An Institutional Curriculum for Opioid Prescribing Education: Outcomes from 2017–2022

Abstract

Introduction:

Prescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients.

Methods:

An annual opioid prescribing education (OPE) curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-minute session which is comprised of several components: pain medications (dosing, indications and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session.

Results:

Pre- and post-session assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median pre-session score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge increase of 18.2%. The median relative improvement was greatest for pre-interns and interns (18.2% for both groups); smaller improvements were observed for PGY 2–5 residents (9.1%) and APPs (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (IQR) self-reported comfort in prescribing opioids increased from 3 (2–5) prior to education to 5 (4–6) after education (p< 0.001).

Conclusion:

Each year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.

INTRODUCTION

Since 1999, opioids have been implicated in over 500,000 deaths in the United States (US).¹ Despite decades of effort in combating the US opioid epidemic, including the 2017 declaration of a Federal Public Health Emergency by the Department of Health and Human Services,² 93,000 deaths were attributed to opioids in the one year period from December 2019 to December 2020.¹ Aside from illicit drugs, prescription opioids – including those prescribed after surgery and other procedures – have greatly contributed to the US opioid crisis.^3,4

The role of prescription opioids, especially those prescribed – often in excess – by surgeons to manage post-operative pain, is well recognized,^5,6 and has been investigated by groups across surgical specialties. These studies describe inter-provider variation in post-operative opioid prescriptions, prescribed quantities of opioids that often exceed the quantity used by the patient, and the need for evidence-based guidelines for post-operative opioid prescription.^5–8

The opioid-related education received by physicians has been linked to their future opioid prescribing practices.^9,10 Thus, efforts at mitigating the consequences of the opioid epidemic focus not only on regulatory and pharmacologic interventions,³ but also on the implementation of standardized protocols for post-surgical prescribing^11–20 and the education of opioid prescribers. This latter topic has received considerable attention over the past 8 years, and multiple groups have described their institutional and/or departmental efforts to positively impact opioid prescribing patterns through standardized provider education.^21–30 In the 6 months following completion of a brief 30-minute lecture among general surgery residents regarding prescribing guidelines and multimodal analgesia, Bohan et al. observed a significant decrease in opioid volumes prescribed and an increase in the use of nonopioid analgesics.²² More broadly, a survey of general surgery residents across several institutions found that trainees who received formal education in opioid prescribing prescribed significantly less opioids.²⁶ The results were marked; for instance, for thyroidectomy, 24.4% of residents without formal education prescribed 20 or more oxycodone 5mg tablets upon discharge compared to 0% of residents with formal education.

Educational initiatives are often paired with complementary initiatives. For instance, Stepan et al. demonstrated how the implementation of hospital-wide opioid education, in the form of a 1-hour mandatory session, and subsequent procedure-specific prescribing guidelines for six common orthopedic procedures was associated with a significant decrease in opioids prescribed – representing nearly 30,000 fewer opioid pills prescribed per year after the 6 operations alone.²⁷ Similar results were observed by Nguyen et al., whereby a 20-minute curriculum – focused on the magnitude and impact of the opioid epidemic, common provider misconceptions regarding opioid prescribing, the utility of multimodal analgesia, and tips for patient counseling – and the implementation of procedure-specific prescribing guidelines was associated with a reduction in opioid prescribing.²³ In these circumstances, the distinct impact of provider education is difficult to characterize. However, a post-education survey of surgical oncology providers reveals some insight regarding the impact of education on provider perceptions of post-surgical opioid use, as providers more commonly agreed that discharge prescriptions should be based on inpatient opioid use and that decreasing the duration (and quantity) of opioids was safe and effective.²¹

While some educational efforts have been aimed at undergraduate medical students;^31,32 most targeted educational interventions have focused on resident trainees who, along with advanced practice providers (APP), are responsible for a large portion of opioids prescribed on discharge.⁵ Effective July 1, 2019, the Accreditation Council for Graduate Medical Education (ACGME) required all residency programs to “provide instruction and experience in pain management if applicable for the specialty including recognition of the signs of addiction”.³³

Prior to this ACGME mandate, a multidisciplinary group of surgeons and anesthesiologists at our institution developed a curriculum for opioid prescriber education. In 2017, this curriculum was implemented at four hospitals in Boston. ³⁴ We identified significant gaps in opioid prescribing knowledge and comfort which improved following a single 75-minute educational session. Surgical providers and residents at our institution have since completed this curriculum annually.

