Postoperative Pain Management Among Dominican and American Health-Care Providers: A Qualitative Analysis.
BACKGROUND
U.S. practitioners have prescribed opioid analgesics increasingly in recent years, contributing to what has been declared an opioid epidemic by the U.S. Centers for Disease Control and Prevention (CDC). Opioids are used frequently in the preoperative and postoperative periods for patients undergoing total joint replacement in developed countries, but cross-cultural comparisons of this practice are limited. An international medical mission such as Operation Walk Boston, which provides total joint replacement to financially vulnerable patients in the Dominican Republic, offers a unique opportunity to compare postoperative pain management approaches in a developed nation and a developing nation.


METHODS
We interviewed American and Dominican surgeons and nurses (n = 22) during Operation Walk Boston 2015. We used a moderator's guide with open-ended questions to inquire about postoperative pain management and factors influencing prescribing practices. Interviews were recorded and transcripts were analyzed using content analysis.


RESULTS
Providers highlighted differences in the patient-provider relationship, pain medication prescribing variability, and access to medications. Dominican surgeons emphasized adherence to standardized pain protocols and employed a paternalistic model of care, and American surgeons reported prescribing variability and described shared decision-making with patients. Dominican providers described limited availability of potent opioid preparations in the Dominican Republic, in contrast to American providers, who discussed opioid accessibility in the United States.


CONCLUSIONS
Our findings suggest that cross-cultural comparisons provide insight into how opioid prescribing practices, approaches to the patient-provider relationship, and medication access inform distinct pain management strategies in American and Dominican surgical settings. Integrating lessons from cross-cultural pain management studies may yield more effective pain management strategies for surgical procedures performed in the United States and abroad.
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts.
Christopher A
CA
Devine
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts.
Amy
A
Yu
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts.
Rachel G
RG
Kasdin
Harvard Medical School, Boston, Massachusetts Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
Laura M
LM
Bogart
Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada.
Aileen M
AM
Davis
Department of Orthopedic Surgery, Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic.
Luis
L
Alcántara Abreu
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts.
Roya
R
Ghazinouri
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts.
Thomas S
TS
Thornhill
Orthopedic and Arthritis Center for Outcomes Research (C.A.D, A.Y., R.G.K., R.G., T.S.T., and J.N.K.), Department of Orthopedic Surgery (T.S.T. and J.N.K.), and Division of Rheumatology, Immunology, and Allergy (J.N.K.), Brigham and Women's Hospital, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts jnkatz@partners.org.
Jeffrey N
JN
Katz
D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000066491:Clinical Decision-Making; D003431:Cross-Cultural Comparison; D004293:Dominican Republic; D006801:Humans; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000188:drug therapy*; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D014481:United States
D000701:Analgesics, Opioid