New Australian study to examine why some chronic pain patients won’t listen to their doctor

Exploring why some Australian chronic pain patients and not others are resistant to specialist advice to reduce or stop taking their opioid medication is the focus of a world-first pain medicine study in Sydney.

The research project involving 150 chronic pain patients is being led by Professor Paul Glare, Chair of Pain Medicine at the University of Sydney Medical School (Northern) and a former head of the Memorial Sloan Kettering Cancer Centre’s pain and palliative care service in New York.
Professor Glare is speaking at a meeting of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists in Torquay, Victoria from September 22-24.
Professor Glare and his co-investigator Dr Claire Ashton-James are approaching newly referred patients to the Michael J Cousins Pain Management and Research Centre at Royal North Shore Hospital who have been on chronic opioid therapy ─ more than 60mgs of morphine or the equivalent for longer than a month ─ to participate in the study which aims to find out why some patients are reluctant to listen to their doctors’ advice when told they should reduce or stop their opioid treatment.
“It’s not about changing their expectations so much as really changing their attitudes to the treatment plan that has been recommended for them,” Professor Glare said.
According to a 2016 report by the International Narcotics Control Board published in The Lancet the use of common opioid painkillers such as codeine, morphine and oxycodone has more than quadrupled in Australia over the last decade. Prolonged opioid use has been found to cause serious health problems including addiction and death from overdoses.
Professor Glare said some patients do react badly to medical advice if they did not like what they were being told. He noted a recent incident in the US where a pain specialist who told a patient she needed to stop taking opioids was murdered by the patient’s husband in the clinic’s car park at the end of his shift.
“We want to get an idea of how common it is for patients to have a negative attitude to advice to discontinue opioids, how strong that attitude is and how emotional people feel about it,” Professor Glare explained.
“Our aim is to collect some local data on the attitude of Australian chronic pain patients who are on opioids and how they react when they receive advice to discontinue it. There seems to be no data in Australia or anywhere that has explored what people think about stopping their opioids when they have chronic pain and how they react to that advice and whether they react negatively to it ─ like terminal cancer patients often do when their oncologist recommends stopping chemotherapy.”
Professor Glare said while a social psychology approach to de-intensifying negative emotions sounded logical, it had never been applied in an Australian or international health setting for doctor and patient consultations with the exception of preventative medicine and end-of-life discussions.
“We want to try and optimise the communication between the doctor and the patient so the doctor proposes the advice in a way that the patient won’t react negatively and reject the idea out of hand.
“It’s about getting to ‘no’ so the patient can think the recommendation through and hopefully comes to realise that de-prescribing is really in their best interests and agrees that not having opioids is the right thing to do,” Professor Glare said.
Professor Glare said he hoped the study would lead to the development of simple communication strategies that pain medicine specialists and other doctors could use when treating patients who are given advice they don’t like.
The study’s participants are being randomised to watch short videos presenting three different pain management scenarios ─ continue with the current opioid treatment, change the opioid treatment, or reduce and stop the opioid and learn to self-manage the pain.
“The way you communicate will make a difference to how the patient responds but how you get people to change their thinking when their initial reaction is negative is not always easy,” Professor Glare said.
“In healthcare a lot of advice is not what the patient wants to hear. It may not be as high stakes as discontinuing treatment but a lot of the time when you go to the doctor you want them to do something whether it’s ordering more tests, losing eight or prescribing antibiotics.
“It’s about trying to get people to not be so quick to decide that they don’t want something because they don’t like the sound of it. If people have an initial negative reaction to a piece of medical advice it’s how do you overcome that and get them to think a bit more carefully about what you’re saying.”
“Unless those conversations are handled properly it can have very bad consequences,” Professor Glare said.
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