Exploring Perspectives and Developing an Evidence-Based Intervention
Chronic pain affects millions worldwide, with opioid medications commonly prescribed despite limited long-term efficacy and growing evidence of harm. As opioid overprescribing persists, there is an urgent need for effective interventions to support appropriate medication use and improve outcomes for those living with persistent pain.
Pharmacists, with their expertise in medication management, are uniquely positioned to lead reviews that address this challenge. By understanding the perspectives of people with lived experience, we can design a pharmacist-led intervention that thoughtfully addresses barriers, leverages facilitators, and puts patient needs at the center.
This article explores the findings of a multi-method qualitative study that used the Theoretical Domains Framework to uncover key considerations for developing a primary care pharmacist-led review for people treated long-term with opioids for persistent pain. The insights gained informed the design of an evidence-based intervention called PROMPPT (Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by clinical Pharmacists in primary care Teams).
Learning to Live with Pain: A Complex Journey
People living with persistent pain often describe a long, winding journey to find ways of managing their condition. Many have tried various pharmacological and non-pharmacological approaches, learning through trial and error what works best for their individual needs and circumstances.
“It has taken me all the years since my injury to find a pain routine that works for me. But it still involves tramadol. My dose has never increased, nor have I had to change painkillers, but I did have to switch to modified release to try and stop the peaks and troughs.”
While opioids may play a role in these pain management routines, participants expressed ambivalent feelings – they “don’t like” or even “hate” taking the medications, citing concerns about adverse effects, long-term risks, and a desire to reduce reliance on drugs. However, the belief that opioids are a necessary part of managing persistent pain often prevails.
Alongside pharmacological approaches, many participants discussed the value of non-drug strategies like physical activity, self-care techniques, and social support. These holistic methods were seen as having physical, psychological, and social benefits that could complement or even replace the role of medication.
For those who had successfully reduced or stopped opioids, the journey involved not just changes in pain management, but also shifts in their understanding of pain, acceptance of its persistent nature, and sense of self. This underscores the highly personal and complex nature of living with chronic pain.
Varying Expectations and Concerns about Opioid Reduction
Participants’ expectations around reducing opioids were mixed. Some felt their medications were essential for managing pain and saw no reason to change. Others had attempted tapering in the past, only to experience “crisis in withdrawal” and fear further deterioration in their condition.
Those willing to consider opioid reduction anticipated potential benefits, such as fewer side effects. However, they also expressed anxieties about the unknown process, concerns about not having anything else for their pain, and a readiness to reinstate opioids if pain worsened.
“… if I reduced it and it wasn’t working, then you just start taking it again don’t you?”
Interestingly, some participants who had successfully reduced opioids spoke of surprising positive outcomes, including less pain and improved quality of life. This highlights the importance of closely monitoring the impact of tapering and providing appropriate support to manage patient concerns.
Adopting a Biomedical Approach to Pain Management
The study found that some participants appeared to adopt a primarily biomedical model of pain management, with a focus on seeking pain relief through prescribed medication. This was reinforced by interactions with healthcare providers who sometimes conveyed the message that opioids were necessary and that there were no alternatives.
“…. at the moment the hip pain has gone but I’m still on a repeat prescription for this co-codamol so I take it.”
In contrast, those with a more holistic view of pain management saw opioids on repeat prescriptions as a consequence of inactivity by the medical system, rather than an active, informed choice. They expressed a desire for a more collaborative approach that considers the broader physical, psychological, and social aspects of their pain experience.
Pharmacist-Delivered Reviews: Key Considerations
Participants emphasized the importance of pharmacists delivering the PROMPPT review having up-to-date knowledge about persistent pain, its impact, and appropriate management strategies – including non-pharmacological approaches and available support services.
They also expressed a preference for a person-centered, collaborative review process where pharmacists actively listen, use the information provided by patients, and work together to agree on goals and outcomes. Avoiding an externally imposed, “tick-box” approach was seen as crucial for building trust and engagement.
“Up to date and sustained development of their knowledge of pain management and routes they can use to resources that support patients.”
The pharmacist-patient relationship emerged as a key facilitator, with participants highlighting the importance of trust, empathy, and continuity of care. Previous negative experiences with healthcare professionals had left some feeling misunderstood, disbelieved, and stigmatized, underscoring the need to intentionally foster a therapeutic rapport.
Engaging Patients in the Review Process
Participants identified several factors that could facilitate their engagement with the PROMPPT review, including knowing the purpose of the review, feeling confident to discuss their pain experiences, and holding positive outcome expectations (e.g., opportunity to address concerns, learn more about their condition and medications).
“I think it would achieve peace of mind … and emotionally I think it would be good … to be able to get it off your chest and talk to somebody who knows and who understands.”
However, some participants expressed concerns that the review could be perceived as a cost-saving exercise by the healthcare system, or that it may have little to offer if they believed no alternative medications existed. Ensuring the review is accessible and fit-for-purpose, with flexible delivery options, was also seen as important.
Designing the PROMPPT Review: Theoretical Mapping and Intervention Components
Using the insights gained from the qualitative data, the research team systematically mapped the identified barriers, facilitators, and valued intervention features to behavior change techniques and the theoretical domains framework. This process informed the development of 17 proposed components and 5 key delivery features for the PROMPPT review.
Some examples of the proposed components include:
– Providing information about persistent pain, its impact, and appropriate management strategies
– Exploring patient’s pain management journey and current routines
– Discussing patient’s beliefs and concerns about opioids and potential for tapering
– Collaboratively setting personalized goals and action plans for opioid reduction or alternative pain management
– Providing skills training and resources to support non-pharmacological approaches
– Ongoing follow-up, monitoring, and adjustment of the plan as needed
The delivery features emphasize the importance of a person-centered approach, shared decision-making, and building a therapeutic pharmacist-patient relationship. Recognizing the need to support pharmacists’ knowledge and skills, the intervention also includes a training component.
Moving Forward: Feasibility, Acceptability, and Effectiveness
This qualitative study provides a strong theoretical and evidence-based foundation for the development of the PROMPPT review. The next steps involve testing the feasibility and acceptability of the intervention in practice, refining it based on feedback, and ultimately evaluating its clinical and cost-effectiveness in a randomized controlled trial.
By centering the perspectives of people living with persistent pain, the PROMPPT review aims to address the complex, multifaceted nature of opioid use and reduction. Fostering collaborative, person-centered pharmacist-led reviews has the potential to improve medication management, enhance pain outcomes, and ultimately support individuals in their journey of living with chronic pain.
As the role of primary care pharmacists continues to expand, interventions like PROMPPT offer an opportunity to leverage their expertise in a way that truly meets the needs of patients. By integrating evidence, theory, and lived experience, we can design solutions that promote more mindful, sustainable, and effective pain management approaches.
