Abstract
Background
Prescribing opioids for chronic non-cancer pain (CNCP) is a challenge due to associated risks from abuse, addiction and adverse effects. We surveyed resident physicians on their knowledge, attitude and practices in opioid prescription practices in the ambulatory setting and conducted an educational module to address their knowledge gaps.
Methods
A phase 1 survey assessed knowledge, attitudes and practices of residents in the out-patient management of CNCP with opioids. Demographics, numbers of patients seen, those with concerns for risky behaviors, adverse effects and the reasons for concern were also recorded. In Phase 2, an educational module in the form of didactics and case based discussions addressed the perceived deficiencies noted from results of phase 1 survey. Pre and post module surveys assessed the effectiveness of the educational module.
Results
In the phase 1 study (45/49, 92% response rate, M:F=30:15) 33.3%(15/45) were in Post-Graduate Year (PGY) 1, 35.6% (16/45) PGY2s and 31.1% (14/45) PGY3s; 80% (36/45) saw more than one patient with CNCP in the previous 3 months; 62.2% (28/45) had at least one patient with concerns for misuse and addiction; 77.8% (35/45) and 86.7% (39/45) reported a lack of training and consistent documentation respectively, and 82.2% (37/45) were uncomfortable to refill for other provider’s patients. All (100%, 45/45) consulted the clinical pharmacist; 86.7% (39/45) believed that either focused education would be beneficial. In the phase 2 study (44/49, 89.7% response rate, M: F = 29: 15), the pre- and post-module responses showed that > 90% of the residents perceived improvement in knowledge and confidence in management of CNCP with opioids after the educational module.
Conclusions
Internal medicine residents perceived deficits in their ability to manage CNCP. Following a focused educational training, residents’ knowledge and confidence in prescription of opioids improved, demonstrating the need to include management of CNCP with opioids into their curriculum.
Introduction
Chronic non-cancer pain (CNCP) is defined as pain that lasts beyond three months of onset, an arbitrary period beyond which the underlying healing process is expectedly complete.1 CNCP has a tendency to worsen over time affecting all aspects of a person’s life and often requires comprehensive approaches for management and prevention.2 The Institute of Medicine (IOM) reported that 100 million Americans suffer from pain at an estimated loss of $ 635 billion every year for treatment and loss of productivity. While the role of opioids in acute pain and cancer related chronic pain is well established, opioids place in therapy for CNCP is controversial. Chronic opioid therapy (COT) is defined as scheduled opioid medications daily or at least near-daily for 90 days or more.3 Prescribing opioids for CNCP is a challenge for physicians in an ambulatory setting due to the need for balancing the risks and benefits of COT, the lack of evidence-based benefit and the potential for abuse, misuse and addiction.4–7 Increased efforts to adequately control pain has resulted in a several hundred fold increase in the prescription of opioids since 1998, but has undoubtedly contributed to the increase in the number of deaths from opioid overdose, emergency room visits and drug abuse.7–9 We conducted a cross-sectional survey of internal medicine residents to assess their current knowledge, attitude and practices in regards to opioid prescription in the ambulatory care setting. Based on the results of this survey, an educational module was designed and delivered. Surveys conducted pre and post module assessed whether the residents perceived improvement in knowledge and hence confidence in prescription of opioids for CNCP.
Methods
The structured ambulatory care experience for each cohort of University of Missouri Internal Medicine residents occurs for one full week in every five weeks. During this time, a cohort of 9–11 categorical Internal Medicine residents attend quality improvement didactic sessions, and there were 5 such cohorts. This study was conducted in two phases as survey research questionnaires. Both phases of the study were approved by University of Missouri Institutional Review Board. The questionnaires were developed by the authors and reviewed by Internal Medicine faculty for face validity and suggested modifications were incorporated. Informed consent was obtained from every participating resident.
For the phase 1 study, the survey was administered at the weekly didactic sessions for five weeks in April and May 2012. The survey was printed as a hard copy and every resident participant manually completed it. Along with resident physician demographics, the survey collected descriptive data about their ambulatory practice in chronic pain management. The survey had open ended questions for resident physicians to quantify their patients on COT, quantify patients causing concern for high risk behavior, and describe the reasons for concern. The 12 Likert-style (seven scaled – strongly agree to strongly disagree) questions assessed resident physician self-reported knowledge of prescribing opioids for CNCP, as well as attitudes toward opioid prescribing in this population and practices towards prescribing opioids for CNCP. All data from the collected surveys were entered in tabular form in an Excel sheet. The data was later exported into SPSS version 20. Demographic data with continuous variables were expressed as mean ± standard deviation (SD) and responses to the Likert scale questions were summed as either agree, neutral or disagree responses and their percentages were deduced. The Cronbach’s alpha for the Likert scale questions of this phase 1 study was 0.67.