In the current study, we present our six-year experience with the curriculum and quality improvement initiative to increase prescriber knowledge and comfort with opioid prescribing.

METHODS

Study Design

Between 2017 and 2022, surgical providers at our institution, including resident trainees and APPs, have completed a one-time opioid prescriber education curriculum. To evaluate the longitudinal effectiveness of this curriculum, participants were invited to complete a brief survey-based knowledge assessment before and after the single 75-minute educational session.

Curriculum Development and Completion

In 2017, a multidisciplinary team of surgeons and anesthesiologists created an opioid educational curriculum for surgical prescribers, including categorical and preliminary general surgery residents, other residents rotating on surgical services, and surgical APPs. The original content and design of the curriculum was previously described.³⁴ In brief, the curriculum includes a 75-minute didactic session which includes several components: pain medications (dosing, indications and contraindications); patients at high risk for uncontrolled pain and patients at risk for opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations.

Since the initial development and implementation of the curriculum, our institution has established an Opioid Education Committee comprised of multidisciplinary stakeholders, including anesthesiologists, surgeons, pharmacists, nurses and other clinicians. This group is responsible for ensuring appropriate opioid prescriber education for trainees and other opioid prescribers as defined by criteria derived from institutional standards as well as federal and state regulations. The committee developed a process for systematically evaluating the content and delivery of existing opioid prescribing curricula which includes annual review by the Opioid Education Review Team. In the annual review, recommendations for modification of and addition to existing curricula are made ensuring the inclusion of established learning objectives. As a result of this process, modifications have been made to our initial curriculum since its development in 2017. Since the original development of the curriculum in 2017, curricular modifications and/or additions have included specific strategies regarding the appropriate management of acute pain in patients with a history of opioid misuse or abuse, including patients receiving outpatient pharmacologic treatment for opioid dependence; additional emphasis regarding stigma and bias reduction in caring for patients with substance use disorder; and additional information regarding opioid overdose prevention, recognition and management.

The presentation materials will be readily shared upon request.

The curriculum was first administered to surgical prescribers at our institution in March 2018. Participants included pre-interns (defined as fourth year medical students who had matched into, but had not yet started, surgical residency), residents of postgraduate years 1 through 5, and APPs (nurse practitioners and physician assistants). Following this first session, the curriculum was completed during intern orientation in June of the following academic years (AY): 2018–2019, 2019–2020, 2021–2022 and 2022–2023. The AY 20–21 session was administered virtually due to COVID-19 and survey responses were not available for analysis in the current study.

Knowledge Assessment

Participants were asked to complete an 11-question opioid knowledge assessment before and after the didactic session to quantify the effectiveness of the curriculum. The assessment was designed by the Pennsylvania Patient Safety Authority and has been previously utilized among healthcare providers, including prescribers, pharmacists and nurses.^35,36 Five questions were added to the knowledge assessment by our study team to evaluate participant practice level and comfort in prescribing, and to obtain feedback regarding the curriculum. There is no consensus regarding what performance on the knowledge assessment constitutes competency in opioid prescribing. Test performance among the initial cohort has been published;³⁵ the median score among all respondents, which included attending providers, resident physicians, advanced practice providers and registered nurses, was 54.5% in 2012 and 63.6% in 2013. The assessment was not altered throughout the study period and is included as Supplemental Material 1.

Statistical Analysis

Knowledge and comfort scores are presented as median (interquartile range, IQR). Anonymous pre- and post-session assessments were paired, enabling analysis of score changes. Wilcoxon signed-rank tests were performed to assess changes in provider knowledge and comfort following the educational initiative. A p value of <0.05 was considered significant. Statistical analyses were performed using Stata (version 17.0, April 2021).

