Unintended Consequences of Opioid Regulations in Older Adults With Multiple Chronic Conditions

Christine S. Ritchie, MD, MSPH; Sarah B. Garrett, PhD; Nicole Thompson, BA; Christine Miaskowski, RN, PhD, FAAN


Gerontologist. 2020;60(7):1343-1352. 

In This Article

Design and Methods

We used inductive thematic analysis (Bradley, Curry, & Devers, 2007; Nowell, Norris, White, & Moules, 2017) to identify and characterize themes in qualitative semi-structured interview data from older adults who met the following criteria: age 65 or above, no cognitive impairment, three or more self-reported chronic medical conditions, and pain for ≥6 months.

We recruited participants with chronic pain from the Optimizing Aging Registry, a research registry comprised of older adults from the greater metropolitan Bay Area. Study coordinators contacted potential participants via phone, described the study, and screened for the criteria described above. Participants reporting increased confusion or memory loss in the past year were evaluated over the phone (Brief Screen for Cognitive Impairment; Hill et al., 2005) and in person (Mini-Cog; Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000) to rule out cognitive impairment. The study team employed purposive sampling to recruit individuals from across the socioeconomic spectrum.

Interviews took place at a location of the respondents' choice, typically the research office or the participant's home, and lasted approximately 45–120 min. The participants reported basic demographic information and described their chronic conditions. Participants selected chronic conditions from a list of 13 common medical conditions taken from the Self-Administered Comorbidity Questionnaire (Sangha, Stucki, Liang, Fossel, & Katz, 2003) and reported additional conditions not on this list. The interviews assessed the respondents' experiences with chronic pain; their pharmacological and nonpharmacological pain management efforts; the effects of pain on their lives; their awareness of the opioid epidemic; and their perceptions of the epidemic's effects on them (see Supplementary Material for the full interview guide).

Interviewees' experiences with opioids and their perspectives on the opioid epidemic were captured by questioning about past treatment experiences and by questions like, "In the past several years, there have been a lot of news around opioids or narcotics, including how they have been misused, and how some people have experienced overdoses or serious side effects from them. Do you think this issue has affected the way your pain is being managed?" and "Have your opinions of pain medications changed over time related to your own experience, those of others, or news reports?" All participants provided written informed consent, approved the digital recording of the interview, and received a $30 gift card. All activities were approved by the UC San Francisco Institutional Review Board.

The interview recordings were professionally transcribed and entered into ATLAS.ti, a computer-assisted qualitative data analysis platform (Scientific Software Development GmbH, Berlin, Germany). One author with qualitative coding expertise who had conducted the interviews (N.T.) and an author with doctoral training in qualitative research methods (S.B.G.) independently reviewed then discussed the data to identify broad topic areas that recurred in respondent discussions of opioid analgesics (e.g., medication access, concerns about opioid use, side effects, effectiveness for pain management). They cocoded 25% of the transcripts in ATLAS.ti with these topics, achieving intercoder agreement of greater than 90%. One author (N.T.) then coded the rest of the data, thereby indexing the data for more in-depth analysis.

For this paper, these authors and two senior clinician-scientists with expertise in thematic qualitative data analysis (Nowell et al., 2017) and clinical pain management (C.R., C.M.) independently reviewed all paragraphs coded with one or more of the following topics: access to opioid medications; concerns about opioid treatment; personal experiences with opioid medication; and perspectives on the opioid epidemic and its effects. Using inductive thematic analysis, the research team iteratively discussed, identified, and characterized themes (Bradley et al., 2007; Nowell et al., 2017). Specifically, over the course of several readings of the data, the authors first independently, then collaboratively, worked to identify (a) experiences, (b) perspectives, and (c) relationships among these that were recurrent and salient in respondents' narratives. To explore potential differences between individuals who had and had not used opioids for chronic pain, they reviewed the data within and across these respondent groups. Finally, they refined identified themes through discussion, reviewing the raw data, and considering counterfactual examples (e.g., attention to stability or improvement of the patient–clinician relationship as counterpoints to the examples of worsened relationships). The research team documented analytic discussions, decisions, and theme development and achieved consensus on the themes presented.