Table 1.

Summary of multifaceted interventions primarily aimed at prescribing in the hospital inpatient setting (n = 16)

Author, year, country	Study size (n; I = intervention, C = standard care)	Study design	Study population Follow‐up duration	Interventiona		Outcomes
				Health care professional education	Other	Prescribing	Clinical
Educational interventions to manage pain mainly using opioid analgesics
Taylor et al., 2015, Australia38	1317(I: 0 mo = 2323 mo = 2476 mo = 238C: 0 mo = 2013 mo = 1996 mo = 200)	Multicentre, cluster‐randomised, controlled intervention trial	ED6 mo	‐ Multidisciplinary face‐to‐face education to reduce pain by increasing provision of adequate analgesia	‐ Audit and feedback (daily)	No change in opioid analgesic use	↑ Patient satisfaction with pain management (42.9–53.9%*)
					‐ Patient education
							↑ Patient education (80.5% vs 86.1%*)
				‐ Hard copy and email material
				‐ Multiple choice self‐assessment
				‐ Online module
				‐ Pain posters
Morisson et al., 2009, USA20	217(I: 129C: 88)	Controlled prospective propensity score‐matched clinical trial	Surgical6 mo	‐ Multidisciplinary face‐to‐face health professional education to improve pain management according to local guidelines	‐ Protocols for analgesia, opioid tapering and treatment of opioid‐related adverse events	↑ Regular opioid analgesic use (98.0 vs 48.0%*)	↓ No or mild pain at rest (66.0 vs 51.0%*) and activity (52.0 vs 38.0%*)
						↑ Concurrent laxatives prescribed (92.0 vs 83.0%*)	No change in opioid‐related adverse effects
				‐ Audit and feedback (monthly)
				‐ NRS pain evaluation
Bingle et al., 1991, USA21	296(I: 147C: 149)	Pre–post intervention study	Surgical 6 mo	‐ Academic detailing education for physicians encouraging pethidine (meperidine) use		↑ Adherence of pethidine prescriptions to appropriateness criteria (30.0 vs 43.0%*)
				‐ Pen and hard‐copy material (Handbook on the Rational Use of Medication for Pain by Gerald M. Aronoff and Wayne O. Evans; pethidine dose <75 mg and administration interval longer than 3‐hourly defined to be inadequate)
Boothby et al., 2003, USA50	(60I: 30C: 30)	Pre–post intervention study	All inpatient3 mo	‐ Academic detailing education for physicians discouraging pethidine use	‐ Opinion leader	↓ Pethidine use by 29.5% (95% CI 1.97–2.88*) ↑ Pethidine switch to morphine or hydromorphone and nonopioid analgesicsIn 85.0% of orders.	↓ Opioid‐related ADEs (53.0 vs 23.0%*)
					‐ Policy change to replace pethidine with alternative opioids
				‐ Hard copy pocket cards for physicians and pharmacists
				‐ VAS pain evaluation‐ Bulletin and table‐top card material	‐ Removal of pethidine from
					PCA
					‐ Pharmacist medication review
Neitzel et al., 1999, USA22	118 (I: 61 C: 57)	Pre–post intervention study	Surgical8 mo	‐ Physician, pharmacist and nurse 8‐h face‐to‐face education to increase evidence‐based pain management (Pain Awareness: Provider Information, Patient Needs syllabus developed by Pain Guidelines Implementation Team 1996) including systematic pain assessment, opioid analgesia, care plan communication	‐ Opinion leader	↑ Hydromorphone use by 18.0%	No change in pain intensity↓ Pethidine use by 48.0%* No change in opioid‐related ADEs↓ Hospital LOS from 5.9 to 5.1 ds*
					‐ Patient education
						No change in morphine use
				‐ Hard‐copy material
Shaw et al., 2003, Australia51	336(I: Pre = 46, Post = 128C: Pre = 116Post = 46)	Pre–post intervention study	All inpatients 6 mo	‐ Academic detailing education for physicians to increase appropriate opioid prescribing		↓ Prescription error rate for drugs of addiction (41.0 vs 24.0%*)
				‐ Hard copy (bookmark) material summarising prescribing guidelines
VanGulik et al., 2010, Netherlands35	190 (I: 130 C: 60)	Pre–post intervention study	ICU 3 mo	‐ Multidisciplinary face‐to‐face education to increase pain assessment (NRS) and treatment with opioid analgesics	‐ CPOE	↑ Morphine use (22.6 vs 29.3 mg/d*)	↓ Pain intensity (OR 2.54, 95% CI 1.22–5.65*)
							No change in ICU LOS or MV time
				‐ Email and bulletin material
Akce et al., 2014, USA52	150 (I: 75 C: 75)	Retrospective serial cross‐sectional study	All inpatients 12 mo	‐ Physician face‐to‐face education through group discussion of opioid case scenarios	‐ CPOE	No change in opioid use	No change in pain intensity
				‐ Hard copy pocket cards for physicians
Educational interventions to manage pain mainly using nonopioid analgesics