Based on the results of the initial survey, phase 2 of the study was designed. This contained an educational module designed by the study investigators with the aim of improving deficiency in the knowledge and confidence in prescribing opioids for CNCP, as observed from the results of the phase 1 study. The specific topics focused by this educational module are mentioned in Table 1. The entire educational module comprised of a didactic presentation divided into the following interactive sections:
Table 1.
Objectives of focus for the educational module for resident physicians
|
Overview
National burden of CNCP, costs, challenges and common obstacles to patients and providers in management of chronic pain and the unintended consequences of national strategies to achieve pain control.
Evaluation of CNCP
Comprehensive history, specific principles that are needed in evaluation of CNCP e.g. non-judgemental reflective listening, spending adequate time, etc. and psychosocial evaluation
Opioid Pharmacology
Evidence based indications for opioids and its use in CNCP, pharmacologic classes of opioids, schedules based on controlled subtances act, opioid dosing in naïve patients, long versus short acting opioids, methadone, adverse effects with conditions that pose high risk for adverse effects, counselling, short-term and long term follow up (assessment of 4As – analgesic efficacy, adverse effects, aberrant behavior and activities of daily living) and opioid equi-analgesic dose conversion with case scenarios.
Risk stratification
Definitions of risk terms (abuse, addiction, aberrant drug related behavior, physical dependence, tolerance, etc.), factors conferring high risk, risk assessment tools (Opioid risk assessment tool [ORT], Screener and opioid assessment for patients in pain [SOAPP], etc.) and urine drug screening [UDS] (when and why to use UDS, drugs screened, evidence behind use of UDS, pros and cons, etc.).
Treatment agreement
Components of physician-patient treatment agreement, Informed consent, documentation of plan of care and creating a treatment plan
The module was delivered to the same residents who completed the phase 1 survey during the weekly didactic sessions in the respective ambulatory week for every cohort between April and May 2013. The educational module included a pre-module survey followed by didactic presentation encompassing the various educational objectives of focus (Table 1) and exercised on opioid conversion, calculations and patient case scenarios, and a post-module survey to determine if this educational module helped them to perceive improvement in knowledge and confidence in prescription of opioids for CNCP. The phase 2 surveys (pre- and post-module) developed by the authors were also structured in the same way as the survey in phase 1, with demographic details and 15 – Likert-scale questions targeting the objectives of focus in the educational module. The Cronbach’s alpha for pre- and post-survey were both > 0.90
Results
Phase 1
Forty-nine residents out of 54 categorical residents completed the survey, of which four were excluded due to grossly incomplete data [45/49, 92% response rate, M: F = 30(66.67%): 15(33.33%)]. The baseline and demographic characteristics are listed in Table 1. The numbers of participants in each of PGY 1 through PGY3 years were comparable [PGY1 =15(33.3%), PGY2=16(35.6%), PGY3=14(31.1%)]. Our residency program is diverse in that 31/45 (68.9%) of residents had graduated from institutions outside of the United States (US).
Resident physician demographics describing prior medical practice before starting at the University of Missouri Internal Medicine Residency program were available in 33/45 participants and of those, 23/33 (69.7%) had practiced medicine outside of the US prior to starting residency. Of the 43 residents who had provided data regarding experience prescribing narcotics 25/43 (58.1%) had not prescribed narcotics in their previous practice, including 48% of residents (12/25) with previous medical experience outside of the US. The rest (18/43, 41.9%) had prior experience with use of opioids and all of them had graduated from Non-US medical schools with all of their prior use of opioids in non-US settings (India, Jordan, UK, Russia, Syria and Pakistan).
Thirty-six (80%) residents reported ambulatory clinic encounters for more than one patient with CNCP in the previous three months, of which 6 (13%) had encountered 6-10 patients and 6 (13%) had cared for 11 or more patients in the same time period (Table 2). Twenty eight (62.2%) reported seeing at least one patient causing concern for opioid prescribing. Among the perceived reasons for concern, misuse (71.1%) and addiction (68.9%) were the predominant reasons (Table 3). All (45/45, 100%) consulted the clinical pharmacist for either dosage adjustment, opioid conversion or patient education.
Table 2.
