Participants
Eleven GPs were interviewed in France (Finistere region). The social and professional profiles of the GPs are presented in Table 2.
Table 2. Participants interviewed
Number of patients on OMT, already seen or currently being seen
|
Number of years’ experience as a practising GP
|
Gender
|
Type of medical practice
|
Place of medical practice
|
15
|
9
|
F
|
Solo
|
Rural / Urban
|
65
|
35
|
M
|
Solo
|
Urban
|
70
|
38
|
M
|
Solo
|
Rural
|
7
|
10
|
M
|
Medical group
|
Urban
|
20
|
26
|
M
|
Medical group
|
Urban
|
2
|
30
|
M
|
Solo
|
Urban
|
14
|
26
|
M
|
Medical group
|
Urban
|
10
|
36
|
M
|
Medical group
|
Urban
|
11
|
14
|
M
|
Medical group
|
Urban
|
5
|
23
|
M
|
Medical group
|
Urban
|
3
|
29
|
M
|
Medical group
|
Urban
|
10
|
1
|
M
|
Medical group
|
Urban
|
Data extraction and analyses:
Data were analysed by 2 researchers with an iterative and interactive process of coding and recoding which permitted the aggregation of codes into 13 sub-themes and subsequently 4 themes. They are collated in Table 3.
Selective and axial codes
|
Themes = selective codes
|
Axial codes
|
Professional links
|
Medical training difficulties
|
Network coordination difficulties
|
Clinical reasoning
|
Pain evaluation
|
Management difficulties
|
Lack of evaluation of efficacity of treatment
|
Doctor-patient relationship
|
Relationship difficulties
|
Particular characteristics of patients on OMT
|
Young patients
|
Drug-users’ links
|
Specific body perceptions
|
Pain specificities
|
Specificities of their relationship with the medication
|
Not involved in care
|
Table 3. Description of subthemes and themes
As it was impossible to describe all the qualitative data: only the main themes and sub-themes are described. Where the themes and sub-themes that emerged had been described in detail, they were illustrated by selected verbatim accounts drawn from all the countries involved. Verbatim accounts are in italics.
FIGURE 1. Heuristic map of different themes and subthemes
Professional links
GPs identified difficulties in medical training and difficulties in network coordination.
Difficulties in medical training
References for OMT management differed significantly, according to GPs . Some followed pain management using WHO levels (WHO, 1997) « I respect the levels (...) in whatever: doliprane (...) codeine, tramadol and, and opiates ». Most of them reported having no references. GPs reported the lack of consensual data on this subject « there is a lack of consensual attitude concerning acute pain management in patients on OMT " .
They developed empiricism. Many mentioned that pain management in patients on OMT was founded on their personal experience of treatment management "I've developed my own methods, I've done things this way, that’s how it works" and for communication management " now I know a lot about it, I know how to take them ".
Some GPs identified lack of training on this subject « I think we lack training on this subject" and described the desire for specific training to develop their knowledge about OMT and pain management. On the other hand, other authors were at ease with pain management for patients on OMT" I'm not a pain specialist at all, but it's not a problem for me.».
Many of them reported lack of time for training. They also found that being confronted with intense pain was a rare situation "the really intense, acute pain, (...), we don't necessarily see it in our surgery; people will have gone beyond that. They will have called(..) they will have called an ambulance, they will have gone to A & E". They said that, if they were not particularly involved with opiate-dependent patients, they did not need to spend time in training on this subject « it is more (...)for the colleagues who are much more involved, who have the time to get training in the field of drug addiction care in particular, because the problem for us is that we have a wide range of problems to deal with ».
Difficulties in network articulation
GPs reported on pain management which was not tailored to the patients during their hospitalisation. This concerned pharmacological treatment and meant that GPs needed to change the treatment after the patient had been discharged: "the pain management had not been satisfactory (...) in the hospital for example (...) so we had to review the whole scheme". Making medication changes is hard for GPs because of the sanctity of hospital doctors' prescriptions versus GPs' prescriptions. Moreover," if something has been said to a patient in hospital and the general practitioner starts to contradict what the hospital has said, it makes management difficult." Relationships with pharmacists were also defined as difficult, with conflicting information between GPs and pharmacists, "Comments are inconsistent, and ultimately run counter to good care". However, they stressed the importance of a professional network and reported informal and evolving networks. The limits of networking were availability of the network, and the negative perceptions that some professionals might hold of opiate-dependent patients: " clichés (...) "the addict is manipulative, (...) he is addicted for the rest of his life", (...) You can't trust him".
