• Laura G Militello, Robert W Hurley, Robert L Cook, Elizabeth C Danielson, Julie Diiulio, Sarah M Downs, Shilo Anders, and Christopher A Harle.
• Applied Decision Science, LLC, 5335 Far Hills Ave, Suite 103, Dayton, OH, 45429, USA. l.militello@applieddecisionscience.com.
• J Gen Intern Med. 2020 Dec 1; 35 (12): 3542-3548.

BackgroundLittle is known about how primary care clinicians (PCCs) approach chronic pain management in the current climate of rapidly changing guidelines and the growing body of research about risks and benefits of opioid therapy.ObjectiveTo better understand PCCs' approaches to managing patients with chronic pain and explore implications for technological and administrative interventions.DesignWe conducted adapted critical decision method interviews with 20 PCCs. Each PCC participated in 1-5 interviews.ParticipantsPCCs interviewed had a mean of 14 years of experience. They were sampled from 13 different clinics in rural, suburban, and urban health settings across the state of Indiana.ApproachInterviews included discussion of participants' general approach to managing chronic pain, as well as in-depth discussion of specific patients with chronic pain. Interviews were audio recorded. Transcripts were analyzed thematically.Key ResultsPCCs reflected on strategies they use to encourage and motivate patients. We identified four associated strategic themes: (1) developing trust, (2) eliciting information from the patient, (3) diverting attention from pain to function, and (4) articulating realistic goals for the patient. In discussion of chronic pain management, PCCs often explained their beliefs about opioid therapy. Three themes emerged: (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment, and (3) Response to pain and opioids is highly variable.ConclusionsPCC beliefs about opioid therapy generally align with the clinical evidence, but may have some important gaps. These findings suggest the potential value of interventions that include improved access to research findings; organizational changes to support PCCs in spending time with patients to develop rapport and trust, elicit information about pain, and manage patient expectations; and the need for innovative clinical cognitive support.

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