Chronic Opioid Therapy for Chronic Pain: An e-Learning Program to Develop Shared Decision-making and Communication Skills
Sullivan MD, Gaster B, Russo J, et al.: Randomized trial of web-based training about opioid therapy for chronic pain. Clin J Pain 2010, 26:512–517.
Rating: •• Of significant importance.
Introduction: Professional efforts to promote evaluation of pain in conjunction with the marketing of sustained-release opioid analgesics for the treatment of chronic noncancer pain (CNCP) likely have contributed to increased rates of opioid abuse. From 1997 to 2002, there was a marked increase in the medical use of commonly prescribed opioids, including oxycodone (403%) . The abuse of prescription opioids has become widely prevalent . In the past decade, a more than a twofold increase in lifetime abuse and a nearly threefold increase in past-month abuse of prescription opioids occurred in the United States (https://nsduhweb.rti.org/). Hydrocodone has become the most widely prescribed opioid with the highest rate of nonmedical use in the general population .
Formal assessments of physicians about opioid therapy for chronic pain demonstrate knowledge deficits in the pharmacology, efficacy, and regulations of opioids . A recent survey of physicians found multiple misconceptions about prescribing this class of medications, including excessive fears of investigation, believing certain practices were unlawful and/or unethical, and not knowing the criteria for the diagnosis of addiction . Physicians admitted to limiting their care of patients with chronic pain receiving opioids. For example, doses of opioids were lowered, refills were restricted, and Schedule II medications were avoided. The consequences for patients were very likely inadequate pain management while at the same time not being very likely to protect them from the risk of addiction. Physicians worry that opioids prescribed for even a legitimate chronic pain syndrome could lead to illicit use and create an “iatrogenic” addiction, despite a lack of evidence quantifying this particular risk .
Educational programs can positively affect physicians’ knowledge, attitudes, and beliefs about pain management, leading to more coherent strategies for optimizing benefit and minimizing the risk of different therapies . The training of residents is of critical importance after studies have documented their lack of preparation in treating CNCP, the negative impact of these patients on their career satisfaction, and their frustration with having to prescribe chronic opioid therapy . Patients presumed to be addicted to opioids often are described by physicians to be manipulative, drug-seeking, and noncompliant . Even in patients with chronic pain who have only a history of substance abuse, physicians are reluctant to prescribe opioids, distrust patients’ motives for requesting opioids, and doubt whether their patients suffer genuine pain . Sullivan and colleagues  have designed educational interventions for medicine residents that improved shared decision making, physician satisfaction, and elements of chronic pain care.
Aims: This randomized clinical trial was conducted to determine if an interactive web-based training focusing on shared decision making for chronic opioid therapy improved knowledge and competence compared with exposure to practice guidelines.
Methods: The participants in this trial were internal medicine residents from five residencies participating in the Residency Review Committee for Internal Medicine’s Educational Innovations Project. The participants were randomized to different modes of training on the use of opioid therapy for CNCP emphasizing a comprehensive plan of care and mutually negotiated goals: 1) Collaborative Opioid Prescribing Education (COPE), an interactive web-based training utilizing case vignettes of real time, simulated clinical interactions; or, 2) the Veterans Affairs (VA)/Department of Defense Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain, a text-based set of management algorithms. The following outcomes were assessed both pre- and postintervention utilizing validated instruments: 1) knowledge of the role of opioids in CNCP; 2) self-rated competence in the management of CNCP and opioid prescribing; 3) physician satisfaction in caring for patients with CNCP; 4) physician patient-centeredness; 5) satisfaction with training; and, 6) the use of four core management strategies (frequency of prescribing opioids, use of urine toxicology screening, patient treatment agreements, and opioid contracts) over a 2-month period. Statistical analyses were conducted using both an intention-to-treat paradigm to investigate main effects, interactions, and influence of time, and then, only the residents who completed the pre- and post-training assessments to determine the measures that differed across training.