Clinical reasoning
Subthemes identified were pain evaluation, difficulties in prescription management and lack of evaluation of efficacity or treatment.
For pain evaluation, some used the visual analogue scale systematically, but most stated that they used no systematic scales. They said that they used a global clinical evaluation and the functional consequences of the evaluation. Their evaluation was also based on the patient's description: "if the patient told me he was in pain, I thought, that's it, he's in pain, if he's in a lot of pain, he's in a lot of pain". Some GPs identified no difficulties at all in pain evaluation ; others described 4 specific difficulties: 1. The reduced pain threshold: "as they have a slightly lower threshold (...) it could possibly be misleading (...) for pains rated higher than 5 (between 0 and 10)"; 2. The self-increasing of OMT by patients limits pain evaluation ; 3. The context of psychological suffering: "often there is a psychological component (...) anxiety, stress, (...) between psychological pain and nociceptive pain (...) the boundary between the two is not always easy to determine"; 4. The risk of supplying patients who are only in search of the ‘high’ effect of opiates "it is hard to make the distinction between what is real pain and what is simply a demand for, for a product".
GPs stressed the need to look for the aetiology of the pain, which guides the choice of treatment “you need to know what the cause is if you can, (…) which will also guide the choice of analgesic ».
Difficulties in prescription management
With regard to prescribing analgesics, a wide variety of practices were described by physicians: Non opioid painkiller analgesics (paracetamol) were the most frequently cited. Weak opioids were widely used by some doctors, and not at all by others: "I felt that pharmacologically it could not work, that we would not have a satisfactory result, because of the competition from substitution treatments, so a priori with the receptors being saturated, it did not seem appropriate to me". Strong opioid painkillers were also described in various ways: Many of the doctors interviewed avoided this prescription. In contrast, there were others who used morphine in combination with MSOs. However, one reported using lower doses. Others still preferred to stop buprenorphine to prescribe morphine. As mentioned above, doctors also prescribed multimodal analgesia, with extensive use of anti-inflammatory drugs, and sometimes antidepressants, for neuropathic pain.
Regardless of their prescription, doctors stressed the importance of using a second category of medication for analgesic treatment. The reasons given were:
-Clarification of the indications: "I prefer to prescribe analgesics;, ultimately, I prefer to dissociate the use of analgesics for analgesic purposes, from a specific analgesic, used for withdrawal, (..) the buprenorphine retains its status as a substitution treatment ".
-Clarification of the provisional aspect of this prescription: "the fact that a (..) second molecule (..) has been prescribed indicates the provisional nature of the treatment".
Some physicians described prescribing OMT fractionation, with or without an increase in daily dosage. Others associated a Non opioid painkiller or weak opioid analgesic with OMT: "when you have to give them morphine, to be sure that methadone is effective I divide it in 2, and then I add either tramadol, or Acupan â, or another level 2 medication, avoiding level 3 analgesics".
However, many doctors mentioned their reluctance to split MSO for analgesic purposes. Many of them stressed the inconsistency of this practice in their efforts to observe the considerations of OMT provision: "That's what is so complicated, explaining to them that all the medication must be taken in one dose, that...". Some doctors feared destabilising the background treatment: "I think my fear would be that they would say afterwards, ‘I still have pain, I have a lot of pain’, knowing that if we don't treat the cause of the pain, and that the cause is not resolved, I am afraid that, afterwards, we will go from 8mg to 12-16mg for weeks". They also reported patients' reluctance to split medication doses. They fear that they might not be able to reduce the dose frequency of MSO back to once a day after the pain had subsided: "She says ‘I could never have split my Subutex’ because she would have felt that, by splitting her daily dose, she might become reliant again on something she had been fighting to be free of for a long time.” As a result, those doctors felt that fractionation of OMT for pain management could only be used with stabilised patients. "I felt that she was ready to hear that she could divide he daily dose in case of pain".