The study was approved by the Institutional Review Board at our institution (2019P000123). Trainee/provider participation in the educational session was required by the residency program and/or department of surgery. Completion of the pre- and post-session knowledge assessments was voluntary; participant consent was obtained as part of the assessment survey.

RESULTS

Excluding AY 20–21, a total of two hundred and twenty unique providers participated (AY 18–19 to AY 22–23). Both pre- and post-session knowledge assessments were completed by 197 (89.6%) prescribers. The completed assessments represented 34 pre-interns (17.2%), 102 interns (51.8%), 54 residents PGY 2–5 (27.4%) and 7 APPs (3.6%).

Across the five studied years, the median (IQR) pre-session score was 54.5% (45.5%-63.6%), which increased to 63.6% (54.5–81.8%) after completion of the curriculum, representing a relative median (IQR) knowledge increase of 18.2% (9.1%-27.3%) (P < 0.001, Table 1 and Figure 1a). Annual score distributions before and after education are presented in Figure 1b; both the relative difference and score distribution after education increased during the study period. During the post-education assessment, nearly all residents performed better than (N=151, 76.7%) or identical to (N=27, 13.7%) their pre-education score (Table 2). Greater than two-thirds of participants performed better on the post-education assessment for all years except AY 19–20 when 58.1% of participants scored higher on the post-education survey. Across all years, more than 50% of participants who did not achieve a higher score on the post-education assessment had a pre-education score at or above the median post-education score. Among the participants who did not achieve a higher score on the post-education assessment, 67.4% (31/46) of participants reported increased comfort in opioid prescribing.

Table 1:

Annual Opioid Knowledge Score Distributions and Net Difference Before and After Opioid Prescriber Education

Cohort	% Correct Pre-Education Median (IQR)	% Correct Post-Education Median (IQR)	% Difference Median (IQR)
AY 17–18 (N=63)	54.5 (45.5–63.6)	72.7 (63.6–81.8)	18.2 (0.0–27.3)
AY 18–19 (N=64)	54.5 (45.5–63.6)	63.6 (54.5–81.8)	18.2 (9.1–22.7)
AY 19–20 (N=31)	45.5 (36.4–63.6)	63.6 (45.5–72.7)	9.1 (0.0–18.2)
AY 20–21	Omitted	Omitted	Omitted
AY 21–22 (N=29)	45.5 (36.4–54.5)	72.7 (63.6–72.7)	18.2 (18.2–27.3)
AY 22–23 (N=10)	45.5 (36.6–72.7)	72.7 (63.6–81.8)	27.3 (9.1–27.3)
All Years (N=197)	54.5 (45.5–63.6)	63.6 (54.5–81.8)	18.2 (9.1–27.3)

Figure 1A: Opioid Knowledge Score Distributions Before and After Opioid Prescriber Education (AY 17–18 – AY 22–23, omitting AY 20–21).

Boxplots of knowledge scores before and after opioid prescriber education curriculum for the entire cohort and study periods (AY 17–18 to AY 22–23, omitting AY 20–21). Boxplot displays median score (middle line of shaded box), with interquartile range (shaded box).

Figure 1B: Annual Opioid Knowledge Score Distributions Before and After Opioid Prescriber Education (AY 17–18 – AY 22–23, omitting AY 20–21).

Boxplots of annual knowledge scores before and after opioid prescriber education curriculum for the entire study cohort (AY 17–18 to AY 22–23, omitting AY 20–21). Boxplot displays median score (middle line of shaded box), with interquartile range (shaded box).

