Management of these situations does not concern primary care

GPs interviewed in this study thought that the level of care needed for these patients was above and beyond what was regularly provided in primary care. GPs expressed anxiety about treating patients on OMT who needed a level of complexity of care, but often felt that they were the patients’ only option.

The GPs found that being confronted with intense pain was a rare situation ‘really intense, acute pain, (…), we don't necessarily see it; people will have done something about it. They will have called (…) they will have called an ambulance, they will have gone to A&E‘E5-l.158–165). The GPs reported that as 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 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’(E5-l.291–295).

Nevertheless they deplored the lack of time available to manage these situations: ‘we don't have an hour ahead of us, you see, you have to understand that an appointment in family practice lasts 15 minutes, for which 25euros are reimbursed by social security, that’s basically the average, okay? So, in 15 minutes we will have everything to deal with, so that’s what you have to keep in mind, and that’s the problem in general practice’(E5-l.185–192).

Finally, the GPs described the difficulty in providing care in response to a patient’s request to be treated solely by their GP: ‘And often the difficulty arises from the fact that, precisely 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, so you have to solve things that are sometimes much more complex than you would like’(E5-l.598–607).

Lack of training prompts GPs to rely on peer and specialist support

GPs interviewed in this study thought that their training was limited and that the lack of time also made the management of these cases complex. They relied on peers and/ or on specialists for difficult therapeutic situations.

Many of the GPs reported lack of time for training. Some GPs identified inadequate training on the subject ‘I think we lack training on this subject’(E5-l.275–278) and they described the desire for specific training to develop their knowledge about OMT and pain management. ‘I would be ready to learn more on this topic’(E2-l.784). On the other hand, other respondents 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.’(E1-l.546–547).

Many GPs spoke of the need to call on colleagues in difficult therapeutic situations. They first mentioned their colleagues in the same general practice: ‘the fractionation of buprenorphine dosage which I had already had to deal with, but then I found, after discussing it with colleagues, that they would have done the same’(E5-l.482–483). 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’ pain centres ‘the’ Cavale Blanche’ pain centres, and the maritime hospital, are quite able to help us with this issue’(E7-l.482–483) and hospitalisation ‘if the pain is so severe that she cannot sleep, well I hospitalise her’(E6-l.292)

Lack of guidelines

GPs interviewed in this study reported a lack of clear guidelines for the management of these complex situations in primary care, and they resorted empiricism from their personal experience of OMT management.

Guidelines for OMT management differ significantly, according to GPs. Some envisage pain management using WHO levels (WHO, 1997) ‘I comply with the dosage (…) whatever the medication: doliprane (…) codeine, tramadol and, and opiates’ (E2-l.92–94). Most of the GPs reported having no reference recommendations. They reported a lack of consensual data on this subject: ‘There is a lack of consensual attitudes concerning acute pain management for patients on OMT’ (E5-l. 713–722).

With regard to prescribing analgesics, a wide variety of practices were described by the physicians: Non-opioid painkiller analgesics (paracetamol) were the most frequently cited. Weak opioids combined with OMT 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 with the receptors being saturated, it did not seem appropriate to me’(E5-l.417–425). Strong opioid painkillers were also described in various ways: Many of the GPs interviewed avoided this prescription. In contrast, there were others who used morphine in combination with OMT, while, one reported using lower doses. Others still preferred to stop BHD before prescribing morphine. As mentioned above, the GPs also prescribed multimodal analgesia, with extensive use of anti-inflammatory drugs, and sometimes antidepressants, for neuropathic pain.

Regardless of their prescriptions, the GPs 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, (…)buprenorphine retains its status as a substitution treatment’. (E9-l. 95–105)’

Clarification of the provisional aspect of this prescription: ‘the fact that a (…) second molecule (…) has been prescribed indicates the provisional nature of the treatment’. (E2-l.107–109)

Some physicians described prescribing OMT dosages staggered during the day, with or without an increase in daily dosage. Others associated a non-opioid painkiller or a 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, or another level 2 medication, avoiding level 3 analgesics’ (E3-l.145–150).

Finally, opinions were spread through the day in relation to the effectiveness of codeine. Some physicians described variable patient feedback. Others said they had noted the efficacy of codeine: ‘So it’s true that, pharmacologically, it shouldn't work, except that it can actually work’(E1-l.47–48). In addition, they did not observe withdrawal syndrome when combining codeine and buprenorphine: ‘In my daily professional life, I have never seen codeine-Subutex withdrawal, never, ever…’(E1-l.757–759).