They mentioned the health and lifestyle advice they provided to reduce pain when they saw patients. They also described the importance of supportive psychotherapy: "I am one of the old doctors who think, yes, that conversation has therapeutic value". They mentioned the need for patient reassurance, which they believed depended on providing sound information. They nevertheless deplored the lack of time available to provide this information: "we don't have 1 hour ahead of us, eh, we have to understand that an appointment in general practice lasts 15 minutes, for which 23 euros are reimbursed by social security, that's basically the average, okay? So, in 15 minutes we will have everything to deal with, well, but that's what you have to keep in mind, and that's the problem in general practice".
Many doctors spoke of the need to call on colleagues in difficult therapeutic situations. They first mentioned the colleagues in the same general practice: "the fractionation of buprenorphine which I had already done, but then found, after discussing it with colleagues, that they would have done the same". They also mentioned the use of addiction networks "the centre for drugs, of course, for the whole aspect of toxic side-effectives and drug treatment", the pain centre ("pain centres of the La Cavale Blanche, the maritime hospital, are quite likely to help us with this issue" and hospitalisation "if the pain is so severe that she cannot sleep, well I hospitalise her".
Lack of evaluation of care effectiveness
Most of the doctors interviewed described the effectiveness of their pain management as good: "Well, they are in less pain. They are better, so they are happy". Some physicians evaluated the effectiveness of pain management through the use of a pain scale and they re-evaluated it after treatment. However, many of them described an evaluation which was based on the absence of repeated requests for painkillers: "I don't get much feedback but, if I don't see them again, I assume that is because they are fine".
They described difficulties in assessing the effectiveness of their management because of the lack of feedback from patients "I rarely get feedback" and there is not enough time to see them again in a timely consultation " we would have to be able to see the patient again the next day, the day after, and in current practice, that's almost impossible in town or city practices, they don't come back, or they move on".
Finally, opinions were divided regarding the effectiveness of codeine. Some physicians described variable patient feedback. Others said they had noticed codeine efficacy: "so it's true that, pharmacologically, it shouldn't work except that it can actually work". In addition, they did not observe withdrawal syndrome by combining codeine and buprenorphine: "in my daily professional life, I have never had codeine-Subutex withdrawal, never, ever..".
Complex therapeutic relationship
A relationship that is often of high quality
Most physicians described a relationship of trust with patients: "it is a relationship of trust that is established over time".
The doctors were more confident with patients known to the practice: "someone who is followed up, with whom there is trust, it goes smoothly, it’s not too stressful". They then described trusting patients complaining of pain: "if they tell me they have pain, I believe them". In return, the patient trusted the doctor and particularly valued the doctor's non-judgemental approach: "as things stand, we are quite open about what we say, I always ask them what they have, if they have taken anything, what they do not have, and so they say, they tell me".
Doctors also stressed their attention to pain. They noted the importance of letting the patient know "so that they can also see that their pain is being taken into account".
This idea was in line with that of the overall management of the patient in general medicine: "the patient who comes to me I take as a whole person, not just as a drug addict , but as a patient, and so a patient on substitution treatment, can also have toothache, (..) or chronic bronchitis, )..( hypertension.. ".
Sometimes difficult relationship.
Doctors' lack of trust: Many doctors mentioned their mistrust of certain patients. They explained it as the fear of being manipulated in the context of trafficking or in misuse of OMT or analgesics. They also mentioned a greater mistrust if the patient was unknown to them.
Complex contact: The doctors interviewed mentioned patients with complex psychological profiles: They were described as having "a particular psychological profile".
There was a distance between them, maintained by the patient: "year after year we still manage to discuss a little bit when we know their history, but for those whose history we don't know, who come to us, they never, or very rarely, tell us what has happened...".
At the time, the GPs being interviewed deplored the role of the doctor, which sometimes boiled down to merely prescribing: "they see us a supplier in some ways".
They also mentioned a difficulty in maintaining a link with these patients because of cancelled appointments and medical nomadism.
Finally, the doctors described the difficulty of providing care in response to a patient’s request to be treated solely by their GP: "And often the difficulty comes from the fact that, just because they are causing you problems and you feel your competence is being stretched to its limit in caring for them, they do not want to leave you… you are their only contact and you remain so, therefore you have to solve things that are sometimes much more complex than you would like".