Table 2:

Change in Opioid Knowledge Score Before and After Opioid Prescriber Education

Cohort	Number (Percentage) of Participants
	Decreased Score	No Change in Score	Improved Score
AY 17–18 (n=63)	5 (7.9)	11 (17.5)	47 (74.6)
AY 18–19 (n=64)	7 (10.9)	8 (12.5)	49 (76.6)
AY 19–20 (n=31)	6 (19.4)	7 (22.6)	18 (58.1)
AY 20–21	Omitted	Omitted	Omitted
AY 21–22 (n=29)	0 (0.0)	1 (3.5)	28 (96.6)
AY 22–23 (n=10)	1 (10.0)	0 (0.0)	9 (90.0)
All Years (n=197)	19 (9.6)	27 (13.7)	151 (76.7)

Scores by rank are presented in Figure 2. Across all years, pre-interns and interns scored similarly on the pre-education assessment (median 45.45% for both groups), which was lower than that of PGY 2–5 residents and APPs (median 54.54% for both groups). Post-education scores improved for all provider groups. The median (IQR) relative improvement was greatest for pre-interns (18.2% [9.1%-36.4%]) and interns (18.2% [9.1%-27.3%]). Smaller improvements were observed for PGY 2–5 residents (9.1% [0%-18.2%]) and APPs (9.1% [9.1%-18.2%]).

Figure 2: Opioid Knowledge Score Distributions Before and After Opioid Prescriber Education by Provider Type.

Boxplots of annual knowledge scores before and after opioid prescriber education curriculum separated by provider rank/role (AY 17–18 to AY 22–23, omitting AY 20–21). Boxplot displays median score (middle line of shaded box), with interquartile range (shaded box).

Aggregate performance on individual questions is presented in Table 3. The percentage of correct of responses was less than 60% for 4 questions, including two questions in which less than 40% of participants selected the correct response. The subject matter of the most frequently incorrect questions related to the identification of opioid overdose within the hospital; definition of an opioid-tolerant patient; in-hospital patient monitoring and opioid use; and patient specific factors and in-hospital opioid use. The full assessment is available as Supplemental Material 1.

Table 3:

Post-Education Performance by Question

Question	Topic Area	Correct Responses (%)
1	Definition of opioid-tolerant patient	117 (59.4%)
2	Identification of opioid overdose within hospital	75 (38.1%)
3	Long-acting opioids	161 (81.7%)
4	MME conversion	148 (75.1%)
5	Patient specific factors and inpatient opioid use	159 (80.7%)
6	Opioids and use of sedatives/sleep aids	170 (86.3%)
7	In-hospital patient monitoring and opioid use	117 (59.4%)
8	Patient specific factors and inpatient opioid use	141 (71.6%)
9	Opioids and use sedatives/sleep aids	138 (70.1%)
10	Patient specific factors and inpatient opioid use	76 (38.6%)
11	Patient specific factors and inpatient opioid use	146 (74.1%)

Among all participants, median (IQR) self-reported comfort in prescribing opioids was 3 (2–5) on a scale of 1 to 10 (with 10 being “Very comfortably, I do not need any training”) prior to education and 5 (4–6) after education (p< 0.001). Before education, participants’ self-reported comfort in prescribing opioids (rated on a scale of 1 to 10) was low, with median (IQR) of 4 (2–5) in AY 17–18 and AY 18–20 which decreased to a median (IQR) of 3 (2–3) and 2.5 (2–4) in AY 21–22 and AY 22–23 respectively (Table 4). Despite the observed year-to-year variability in baseline comfort, comfort levels after education were similar across all study years, with median (IQR) score ranging from 4 (4–6) in AY 18–19 to 6 (5–6) in AY 22–23. Self-reported comfort in prescribing opioids varied by provider type (Figure 3). Pre-interns and interns reported the lowest baseline comfort (median [IQR]: 2 [1–3] and 3 [2–4]), and exhibited the greatest improvement (median [IQR]: 4 [4–5] and 5 [4–6]). Minimal differences in prescribing comfort were reported among PGY 2–5 residents (pre: 5 [4–6.5] and post: 5 [4–6]).

