Abstract
Background
Taiwan implemented a reformed 6-year medical education in 2013, with a subsequent 2-year postgraduate training programme starting in August 2019. This study investigated the perceptions of acute and chronic pain management in postgraduate physicians.
Methods
In late July 2023, a cross-sectional questionnaire survey was conducted of Taiwanese physicians who had almost completed their postgraduate 2-year or 1-year training and those who were starting a postgraduate programme in early August 2023. This survey evaluated their knowledge, attitude and clinical experience related to opioid-based pain management and their perceptions of the opioid crisis in the United States and Taiwan.
Results
Of the 197 postgraduate physicians, 169 (85.8%) responded to the survey. Physicians who had received postgraduate 2-year (n = 48) and 1-year (n = 51) training had a deeper understanding of opioids (p < 0.001) and exhibited greater confidence in acute and chronic pain management (both p < 0.001) compared with those who were just starting a postgraduate programme (n = 70). Of the included physicians, 92 (54.4%) were aware of the ongoing opioid crisis in the United States, but only 28 (16.6%) disagreed with the notion of a current opioid problem in Taiwan. Approximately 27.8% had never heard of multimodal analgesia, and 86.4% expressed a need for further pain management education.
Conclusions
The postgraduate training programme in Taiwan provides enhanced knowledge of opioids and improves physicians’ levels of confidence in acute and chronic pain management. However, only one-sixth of postgraduate physicians are aware that Taiwan does not have an opioid problem.
Keywords: Attitude, knowledge, opioid, pain management, postgraduate
Graphical Abstract
1. Introduction
1.1. Opioid crisis in the United States
Since 1996, emphasis on pain as the fifth vital sign has resulted in the overprescription of opioids for both inpatients and outpatients in the United States, thereby increasing the risk of opioid misuse and addiction [1]. In March 2016, in response to this opioid crisis and the alarming increase in drug-related overdose deaths [2], the U.S. Centers for Disease Control and Prevention (CDC) formulated the CDC Guideline for Prescribing Opioids for Chronic Pain to give primary care clinicians recommendations for the appropriate and safe prescription of opioids for adult patients with chronic pain in outpatient settings [3]. Consequently, the number of drug-related overdose deaths was 4.1% lower in 2018 than in 2017 [4]. However, during the COVID-19 pandemic (2020 and 2021), the number of drug-related overdose deaths increased again [5], and efforts in education, regulation and intervention were ineffective [6]. Therefore, in November 2022, an updated CDC guideline was released to provide recommendations for managing acute (<1 month), sub-acute (1–3 months), and chronic (>3 months) pain [7].
1.2. Opioid-free anaesthesia and analgesia
Although the CDC guidelines and the subsequent regulatory changes have resulted in an overall reduction or even cessation of opioid prescriptions [5], the aggressive tapering or abrupt discontinuation of chronic opioid therapy has in certain cases been associated with mental health problems and overdose deaths, particularly during the pandemic [8]. Therefore, in response to these challenges, both opioid-free anaesthesia [9] and opioid-sparing post-operative analgesia [10] have been used to minimize side effects and reduce unnecessary opioid prescriptions that may contribute to the opioid epidemic. In addition, multimodal analgesia, which encompasses opioid and nonopioid analgesics, adjuvant medications, regional blocks and non-pharmacologic interventions, has been widely used for managing acute pain [11], highlighting the concept of enhanced recovery after surgery in clinical practice [12]. Overall, safe opioid prescriptions, perioperative multimodal analgesia and multidisciplinary chronic pain management have been included in pain medicine education not only for resident training and physician clinical practice but also for upstream medical training [1].
1.3. The new 2-year postgraduate training programme in Taiwan
After the outbreak of severe acute respiratory syndrome in 2003, Taiwan began implementing a 3-month postgraduate general medical training programme to enhance its holistic care, and this programme was extended in 2011 to a 1-year course [13]. In the academic year of 2013, the medical education programme of medical schools in Taiwan was reformed from 7 years to 6 years. Consequently, in August 2019, the first medical graduates of the 6-year programme started to receive 2-year postgraduate training in general medicine [14]. This training offers courses aimed at both enhancing the holistic medical care knowledge of postgraduate physicians and offering practical training for palliative care, geriatric medicine and primary care, among other specialties. During this period, medical graduates receive standardized professional training under the guidance of experienced clinical instructors, and they work on enhancing their professional core competencies to gain independent clinical practice capabilities [14], including acute and chronic pain management skills. However, no exclusive pain education course was provided in the current 2-year training programme in Taiwan.