A specific patient population.
A young population
Doctors agreed that this is quite a young patient population: "it is often patients who are still quite young".
Relationship between consumers
They mentioned links between consumers in the context of trafficking or misuse of OMT: "they gave their capsules to everyone".
Perception of their own bodies
One doctor mentioned patients having a different perception of their own body compared with the general population: "they have notions about their own body which are not be the same as other people’s".
Pain experienced
Opinions about pain were divided. Thus, some doctors did not observe any specificity in the pain: “I do not get the impression that they suffered more pain than other patients".
Other doctors referred to their knowledge of acquired hyperalgesia, and described having observed this lowering of the pain perception threshold: "They feel increased pain".
On the other hand, the doctors mentioned a more important psychological aspect of the pain: "In terms of pain, we are just as concerned about understanding emotional pain, the mental component of the physical pain."
Others, on the contrary, mentioned a better tolerance of pain: "that's what it says, that they would be hypersensitive to pain compared with a standard population, I admit that I didn't particularly experience that, I even saw some who were quite resistant to pain".
Relationship to drugs and meds
Immediate satisfaction: The physicians interviewed described a request for immediate pain relief from patients: "these patients are often still at the…the impetuous stage of expecting rapid results". In this context, they observed excessive consumption and the search for repeated and symptomatic medication in relation to painkillers: " it is precisely (..)the addictive attitude that I am trying to remove with regard to medication, and that is the main difficulty".
Patient knowledge of pharmacology
Interviewees reported a good understanding of pharmacology by patients: "They know, they can generally manage pharmacology, many of them at least know which drug to use and how to use it, in the normal way, that is ".
Perception of meds and drugs
The physicians interviewed agreed that these patients had a specific attitude towards drugs: "they also have a somewhat specific attitude towards drugs". Thus, one doctor stated that the prescribed drugs were considered a highly addictive risk by some patients: "the drugs they are prescribed are often ultimately experienced as even more addictive, more addictive than their own substance of choice". They had a strong awareness of tolerance to painkillers: "Yes, but I am addicted to drugs, I don't like taking products anymore". In this context, they described frequent refusals of paracetamol.
Self-medication
Opinions were divided on the frequency of self-medication. One doctor noted an uncontrolled and indiscriminate use of products by some patients. Another mentioned a modified intake of analgesics adopted by stabilised patients: "those who are really well stabilised or who take small or regular doses and who are consistent (..) take analgesics more easily".
They observed self-medication with OMT: "those who overuse for analgesic purposes tend not to take it, or to take it in 2 doses easily, morning and evening, or in case of pain which is a little more acute, they split the medication, also for analgesic purposes"
They mentioned guilt expressed by patients on this subject : "I don't know if they feel guilty (..)But (..) they justify their increase in buprenorphine and they apologise for taking it (..) or try to clear themselves of the pain by taking, buprenorphine, that's it, and they don't necessarily think about taking anything else, other than buprenorphine".
Potential for misuse:
Physicians described difficulties arising from the misuse of several analgesic active ingredients, such as nefopam, tramadol and morphine.
Low investment in care
Care provision seemed constrained
The doctors interviewed spoke of patients who felt the treatment they received was holding them back "patients with OMT follow-up in specialized care constantly talk, among themselves, about how they are being kept drug-dependent".
Observance
One doctor mentioned that some patients adhered somewhat better to treatment than the general population. However, most of the doctors interviewed mentioned that it was difficult to obtain compliance: "I try, of course, to ensure that they take buprenorphine once a day in the morning and not on demand, which is complicated".
They went on to mention the need for a more important framework for prescribing: "Some patients had a rather unusual attitude towards drugs so, for these people, prescribing needed to be extremely precise ".
Delays in providing somatic management :
The physicians interviewed agreed about the delays that patients were experiencing in their somatic management. They identified delays for acute pathologies ("he broke his metatarsus, he only came 4 days later because he was in pain"), dental care ("they had to go to the dentist for 6 months") and check-ups requested by their general practitioner ("we make them have check-ups, most of the time they do not go for them").