Table 4:

Change in Self-Reported Comfort in Opioid Prescribing Before and After Opioid Prescriber Education (on a scale from 1 to 10 with 10 being very comfortable)

Cohort	Comfort Score Median (IQR)
	Pre-Education	Post-Education
AY 17–18 (N=63)	4 (2–5)	5 (4–6)
AY 18–19 (N=64)	4 (2–5)	4 (4–6)
AY 19–20 (N=31)	3 (2–4)	5 (4–6)
AY 20–21	Omitted	Omitted
AY 21–22 (N=29)	3 (2–3)	5 (5–6)
AY 22–23 (N=10)	2.5 (2–4)	6 (5–6)
All Years (N=197)	3 (2–5)	5 (4–6)

Figure 3: Self-Reported Comfort in Opioid Prescribing by Provider Type.

Comfort in opioid prescribing before and after opioid prescriber education curriculum across the entire study cohort (AY 17–18 to AY 22–23, omitting AY 20–21). Comfort scale ranged from 1–10 with 1 being “very uncomfortable” and 10 being “very comfortable”. Boxplot displays median comfort level (middle line of shaded box), with interquartile range (shaded box).

Nearly all participants (191/197, 97.0%) reported that the education would impact their practice. After the first year of implementation, only one of the 134 participants reported that the session would not impact their practice. Overall, participants rated the education sessions favorably, with satisfaction median (IQR) of 8 (7–9). Participant satisfaction was lowest in AY 17–18 and AY 19–20, with median (IQR) of 7 (6–8) and 7 (5–8), respectively.

DISCUSSION

In 2017, our institution designed a 75-minute curriculum for surgical prescribers at our institution. In its first year of implementation (2018), it was shown to significantly increase provider knowledge and comfort in prescribing opioids.³⁴ In the current study, we describe outcomes of this educational and quality improvement initiative over the past six years. Despite increased national awareness and multiple institutional efforts to promote optimal opioid prescribing among surgical patients, there is a gap in opioid prescribing knowledge among new surgical providers, which is improved by the curriculum evaluated in this study. Notwithstanding improved performance on the knowledge assessment, provider comfort in this domain remains sub-optimal, underscoring a need for further provider education and clinical resources.

Foremost, our findings highlight the ongoing need for opioid prescriber education among surgical trainees entering residency programs. Despite national and institutional initiatives to promote safe and appropriate use of opioids among surgical patients,^30,37–41 as well as changes in medical school curricula designed to equip trainees with the necessary skills and knowledge to enter clinical practice,^42–44 scores on our pre-curriculum knowledge assessment were low and remained low throughout the six year study period. The minimal change in pre-intervention knowledge assessment observed over a six year period reinforces the value of the OPE curriculum. Importantly, participants’ self-reported comfort in opioid prescribing was low (median score of 5, corresponding to “Comfortable, I know the basics!”), and appeared to decrease slightly over the study period. This may suggest that greater awareness of the potential harms of opioid prescribing has led to greater discomfort and uncertainty in how to appropriate use opioid medications and other modalities to manage post-surgical pain. Median post-education knowledge was lowest in AY 18–19 and AY 19–20, which interestingly coincided with the lowest reported comfort in opioid prescribing suggesting a degree of insight among providers with regard to their opioid-related knowledge. This observation may link provider knowledge and comfort, again highlighting the value of an opioid curriculum shown to improve both measures of prescriber competence. It does not appear that provider comfort increases with experience alone; future research is needed to investigate barriers to provider comfort in this area and to determine how to better support providers as they make prescribing decisions.

In addition, the current findings emphasize the reality that relative to PGY2–5 residents and APPs, pre-interns and interns have the lowest degree of baseline knowledge and comfort. Given that intern physicians prescribe the majority of opioids prescribed to surgical patients upon discharge, this intuitive observation supports the implementation of the OPE curriculum at the onset of residency training. While PGY2–5 residents and APPs had higher baseline knowledge scores, their scores also improved with education. Rather than assuming adequate knowledge will be naturally attained by means of increased clinical experience throughout the course of training, a dedicated opioid prescriber curriculum should be implemented for all providers.