Titsworth et al., 2016, USA23	96 (I: 48 C: 48)	Prospective, interrupted time‐series trial	Surgical 10 mo	‐ Physician and nurse face‐to‐face education to increase pain assessment and use of nonopioid analgesia (paracetamol, NSAIDs, ketamine, gabapentin) ‐ NRS pain documentation	‐ Acute pain service support ‐ Clinical rounds ‐ OME calculation tool‐ Patient education‐ Analgesia protocol	No change in morphine use on first postoperative d↓ Morphine use (3rd postoperative d: 72.3 ± 70.7 vs 39.2 ± 36.5 mg/d ± SD*)↑ Paracetamol use (56.3 vs 75.0%*)↑ NSAID use (8.3% vs 31.3%*) ↑ Gabapentin use (12.5 vs 33.3%*) No change in hospital LOS	↓ Pain intensity (NRS: 4.31 vs 2.94*)
Benditz et al., 2016, Germany24	367	Prospective cohort study	Surgical24 mo	‐ Physician and nurse face‐to‐face education to reduce pain by using nonpharmacological methods, nonopioid and opioid analgesics (German Guidelines of Pain Management in Nursing)‐ NRS pain evaluation	‐ Adverse drug event evaluation‐ Internal benchmarking ‐ Monthly audit and feedback‐ Patient education		↓ Pain intensity by 24.4%*No change in opioid‐related ADEs of nausea, dizziness or tiredness
Auyong et al., 2015, USA25	252 (I: 126 C: 126)	Pre–post intervention study	Surgical 1 mo	‐ Multidisciplinary face‐to‐face education regarding updated Enhanced Recovery After Orthopedic Surgery Pathway‐Electronic and hard‐copy material ‐ NRS pain evaluation	‐ Multimodal analgesia protocol including regular oral paracetamol, NSAIDs and gabapentin and when‐required oxycodone.‐ Physical therapy‐ Patient education	↓ Morphine use on postoperative d 1 (IV equivalent 32.0 vs 23.5 mg*) and d 2 (IV equivalent 23.3 vs 15.9 mg*)	↓ Hospital LOS (76.6 vs 56.1 h*)↓ Opioid‐related nausea on postoperative d 1 (37.3 vs 25.4%*)
Chan et al., 2018, Hong Kong26	642 (I: 332 C: 310)	Pre–post intervention study	Surgical 8 mo	‐Physician and nurse face‐to‐face education to encourage safe opioid use, nonopioid analgesia and nurse education to improve PCA safety‐ NRS pain evaluation	‐ Audit and feedback (every 6 mo)‐ Patient education	↑ Morphine use (88.6 vs 99.3%*) ↑ Diclofenac use (1.0 vs 96.9%)	↓ Pain intensity (VAS > 7; 55.5 vs 21.0%*)↑ Pruritus incidence (12.4 vs 26.5%*)
Humphries et al., 1997, UK27	242 (I: 122 C: 120)	Pre–post intervention study	Surgical12 mo	‐ Posters and hard‐copy material outlining opioid guidelines (Victoria Hospital Blackpool Acute Pain Service) for physician and nursing staff	‐ Analgesia protocol	↑ Adherence of opioid prescriptions to British National Formulary (41.0 vs 61.0%*) and acute pain service (16.0 vs 26.0%*)
Juhl et al., 1996, Denmark28	317 (I: 126 C: 191)	Pre–post intervention study	Surgical 12 mo	‐ Physician and nurse face‐to‐face 1‐d compulsory education to encourage routine use of nonopioid analgesia‐ Bedside tuition continued until all nurses familiar with new procedures	‐ Performance feedback ‐ Nurse‐administered morphine	↑ Non‐opioid analgesic use (15.0 vs 94.0%*)	↓ Pain intensity (93.0 vs 86.0*)
Majumder et al., 2016, USA29	200 (I: 100 C: 100)	Pre–post intervention study	Surgical 3 mo	‐ Physician face‐to‐face education to minimise the use of opioid analgesics and paralytic agents	‐ Multimodal analgesia (IV hydromorphone, oxycodone, oral gabapentin, paracetamol, NSAIDs)‐ Patient education	↑ Switch from IV to oral opioid analgesia (2.2 vs 3.6 d after opioid initiation*)	↓ Hospital LOS (4.0 vs 6.1 d*)↓ Hospital 90‐d readmission (16.0 vs 4.0%*)
Usichenko et al., 2012, Germany30	520 (I: 251 C: 269)	Pre–post intervention questionnaire study	Surgical 14 mo	‐ Multidisciplinary face‐to‐face education to increase nonopioid analgesic use ‐ Procedure‐specific, multifaceted analgesia protocol (PROSPECT and German Society of Anaesthesiology and Intensive Care Guidelines)‐ NRS pain evaluation	‐ 24 h acute pain service‐ Audit and feedback (every 6 mo)‐ ADE treatment protocol ‐ Patient education		↓ Pain intensity by 25.0–30.0% on visual rating scale* ↓ Nausea incidence (40.0 vs 17.0%*)↓ Vomiting incidence (25.0 vs 11.0%*) ↓ Tiredness incidence (76.0 vs 30.0%*)↑ Patient satisfaction with pain treatment*↑ QOL*

Sorted in descending order of intervention complexity, as assessed by the iCAT_SR Tool,19 and subclassified in descending order of study design.68

^* Denotes statistical significance (P < .05).

ED = emergency department; ICU = intensive care unit; VAS = visual analogue scale; NRS = numeric rating scale; CPOE = computerised physician order entry; PCA = patient controlled analgesia; NSAID = nonsteroidal anti‐inflammatory drug; LOS = length of stay; ADE = adverse drug event; MV = mechanical ventilation; OR = odds ratio; CI = confidence interval; OME = oral morphine equivalents; IQR = interquartile range; QOL = quality of life; IV = intravenous; PROSPECT = procedure specific postoperative pain management