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

Disclosures

Gerontologist. 2020;60(7):1343-1352. 

In This Article

Sidebar

Description of Pain

I would like to start by understanding more about the pain that you experience.

• Tell me the story of your chronic pain.(Alt: give me all the details of your chronic pain/help me understand the history of your chronic pain.)

   • Probe: Walk me through a typical day with pain.

   • Probe: What does a good day look like?

   • Probe: What does a bad day look like?

   • Probe: How does your pain affect you physically?

   • Probe: How does your pain affect you emotionally?

   • Probe: How has your sleep changed since your chronic pain started?

   • Probe: How many hours of sleep did you normally get before your chronic pain started?

   • Probe: Can you give me a couple descriptive words?

   • Probe: Can you tell me where you experience pain?

      • Generalized vs. specific site (options: head/neck/shoulder/arms/wrists/hands/back/chest/Stomach/HIP/knees/legs/feet/other

• Take a few minutes to think about how you would complete this sentence: 'If it weren't for my chronic pain, I'd be able to ____.'

• Describe how often your pain bothers you.

   • Probe:

      • EVERY DAY (7 DAYS A WEEK)

      • MOST DAYS (5-6 DAYS A WEEK)

      • SOME DAYS (2-4 DAYS A WEEK)

      • RARELY (ONCE A WEEK OR LESS)

• When did your pain start?

   • Probe: What contributes to your pain?

   • Probe: How has your experience of pain changed over time, as you have aged?

• I want to ask you a couple specific questions about the intensity of your pain. I apologize if you have already described this to me, but we are trying to put some numbers to your experience as a way to compare to others. [Pain Intensity (from PROMIS Item Bank)]:These next questions have answer choices I will read aloud. [If participant is having hard time with questions or their response elicits a story, let the questions become qualitative and then circle back at the end to get numbers/quantification]]

   • In the past 7 days, how intense was your pain at its worst?

No pain  Mild pain  Moderate pain  Severe pain  Very severe pain

   • In the past 7 days, how intense was your average pain?

No pain  Mild pain  Moderate pain  Severe pain  Very severe pain

   • What is your level of pain right now?

No pain  Mild pain  Moderate pain  Severe pain  Very severe pain

• These next questions ask how your pain interferes with your life [Pain interference form 8a (from PROMIS Item Bank)]: [If participant having hard time with questions or their response elicits a story, let the questions become qualitative and then circle back at the end to get numbers/quantification]

   • In the past 7 days, how much did pain interfere with your day-to-day activities, which can include work around the home or household chores?

   Not at all  A little bit  Somewhat  Quite a bit  Very much

   • In the past 7 days, how much did pain interfere with your ability to participate in social activities or things you usually do for fun?

   Not at all  A little bit  Somewhat  Quite a bit  Very much

   • In the past 7 days, how much did pain interfere with your enjoyment of life?

   Not at all  A little bit  Somewhat  Quite a bit  Very much

   • In the past 7 days, how much did pain interfere with your family life?

   Not at all  A little bit  Somewhat  Quite a bit  Very much

Medications

Next, I would like to talk with you about themedications you have taken for pain.

• Walk me through the medications you are taking now to manage your pain.

   • [If they are not able to remember the names of medications, probe:] Some medications that are used to manage pain are:

      • Opioids like:

         • Fentanyl: Brands- Duragesic, Subsys, Abstral, and Ionsys

         • Hydrocodone and Acetaminophen: Brands- Norco, Vicodin, Lorcet, Hycet, Zamicet,

         • Morphine

         • Methadone

         • Oxycodone

         • Oxycontin

         • Tramadol

      • Tylenol (Acetaminophen)

      • Aspirin (Bayer)

      • Gabapentin (Neurontin)

      • Pregabalin (Lyrica)

      • Duloxetine (Cymbalta)

      • Lidocaine patches

      • Xanax, Ativan, Restoril

      • Valium

      • Marijuana

      • [For each medication answer]:

• How much pain relief do you receive from [medication]?

• When you take these medicines, how much did your pain interfere with your day-to-day activities?

• Now I am going to ask you to think about medications that you have taken in the past for pain: tell me about those medications.

   • [For each medication answer]:How much pain relief did you receive from [medication]?

      • For the medications you stopped taking, what was the reason you stopped taking them?

   • When you took these medicines, how much did your pain interfere with your day-to-day activities?

• Which medications had the biggest impact on your pain?

   • What did you like about the medication/treatment(s)?

   • What side effects did you experience?

      • How severe were these side effects?

      • How did the side effects affect whether or not you continued taking the medication

      • Did you stop using the medication? If so, for what reason(s)?

Non-medication Methods to Manage Pain

Ok, now I would like know of any other ways that you manage your pain beyond medications. Are there other non-medication methods you have used to manage your pain?

I am going to go through a list of non-medication approaches that some older adults use to address their chronic pain. I would like to know if you have tried them, and if so, about your experiences with them. For each approach you have tried [hand participant card], I'll also ask you---what led you to trying the approach, your experience with the approach, and what impact it had on your pain.

   • [For each non-med method]

      • Have you tried [method]?

      • Whatled you to try this (or what was the reason you tried this) [activity/method]?

      • How did it make you feel or what was your experience with it?

      • Did it have any effect on your chronic pain?

            • If yes, how much pain relief do you receive from [treatment option]?

   • acupuncture

   • massage

   • chiropracty

   • physical therapy

   • mindfulness/breathing exercises

   • working with a psychologist or therapist

   • exercise

   • yoga

   • tai chi

   • ice

   • Which of themethods had the most impact on your pain?

      • What did you like about the method(s)? What did you dislike?

      • When you were using _XX (described by participant) approach to manage your pain, how much did your pain interfere with your day-to-day activities?

      • What side effects did you experience?

         • How did the side effects affect whether or not you continued taking the medication?

         • Did you stop using the approach? If so, for what reason?

   • For any of the approaches above, was an approach recommended by your health care provider and you didn't do it? If you didn't, what was the reason?

Opinions on Pain Manamgement

Now I would like to ask your opinions on pain management, based on your own experiences and experiences you might have heard about from others.

• When you think about various ways older adults are being treated for pain, what treatments come to mind? [If unable to answer- probe: I'm going to list some things that others have done to alleviate their pain: exercises, medications, alternative therapies]

   • Are there treatment approaches for pain that you would never try?

      • Why would you not try these treatments?

   • Are there any pain medications you have fears about taking?

   • Are there treatment approaches that you would like to try, but are unable?

      • Why? How do cost or availability impact your decision?

• How have your opinions of pain medications changed over time? Changescan be related to your own experiences, those of others, or news reports.

• In the past several years, there has been a lot of news about "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? [If they are unaware of the "opioid epidemic": the opioid epidemic is the rapid increase in the use of prescription and illegal opioid drugs in the US that has led to overuse deaths]

   • If yes, in what way?

Unmet Needs

• In your opinion, what is one thing you think a lot of doctors and other health care providersdo not understand about pain and its treatment?

• What would be ideal pain management for you?

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