Our institution’s OPE curriculum pre-dates the 2019 ACGME mandate that residency programs provide instruction and experience in pain management. Despite concurrent initiatives to implement evidence-based opioid prescribing practices at our institution,^20,21 a substantial gap in knowledge and comfort persisted during the study period. Our findings reinforce the need for and potential impact of the ACGME’s mandate for dedicated OPE among trainees, and highlight the longitudinal experience of one institution with implementing and evaluating an OPE curriculum. We hypothesize that sustained educational initiatives, as reported in the current study, are an important step to changing opioid prescribing culture and thus building a community of responsible prescribers. Our experience may provide a framework for further guidelines and regulation regarding the adoption of OPE curricula for resident physicians.

Few studies examine the impact of educational and quality improvement initiatives after their initial implementation. Notwithstanding promising initial results, we made iterative changes to the curriculum in an effort to address identified gaps and optimize the educational experience. Our findings demonstrate a gradual increase in post-session knowledge scores over time, suggesting there is value in iterative programming. Initial modifications were driven largely by qualitative observations by the study team and departmental leadership, as well as the recommendations of the Opioid Education Commiteee, who reviewed the curriculum annually. By analyzing longitudinal performance, the current study reinforces the validity of findings from any single year, and emphasizes the overall impact of the curriculum. In particular, longitudinal assessment allows sub-group analysis by provider type, demonstrating that pre-interns and interns benefit immensely from the OPE curriculum. In addition, by reviewing performance on individual questions, we are able to identify topics which warrant further emphasis and/or clarification in the curriculum. Based on the results of the present study, as well as the consistently sub-optimal comfort scores, we plan to strategically further modify the curriculum.

The current study has some limitations. First, the survey outcomes, notably prescriber opioid knowledge and self-reported comfort with opioid prescribing are indirect measures of competency -- and may not reflect the ultimate endpoint of appropriate opioid prescribing. However, these metrics were assessed as they are believed to contribute to responsible opioid use and improved pain management among post-surgical patients. Analyzing prescriber practice before and after education may be a more optimal study design; however, we felt providing upfront education (during intern orientation) was a stronger priority. In addition, our institution employs multiple resources to advance opioid prescribing, and have observed substantial reductions in the total number of opioids prescribed over the past 6 years.⁴⁰ It would be very difficult to discretely attribute changes in opioid prescribing to the curriculum. While many studies assess the impact of education on this end-point, we believe assessing knowledge and comfort may be a more apt means of evaluating the merits of the curriculum. Furthermore, each cohort of participants was comprised of providers of varying experience, including pre-interns, interns, PGY 2–5 residents and APPs. After the first year, the cohort was comprised predominately of pre-interns and new interns, as most PGY 2–5 residents and APPs completed the curriculum in the first year. Similarly, the knowledge assessment did not control for providers’ prior experience and exposure in this domain. Medical school curricula and pre-residency clinical experiences vary greatly, and these differences would likely alter survey results. In addition, the current OPE curriculum is not designed nor administered to surgical faculty. Ongoing research by our group has underscored the influence of attending surgeons on opioid prescribing practice; thus, future efforts should assess potential knowledge and competency gaps within this group. While recently published data from our group has demonstrated knowledge retention and slightly increased comfort in prescribing among intern participants at 7-month follow-up, future studies are needed to longitudinally assess knowledge retention amongst participants to determine whether interval education is needed to further optimize prescriber practices. Our assessment was anonymous and did not investigate the impact of provider demographics beyond provider role and/or level of training; future research should evaluate whether the effectiveness of the curriculum is associated with any provider attributes. Lastly, the curriculum was completed via video-conference during AY 20–21 due to the COVID-19 pandemic; given this change, data from AY 20–21 were excluded from the study.

In conclusion, we successfully implemented an OPE curriculum for each of the past six years and observed associated improvement in knowledge and comfort in opioid prescribing. The current study demonstrates how a brief, dedicated OPE curriculum may better position trainees to responsibly prescribe opioids, more effectively manage acute pain among surgical patients and limit the role of prescription opioids in the ongoing opioid epidemic. Consistent with the ACGME mandate, opioid prescribing is a domain of resident education that warrants attention, and as evidenced by ongoing gaps in prescriber comfort, further work is critically needed.

Supplementary Material

1

Supplemental Material 1: Knowledge Assessment and Participant Survey