Adapting the Social-Ecological Framework for Chronic Pain Management and Successful Opioid Tapering

Context: In 2015, Solano County's Medi-Cal insurer implemented a new policy to taper patients using high-dose opioids (>= 120-mg morphine equivalent dose) to a safer level to follow best practices to address the opioid epidemic. Objective: To evaluate the effect of the 2015 Solano County Medi-Cal prescribing policy, gain insight into the patient experience of undergoing opioid tapering, and generate hypotheses for further study. Methods: Using a case series approach, researchers completed medical record reviews of affiliated clinical records, Solano County Vital Statistics, and California's prescription monitoring program in 2018. After exclusions, eligible patients were asked to participate in a comprehensive qualitative interview. Results: Medical record reviews of 38 patients found the majority were not using opioids using them at a morphine equivalent dose of 90 mg or less. The reviews also found that mental illness and obesity prevalence were higher than Solano county baseline levels. Furthermore, naloxone was not prescribed to any of the 38 patients. Researchers reached 15 of the 38 patients by phone, and ultimately 6 completed the interview process. Themes and emergent concepts from interviews identified a lack of empathetic connection with health care professionals, poor understanding of overdose risks, persistent pain, and confirmed naloxone underuse. Conclusion: Safer prescribing policies may take multiple years to fully implement and need to be employed across the jurisdiction to minimize doctor-shopping and adverse effects on patients with chronic pain. Approaching pain management through the social-ecological model can address potential root causes of addiction and establish a framework for doctors to provide compassionate care, community leadership, and advocacy for these patients.