Results: Initially, 570 residents were eligible to participate and 213 were consented for randomization. Both pre- and post-training tests were completed by 143 residents, and 70 residents were missing one or both tests. No significant group differences were found across interventions or between those with and without missing data. Analyses of the training showed significant differences over time and between the two interventions. The web training group had greater increase in knowledge with training and greater self-rated competence in the management of outpatients with chronic pain, including the use of opioids in this management. While residents in both groups reported more satisfaction with managing chronic pain care after training, the web training was superior regarding concerns about training adequacy and relationship quality. For example, about 30% of the web-trained group reported that they did not feel competent managing outpatients with CNCP compared to over 40% of the guideline-trained group. Both groups of residents reported increased satisfaction as the year of residency training increased. The web-based training produced greater improvements on the subscales of training adequacy and relationship quality, but not on those relating to adequacy of data collection, appropriate use of time, and patient’s cooperative nature. Similarly, physician patient-centeredness and information sharing increased with training, but there were no group differences. Both groups reported they were less likely to prescribe opioids when requested by patients and more likely to complete opioid contracts and patient treatment agreements.
Discussion: This educational trial demonstrated that exposure to an interactive web-based training focused on shared decision-making and communication skills was more effective than exposure to compatible practice guidelines for knowledge and self-reported competence in the management of chronic pain. Both types of training improved satisfaction with chronic pain clinical encounters, especially in more experienced residents. The web-based training produced greater improvement than the guideline-based training on measures of training adequacy and relationship quality facets of satisfaction. These results were achieved with interactive training that required only a 1- to 2-hour time commitment and included communication skills training beyond just cognitive content. Previous customized face-to-face training produced stronger effects on management practices only, but did not assess knowledge differences. Limitations of this study include the generalizability of results and the focus on resident self-reports about knowledge, competence, and satisfaction instead of the adoption of management practices and patient outcomes.
Enough evidence exists about the efficacy of opioids for the treatment of chronic nonmalignant pain to support their use in clinical practice . However, long-term opioid therapy remains a controversial practice and may be complicated by a number of adverse outcomes . Other systematic reviews of chronic opioid therapy have failed to solidify support for this practice, citing lack of efficacy, limitations in design, sample size, and inadequate follow-up . Much of this controversy could be attributed to the ignorance and bias of physicians about chronic opioid therapy for the treatment of chronic pain.
Physicians describe patients with chronic pain as frustrating and dissatisfied. Rates of aberrant medication-taking behaviors in patients with chronic pain range up to about 50% of those prescribed opioids . Despite the development of numerous self-report questionnaires, the best overall predictor of a patient engaging in aberrant drug-taking behavior was a standardized interview. These results reinforce the rationale that a comprehensive evaluation by an expert clinician is more likely to produce the best formulation of the case and outcome for the patient than any psychometric instrument .
The prescribing guidelines for long-term opioid therapy focus on principles of effective and safe use of these medications . The approach attempts to balance the potential benefits and risks of opioids. The basic tenets include performing a comprehensive initial evaluation, establishing a diagnosis and medical necessity for opioids based on lack of acceptable response to other therapies, assessing the risk–benefit ratio, outlining treatment goals, obtaining informed consent and agreement, initiating a dose adjustment phase, and if continued, implementing a stable phase of ongoing assessment to document outcome and adherence monitoring to minimize risk of aberrant medication-taking behaviors.
A standard approach of universal precautions incorporates ongoing evaluation of aberrant medication-taking behaviors along with monitoring the degree of analgesia, ability to perform activities of daily living, and adverse events attributable to opioid therapy. However, physicians must be actively trained in the evaluation of patients with chronic pain and about the use of all treatment modalities, especially opioids. A recent clinical trial showed that a brief behavioral intervention utilizing urine screens, compliance checklists, and motivational counseling significantly improved measures of medication misuse in patients identified as high-risk for this behavior .
There is nothing wrong with a “how to” algorithm, and it does imply that each step has a foundation of knowledge that must be taken into consideration. For example, a “comprehensive evaluation” presumably would explore the patient’s personal and family history of substance abuse and that an assessment of “aberrant medication-taking behavior” would require the working through of a differential diagnosis as to the causes of that behavior, such as undertreatment versus addiction. The problem with these recommendations is that they are not a recipe for individual success, but focus on the mechanics of prescribing opioids for the “typical” patient. An educational experience like the web-based training provided by Sullivan et al. engages the physician, with the end result being expertise that can be tailored to the individual patient.
No potential conflict of interest relevant to this article was reported.
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