Baseline and demographic characteristics from phase 1 (*N= 45, except for ¶ N=33 and ¥ N=43)
| Baseline Characteristics | N* = 45 | |
|---|---|---|
| Age (Mean ± SD) | 29.82 ± 2.93 | |
| Gender [N (%)] | Male | 30 (66.7%) |
| Female | 15 (33.3%) | |
| Level of training [N (%)] | PGY1 | 15 (33.3%) |
| PGY2 | 16 (35.6%) | |
| PGY3 | 14 (31.1%) | |
| Years since graduation (Mean ± SD) | 4.80 ± 3.31 | |
| Country of graduation [N (%)] | USA | 14 (31.1%) |
| Other countries | 31 (68.9%) | |
| Prior practice [N (%)]¶ | Yes | 23 (69.7%) |
| No | 10 (30.3%) | |
| Narcotic prescribing prior practice [N (%)]¥ | Yes | 18 (41.9%) |
| No | 25 (58.1%) |
Table 3.
Number of ambulatory patients causing concern for opioid prescribing, per resident, in previous 3 months and resident perception for concern.
| Number of patients causing concern [N (%)] | N=45 |
|---|---|
| None | 9 (20%) |
| <5 | 20 (44.4%) |
| 6-10 | 9 (20%) |
| 11-20 | 3 (6.7%) |
| Reasons for concern [N (%)] | |
| Misuse | 32 (71.1%) |
| Addiction | 31 (68.9%) |
| Diversion | 4 (8.9%) |
| Adverse effects | 13 (28.9%) |
| Intolerance | 1 (2.2%) |
| Uncontrolled pain | 4 (8.9%) |
As evidenced by resident responses to Likert scale items (See Figure 1), 73.3%(33/45) reported lack of access to pain specialist; 77.8% (35/45) reported a lack of training in the management of CNCP [88% (22/25) of residents with no prior work experience and 72.2% (13/18) of residents with prior work experience] ; 86.7% (39/45) reported a lack of consistent documentation and treatment method among different providers and 82.2% (37/45) were uncomfortable in prescribing opioid refills for patients of other providers. Sixty-four percent agreed that urine drug testing was helpful at the initial visit and 46.7% agreed that it was a useful tool to assess compliance. Thirty-nine respondents (86.7%) agreed that continuing medical education would benefit them with preference to either in-service presentation or case based discussion.
Figure 1.
Residents responses to Likert scale items in Phase 1 study.
Phase 2
Of the surveys completed pre-and post-module from the same 49 residents, 5 (in each of pre-and post-surveys) needed to be excluded due to grossly incomplete data. Demographics were grossly unchanged except that response rate was 44/49 [Response rate 89.7%, M:F = 29(65.9%) : 15 (34.1%)].
The responses of the residents to the Likert scale questions, pre and post module are depicted in Figure 2 and Figure 3 respectively. From these figures it is evident that the educational tool developed and implemented, helped to improve current knowledge about safe and confident opioid prescription practices in our university ambulatory care setting among internal medicine residents.
Figure 2.
Pre-educational module survey responses to Likert scale questions in Phase 2 study.
Figure 3.
Post - educational module survey responses to Likert Scale Questions in Phase 2 study.
Discussion
Our study demonstrates that prescribing opioids for CNCP poses a challenge for internal medicine residents. Our results support those of other surveys of residents from other programs 10–12. Several deficiencies were reported by residents, notably 77.8% clearly indicated that there is lack of adequate training in chronic pain management. Residents as primary care physicians often inherit patients who have been on chronic opioid therapy or encounter a new patient with chronic pain who is opioid naive. Prescribing of opioids not only requires clinical decision-making, but also consideration and discernment of social and behavioral patterns. During the first clinic visit it is often difficult to identify patients with a history of opioid misuse or to predict which patients will be problematic users of prescribed opioids. The fine balance between confident prescribing and fear of problematic use can be bridged by reviewing previous health records, performing a thorough interview and physical assessment as well as obtaining knowledge about patient history of chronic pain.
In our study cohort, 68.9% (31/45) residents had graduated from non – US medical schools. Of this 58.1% (18/31) had prior experience with use of opioids in Non-US settings (India, Jordan, UK, Russia, Syria and Pakistan). As we did not gather data regarding the reasons for the use of opioids in their prior practice, we could not derive any conclusions. Nevertheless, irrespective of country of graduation (U.S. and non U.S. countries), a majority perceived a lack of training [88% (22/25) of residents with no prior work experience and 72.2% (13/18) of residents with prior work experience] in management of CNCP with opioids.
Improved documentation of risk factors, compliance, response to therapy and adverse effects are important factors in safe and vigilant opioid prescribing due to its potential for significant adverse outcomes.13,14 In our study, 86.7% reported a lack of consistent documentation by different clinic providers. This likely resulted in a majority of respondents (82.2%) reporting that they were uncomfortable prescribing opioids for other providers’ patients in the clinic.