1.4. Doctor’s dilemma in chronic pain management
A critical scoping review of medical education training highlighted significant discrepancies in addressing the prevalence of chronic pain in society [1]. A systematic review of pain management education in graduate medical programmes, which included 26 studies, concluded that most evaluations of chronic pain management and interventions were based on assessments of learner reactions or knowledge [15]. However, both patients and care providers often report low satisfaction with chronic pain care [16], citing issues such as patients being perceived as potential drug-seekers and physicians’ concerns about overprescribing opioids and the associated risk of addiction [1]. Given the advent of relapsing opiophobia (underprescribing) in response to the opioid crisis in the United States [1], research should focus on how future physicians are trained to perceive and manage pain through the multimodal analgesia with opioid and nonopioid treatments.
1.5. The goals of this study
In this study, we evaluated learners’ experience of acute and chronic pain management within graduate medical education. Specifically, we focused on evaluating the opioid knowledge, attitude towards opioid therapy for chronic pain, and perceptions regarding multimodal analgesia and the opioid crisis of postgraduate year (PGY) physicians in Taiwan.
2. Methods
2.1. Participants
The questionnaire survey conducted in this study was approved by the Institutional Review Board of Tri-Service General Hospital (TSGHIRB-A202105015), with a waiver for written informed consent. Registration before participant enrolment was not applicable because the participants were not assigned to treatment groups. Physicians who received PGY training at the Department of General Medicine, Tri-Service General Hospital, Taiwan, a tertiary teaching hospital, were recruited in July and August 2023. The Department of General Medicine provided the trainee list, and a trained research assistant distributed questionnaires to all trainees. Participants completed the anonymous questionnaires independently or with verbal assistance when needed. Those who received postgraduate 2-year and 1-year training in late July 2023 were designated groups PGY2 and PGY1, respectively, whereas those who completed their undergraduate education and started a new PGY training programme in early August 2023 were designated group PGY0.
2.2. Study instruments
The Chinese language questionnaire employed in this study was based on the Taiwan Physician’s Prescribing Opioid Survey in traditional Chinese [17] and on items in similar prior surveys [18,19] and also included items invented by the authors. To ensure the content validity of the questionnaire, a review committee of seven senior specialists with relevant expertise was assembled. The committee included four pain specialists with extensive clinical experience in managing outpatients with chronic non-cancer pain. These specialists contributed a deep understanding of the clinical nuances and practical considerations in assessing pain. Two anaesthesiologists, with specialized knowledge in anaesthetic techniques, provided insights into post-operative acute pain management. Additionally, one epidemiologist, skilled in study design and data analysis, offered a public health perspective, ensuring that the questions were relevant and appropriately structured to capture epidemiological data. The review process involved three rounds of evaluation, where each question was carefully examined for clarity and clinical relevance. The questionnaire was revised based on feedback from each member. An online meeting was then held to further refine the questionnaire iteratively. The final version was sent to all specialists for approval, with the aim of achieving ‘agree’ or ‘strongly agree’ responses for each question.
To examine test–retest reliability (i.e. stability over time), 20 first-year postgraduates in Taipei, Taiwan were contacted to complete a follow-up questionnaire after 2–3 weeks following completion of the first questionnaire. Test–retest reliability was evaluated by calculating the intraclass correlation coefficient of each item in the knowledge, attitude and practice scales (Supplement 1). To estimate the internal consistency reliability of the knowledge, attitude and practice scales in the questionnaire, Cronbach’s α internal consistency coefficients were calculated; the coefficients were 0.85 for the knowledge scale, 0.83 for the attitude scale and 0.63 for the practice scale (Supplement 1). In addition to evaluating the participants’ perceptions of the current opioid crisis in the United States and Taiwan, this study collected physicians’ demographic data and data on their clinical experience of pain medications and multimodal analgesia, continued pain education, knowledge of opioid pharmacology, attitude towards opioid therapy and hesitation to prescribe opioids. Additional information regarding the content in the assessment can be found in the tables.
2.3. Data analysis
All statistical analyses were conducted using IBM SPSS Statistics version 22 (IBM, Armonk, NY, USA). Demographic data are presented as number (%) or as mean ± standard deviation. Categorical responses were given as ‘strongly agree’, ‘agree’, ‘uncertain’, ‘disagree’, or ‘strongly disagree’ for statements regarding opioid knowledge and attitude. Categorical variables were estimated using the chi-squared test or Fisher’s exact test. Correct responses regarding opioid knowledge are presented as number (%) and were compared using Student’s t test or the Mann–Whitney U test. In all cases, p < 0.05 was considered statistically significant.
