief, and physicians’ narratives describe the challenges of treating patients with chronic pain on COT.
Results elucidate the perceptions of ideal vs difficult patients and show that divergent patterns surrounding the consequences, utility, and goals of COT can negatively affect the doctor-patient relationship.
The findings have significant implications for improving doctor-patient communication and health outcomes by encouraging shared decision making and goal-directed health care encounters for physicians and patients with chronic pain on COT.
Below is what the AMA Journal of Ethics thinks:
This commentary responds to a case and examines pragmatic concerns about operating a busy outpatient practice in compliance with new laws that regulate opioid prescribing.
Specifically, the article considers how regulating opioid prescribing can influence the therapeutic alliance in patient-physician relationships and how innovations in decision science can facilitate shared decision making given time constraints.
Several studies have demonstrated SDM’s benefits in the context of opioid prescribing. SDM can reduce opioid use and increase physician satisfaction in prescribing opioids for patients with chronic pain.
Moreover, the finding that patients and clinicians offer conflicting narratives about chronic opioid therapy underscores the special need for SDM among these patients.
Enter Decision Science
Choice architecture is one such technique described by Moore et al as “the art of shaping decisions by designing choices within a framework that will encourage a certain choice.”
One technique in particular—nudging—can be especially useful in facilitating SDM in such circumstances.
Nudges can be used to frame decisions about the appropriate treatment without eliminating patient choice.
There are many damaging ways to offer decisions “without eliminating patient choice”, like “framing a decision” as “do you want to die in a year or in two years?”.
For example, whether Dr M tells LJ that
- “continuing your current opioid prescription has a chance of leading to opioid dependence in 15% of cases” or
- “continuing your current opioid prescription will not lead to dependence in 85% of cases”
can influence how LJ frames the decision and chooses to proceed.
Dr M’s choice of which phrase to use during shared decision making with LJ would enable LJ to retain decision-making authority and Dr M to bring to bear her clinical expertise and experience.
the ethicality of nudges is context dependent, and prescribers should use language to influence the formation of patients’ perspectives and decisions only to promote patients’ best interests.
This sounds awful: disrespectful and ethically wrong. However, if the result of this influence is to prolong a life or prevent an illness, it becomes very hard to draw a line between “good healthy” nudges and “self-interested” nudges.
However, it should be noted that Tobin et al question the language used in an analogous form, the patient-provider agreement (ie, “pain contracts” for patients receiving chronic opioid therapy), which seems to stigmatize the patient and thereby risk undermining patient-clinician trust.
Although the Opioid Start Talking form could facilitate shared decision making in some cases, it could threaten the therapeutic alliance in others.
Framing the Opioid Start Talking form in terms of shared decision making about opioid management for pain care could help avoid distrust.
And that very attitude of “framing” from the start is clearly visible in all such “forms” related to opioids.