However, many GPs mentioned their reluctance to spread OMT intake for analgesic purposes. They reported difficulties in arguing for the splitting of the OMT in case of acute pain. Indeed, in their opinion this advice is not compatible with their usual efforts which are centred on maintaining once daily doses of OMT, as recommended.: ‘That’s what is so complicated, explaining to them (patients) that all the medication must be taken in one dose…’(E1-l.275–276).

They resorted to 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’ (E2-l.785–786) and for communication management ‘now I know a lot about it, I know how to talk to them’ (E1-l.157–158).

Conflicting recommendations between clinicians in different settings

GPs interviewed in this study reported a lack of multidisciplinary network, a lack of availability of the network, and conflicts around management of these situations.

The GPs reported on pain management that 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’(E5-l.260–273). Making medication changes is hard for GPs because of the sanctity of hospital doctors' prescriptions vs GPs’ prescriptions. Moreover, ‘f something has been said to a patient in hospital and the family physician starts to contradict what the hospital has said, it makes management difficult.’ (E5-l.340–343).

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’.(E5-l.542–545). 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 opioid-dependent patients: ‘Clichés (…) ‘the addict is manipulative, (…) he is addicted for the rest of his life’, (…) You can't trust him’ (E5-l. 687–691).

An individualised patient-centred approach

GPs interviewed in this study underlined that the management of pain for patients on OMT were integrated in a global management of patients, in a patient-centred approach.

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,)…(or hypertension…(E5-l.232–243). They described a global relationship between patient and GP ‘it is better to know the person, his family, (…) to discuss the weather and things of life … simply …(…)’ (E7-l.359–368)

The GPs reported certain specificities of the population on OMT, they agreed that this is quite a young patient population: ‘They are often patients who are still quite young’ (E6-l.57). They also mentioned patients with complex psychological profiles: ‘a particular psychological profile’(E8-l.72). For pain evaluation, the specificities of patients on OMT were taken in account : 1. The reduced pain threshold: ‘as they have a slightly lower threshold (…) it could possibly be misleading (…) for pain rated higher than 5 (scores range from 0 to 10)’(E1-l.670–673); 2. The self-regulation of OMT by patients limits scope for 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’ (E12-l.84–91). One GP also mentioned patients having identified different perceptions of their own body compared with the general population: ‘They have notions about their own body as not being the same as other people’s’(E6-l.99–100).

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-time GPs who think, yes, that conversation has therapeutic value’.(E2-l.762–763) They mentioned the need for patient reassurance, which they believed depended on providing information.

A relationship based on trust

GPs interviewed in this study reported that their relationship with patients was based on trust, they were confident with patients known to the practice and they trusted patients abilities for drugs management.

Most physicians described a relationship of trust with patients: ‘It is a relationship of trust that is established over time‘(E7-l.358–359). The GPs were more confident with patients known to the practice: ‘someone who is followed, with whom there is trust, it goes smoothly, it’s not too stressful’(E12-l.187–189). They then described trusting patients who complain of pain: ‘If they tell me they have pain, I believe them’(E4-l.151). In return, the patient trusts the GP and particularly values 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 talk, they tell me’(E2-l.573–575). One GP even mentioned a strengthening of the relationship through the management of the patient’s pain: ‘If we can have subjects for discussion other than the simple exchange from addict to GP, then so much the better. It helps to have some knowledge of the person, of his family, to treat him for other medical conditions, to discuss the weather and other aspects of life’.(E7-l.359–368)

The interviewees reported a good understanding of pharmacology by patients and trust in their abilities to manage drugs: ‘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’(E7-182-193).

Fear of destabilising patients

GPs interviewed in this study feared that pain and the management of pain could destabilise patients and their background treatment, and in the management, GPs integrated patients specific attitudes to drugs.

Some GPs 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 if the cause is not resolved, I am afraid that we will then go from 8 mg to 12–16 mg for weeks’(E1-l.299–303). They also reported patients' reluctance to split medication doses. They fear that they might not be able to reduce the intake frequency of OMT back to once a day after the pain has 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.’(E1-l.356–357). As a result, these GPs felt that fractionation of OMT for pain management could only be applied to stabilised patients. ‘I felt that she was ready to hear that she could divide the daily dose in case of pain’(E1-l.360–361).

The physicians interviewed agreed that these patients had a specific attitude towards drugs: ‘They also have a somewhat specific attitude towards drugs’(E6-l.119–120). Thus, one GP stated that the prescribed drugs were considered as 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’(E5-l.553–554). They had a strong awareness of tolerance to painkillers: ‘Yes, but I am addicted to drugs, I don't like taking medications anymore’(E1-l.716–717). In this context, they described frequent refusals of paracetamol.

