When the Plan Must Change: A Qualitative Study of Communicating Opioid Deprescribing Decisions

Context With increased survival in cancer and other serious illness, palliative care clinicians are increasingly facing decisions about the benefits versus burdens of opioid therapy in individuals with longer prognoses. When a patient who is prescribed opioids develops an opioid use disorder, guidelines recommend transitioning to a medication for opioid use disorder (MOUD) such as buprenorphine. However, how best to communicate this transition is unknown. Objective We developed a framework for these conversations based on our clinical experience, and, using directed content analysis, we sought to qualitatively evaluate the framework in clinician and non-clinician interviews. Methods We first created a 13-minute demonstration video of a physician-patient interview in which the physician used our proposed skills, and an interview guide. Participants (10 clinicians with experience caring for patients with cancer, 11 individuals with lived experience) reviewed the video, and then were asked to comment on the skills used, and bring up additional skills. We used coding and thematic analysis to identify themes. Conclusion We identified six themes which refined our initial communication framework: raising a concern directly, balancing boundaries with shared decision-making, expressing empathy, embedding these conversations within a long-term clinician-patient relationship, countering stigma, and preserving positive regard. When a patient prescribed opioid therapy for pain has developed an addiction, clinicians should balance setting clear limits on opioid prescribing with expression of concern. Further, clinicians should work to develop awareness around their own attitude towards the patient with chronic pain and substance use disorder, and actively repudiate stigma in these conversations.