While evidence to support periodic urine drug screening (UDS) in the context of COT for CNCP is lacking, many chronic pain management experts recommend UDS at the initial evaluation and randomly during follow-up of new patients especially those with high risk behavior. 4,15,16 While 64% believed that an initial UDS will help to identify current illicit drug use, only 46.7% were aware of its use as a tool for assessing compliance. In each of these categories 22.2% of the respondents were unsure about the usefulness of UDS. While a large proportion of residents recognized the utility of UDS, only 46.7% believed in its usefulness in predicting high risk behaviors, 22.2% were neutral and 31.1% did not find these tools to be available. We anecdotally suspect that among those residents who were aware of available risk assessment tools, they did not implement them nor document such use in their clinic records. This is similar to findings in another recent study that reported limited use of risk reduction strategies by primary care physicians. 17
In the phase 1 study, 39(86.7%) respondents reported a lack of consistent treatment methods among different providers. We suspect that this variability in pain management likely results from a combination of factors including: individual clinical judgment, personal preference, fear of legal implications from use in patients with high risk behavior as well as limited and outmoded knowledge and attitudes about opioid prescribing for CNCP. 18 As part of an educational institution, resident physicians and their supervising attending physicians rotate periodically in clinics, providing a milieu for variable knowledge, practice patterns and patient care. The results of our phase 2 study demonstrates a clear improvement in knowledge and confidence in prescribing opioids after implementing an educational module addressing the deficiencies perceived by practicing providers in training. Such focused educational approach to improve competence and confidence in pain management among trainees may translate into not only improved clinical outcomes, but also help develop future providers equipped with essential skills for individual practice.19
The results of phase 2 study clearly showed that residents perceived improved knowledge and confidence in prescribing opioids for CNCP after the educational module and these results are consistent with previous other studies done in resident populations.20 Even at this time, medical education in chronic pain management is still not a mandatory Accrediting Council of Graduate Medical Education (ACGME) component, alternatively it is often and only optionally available through various workshops, lectures and Continuing Medical Education (CME) venues. This lack of uniformity or standardization results in an education that is fragmented and diverse.21
We recommend that the ACGME re-evaluate the requirements for residency education in the area of opioid prescribing, particularly for CNCP, to increase resident physician confidence in prescribing this highly regulated class of medications. Educational content reviewing opioid pharmacology, toxicology and pharmacokinetics/dynamics, as well as incorporation of risk assessment tools and risk reduction methods into pain management practice would fulfill this unmet need. There is a paucity of objective evidence-based benefit of opioid therapy. However, true benefit can be achieved from opioids in selected patients with CNCP. Given these things, and coupled with the structured, yet dynamic rotation schedule of a residency training program, an algorithmic approach for management of CNCP and opioid prescribing could provide a backbone for consistency in management of CNCP. Such an approach would alleviate the fear of associated risk and also institutionally standardize pain management care. A vigilant and transparent relationship has to be established between the primary care physician and the patient with CNCP, sharing the challenges and responsibilities.
Although the results are purely descriptive, they have revealed an important chasm in the medical education. Other limitations in the phase 2 study include that the post-module survey was done soon after the delivery of the educational module and exercises, as thus may not translate into meaningful benefit in the consistent clinical practice over the long run. Also, the study was not designed to see or measure a true change in the prescription practices of resident providers in their respective ambulatory care setting.
Conclusion
Our survey demonstrated that internal medicine residents do perceive deficits in their ability to manage patients with CNCP. Structured and focused curriculum on a recurring basis, targeting chronic pain management and safe prescription of opioids may help to alleviate physician fear of inappropriate prescription and misuse of opioids as well as improve patient care. The resident curriculum should incorporate chronic pain management in the ambulatory care setting as a mandatory requirement, without which the noted deficiencies in knowledge, attitude and practices will continue to persist. A standardized and institutionalized algorithmic approach for risk assessment, opioid prescription, and consistent documentation may all help improve opioid prescription practices.
Biography
Hariharan Regunath, MD, (above) is in the Department of Medicine, Division of Infectious Diseases and Division of Pulmonary and Critical Care, University of Missouri. Kelly Cochran, Pharm D, BCPS, is at the University of Missouri-Kansas City School of Pharmacy, Columbia, Mo. James Shortridge, DO, is in Department of Medicine, Division of Hematology and Oncology, University of Missouri. Syed Akbar, MD, is in Department of Medicine - Division of Hematology and Oncology, SUNY Upstate Medical University, Syracuse, NY. Jyotsna Reddy, MD, is in Landmark Hospitals, Columbia, Mo. Barbara Boshard, BSN, MS, RN, Rebecca Chitima-Matsiga, MS, MPH, Daniel Kim, MD, Kasey Cornell, MD, Steven Keithahn, MD, MSMA member since 1998, and James P. Koller, MD are in the Department of Medicine, University of Missouri.
Contact: regunathh@health.missouri.edu
Footnotes
Disclosure
None reported.
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