Difficulties in evaluating and treating pain

GPs interviewed in this study stressed the importance of pain evaluation, and difficulties to assess the effectiveness of the pain management. But opinions on perception of pain in patients with OMT were divided.

Opinions about pain were divided. Thus, some GPs did not observe any specificity in pain: ‘I do not get the impression that they were suffering more pain than other patients’(E8-l.29–30). Other GPs referred to their knowledge of acquired hyperalgesia, and described having observed this lowering of the pain perception threshold: ‘They feel increased pain’(E1-l.671). On the other hand, the GPs mentioned a more important psychological aspect of pain: ‘In terms of pain, we are just as concerned about understanding emotional pain, the mental component of physical pain.(E12-l.84–91). Others, on the contrary, mentioned a better tolerance of pain: That’s what it says, that they could be hypersensitive to pain compared with a standard population, I admit that I haven't particularly experienced that, I have even seen some who were quite resistant to pain(E5-l.247–251).

The GPs stressed the importance of 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’(E4-l.151). The 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’ (E6-l.393–396). Most of the GPs interviewed described the effectiveness of their pain management as good: ‘Well, they are in less pain. They are better, so they are happy(E8-l.180–182). Some physicians evaluated the effectiveness of pain management using a pain scale, and they re-evaluated it after treatment. However, many of them described an evaluation 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’(E1-l.566–567).

They described difficulties in assessing the effectiveness of their management because of the lack of feedback from patients ‘I rarely get feedback’ (E1-l.617) and there is not enough time to see them again in consultation before too long’. ‘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’(E5-l.145–151).

Difficulties for care adherence

GPs interviewed in this study identified delays that patients with OMT experienced in their somatic management, when they suffered from medical disorders, they took a long time to seek medical help. They also underlined difficulties in compliance and due to medical nomadism.

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, but he only came 4 days later because he was in pain’(E12-l.24–25), for dental care: ‘They had to go to the dentist for 6 months’(E2-l.133–134) and for check-ups requested by their family physician: ‘We make them have check-ups, most of the time they do not go for them’(E8-l.80).

The GPs interviewed spoke of patients who felt the treatment they received was holding them back: ‘Patients with OMT follow-up in specialised care constantly talk, among themselves, about how they are being kept drug-dependent’(E5-l.585–586). One GP mentioned that some patients adhered somewhat better to treatment than the general population. However, most of the GPs interviewed mentioned that it was difficult to obtain compliance: ‘I try, of course, to ensure that they take their buprenorphine once a day in the morning and not as they need it, which is complicated’(E6-l.112–113).

They also mentioned a difficulty in maintaining a link with these patients because of cancelled appointments and medical nomadism.

Fear of misuse and diversion

GPs interviewed in this study reported fear of misuse or diversion of OMT, but they mentioned mistrust towards patients unknown to them. Self-medication was cited by GPs either as a reflect of misuse and uncontrolled intake of drugs, or as a consistent self-medication on patients stabilised with their OMT.

Regarding pain evaluation, the GPs reported the risk of prescribing to patients who are only looking for 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’ (E12-l.111–116). Many GPs 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 their mistrust towards patients unknown to them., The GPs being interviewed deplored the role of the doctor, which sometimes boiled down to merely prescribing: ‘They see us as suppliers in some ways’(E8-l.82). They mentioned links between consumers in the context of trafficking or misuse of OMT: ‘They gave their capsules to everyone’(E1-l.231). The physicians described difficulties arising from the misuse of several analgesic active ingredients, such as nefopam, tramadol and morphine.

The physicians interviewed described requests for immediate pain relief from patients: ‘These patients are often still at the…the impetuous stage of expecting rapid results’(E6-l.430–431). In this context, they observed excessive consumption and the search for repeated and symptomatic medication in relation to opioid painkillers: ‘t is precisely (…) the addictive attitude that I am trying to remove with regard to medication, and that is the main difficulty’(E6-l.540–547).

Opinions were divided on the frequency of self-medication. One GP 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 ‘(E9-l.142–144). They observed self-medication with OMT: ‘Those who overuse for analgesic purposes tend not to take it, or to take it in 2 doses, morning and evening, or in case of pain that is a little more acute, they split the medication, also for analgesic purposes’(E9-l.163–168).

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’(E9-l.133–140).

They went on to mention the need for a clearer framework for prescribing: ‘Some patients had a rather unusual attitude towards drugs so, for these people, prescribing needs to be extremely precise’ (E6-l.122–125).