Deflecting Before Prescribing: Negotiating About Opioids and Chronic Pain in Primary Care

In this study, we examine opioid-related treatment negotiations during primary care visits for chronic pain. We video-recorded 86 visits involving established patients on chronic opioids seeing primary care physicians; participants completed post-visit assessments. We used conversation analysis to identify patient requests (direct and indirect) for better pain control, create a taxonomy of eight "deflection" practices physicians used to respond before making opioid-related treatment recommendations (gathering information, evaluating pain, quelling, proposing alternative treatment options, empathizing, praising positive behavior change, warning about opioid risks, and discussing the pain contract), and identify seven visit-level physician communication styles (staller, quick-to-decide, positive affirmation, policer, no-stone-left-unturned, forward-focused, and heterogeneous). We used generalized linear mixed models to explore whether deflection frequency or visit style were associated with participant experience. Most patients (96%) used indirect requests to ask for better pain control. On average, physicians produced 67 deflections before articulating treatment recommendations. More total deflections were associated with worse patient and physician visit experience. Specific deflection practices and visit styles were associated with patient and physician visit experience. Physicians do substantial work before making opioid-related treatment recommendations. Attention to negotiation practices may help explain and ultimately identify strategies to reduce unease associated with opioid discussions.