3. Results
Of 197 PGY physicians, 169 (85.8%) completed the survey, including 48 (80.0%) out of 60 PGY2 physicians, 51 (83.6%) out of 61 PGY1 physicians and 70 (92.1%) out of 76 PGY0 physicians (Table 1). Compared with the PGY0 group, greater proportions of the PGY2 and PGY1 groups were familiar with the World Health Organization (WHO) analgesic ladder for cancer pain (p < 0.001) and Taiwan’s narcotic regulations for chronic non-cancer pain (p = 0.003). However, only 81 (51.5%) and 46 (27.2%) of all PGY physicians were familiar with the WHO analgesic ladder and Taiwan’s narcotic regulations for chronic pain, respectively.
Table 1.
Demographic data of physicians in postgraduate year training programme (N = 169).
| Postgraduate year training |
||||
|---|---|---|---|---|
| All, N = 169 | Year 2 n = 48 |
Year 1 n = 51 |
Year 0 n = 70 |
P valuea |
| Gender, n (%) | ||||
| Male, n = 140 (82.8) | 42 (87.5) | 38 (74.5) | 60 (85.7) | 0.163 |
| Female, n = 29 (17.2) | 6 (12.5) | 13 (25.5) | 10 (14.3) | |
| Ever received an elective pain medicine curriculum at the medical school | ||||
| Yes, n = 27 (16.7) | 14 (29.2) | 5 (9.8) | 8 (11.4) | 0.013 |
| No, n = 142 (84.0) | 34 (70.8) | 46 (90.2) | 62 (88.6) | |
| Ever received a pain-related course at the hospital | ||||
| Yes, n = 132 (78.1) | 39 (81.2) | 42 (82.4) | 51 (72.9) | 0.378 |
| No, n = 37 (21.9) | 9 (18.8) | 9 (17.6) | 19 (27.1) | |
| Ever rotated at the Department of Anaesthesiology (multiple choice) | ||||
| PGY2, 1 month, n = 16 (9.5) | 16 (33.3) | 0 (0.0) | 0 (0.0) | <0.001b |
| PGY1, 1 month, n = 19 (11.2) | 5 (10.4) | 14 (27.5) | 0 (0.0) | <0.001 |
| Clerkship, 2 weeks, n = 124 (73.4) | 30 (62.5) | 38 (74.5) | 56 (80.0) | 0.105 |
| Never, n = 24 (14.2) | 4 (8.3) | 7 (13.7) | 13 (18.6) | 0.292 |
| World Health Organization analgesic ladder for cancer pain | ||||
| Familiar, n = 81 (51.5) | 33 (68.8) | 35 (68.6) | 19 (27.1) | <0.001 |
| Uncertain, n = 62 (36.7) | 13 (27.1) | 12 (23.5) | 37 (52.9) | |
| Unfamiliar, n = 20 (11.8) | 2 (4.2) | 4 (7.8) | 14 (20.0) | |
| Taiwan’s narcotics regulations for chronic non-cancer pain | ||||
| Familiar, n = 46 (27.2) | 21 (43.8) | 14 (27.5) | 11 (15.7) | 0.003 |
| Uncertain, n = 62 (36.7) | 15 (31.2) | 23 (45.1) | 24 (34.3) | |
| Unfamiliar, n = 61 (36.1) | 12 (25.0) | 14 (27.5) | 35 (50.0) | |
| Ever learned pain scale | ||||
| Visual Analogue Scale, n = 161 (95.8) | 47 (97.9) | 47 (92.2) | 67 (97.1) | 0.419b |
| Numerical Rating Scale, n = 60 (35.7) | 17 (35.4) | 15 (29.4) | 28 (40.6) | 0.450 |
| Faces Pain Scale, n = 51 (30.4) | 16 (33.3) | 9 (17.6) | 26 (37.7) | 0.054 |
| Face, Legs, Activity, Cry, and Consolability Scale, n = 11 (6.5) | 6 (12.5) | 0 (0.0) | 5 (7.2) | 0.018b |
The data are presented as number (%) or mean ± standard deviation.
aP-values were estimated by chi-square test.
bP-values were estimated by Fisher’s exact test.
Table 2 presents the rates of correct responses related to opioid knowledge and pain management. Compared with the PGY0 group, the PGY2 and PGY1 groups gave more correct responses (75.0% ± 26.6%, 68.0% ± 20.4% and 53.9% ± 26.0%, respectively, p < 0.001) with effect size eta squared (η2) = 0.120. Of all the PGY physicians, only 71 (42.0%) correctly responded to the statement ‘One-quarter of patients on long-term opioids may experience addiction or struggle with it’.
Table 2.
Knowledge of prescribing long-term opioids among physicians in postgraduate year training programme (N = 169).
| Postgraduate year training |
||||
|---|---|---|---|---|
| Correct response to true statement | Year 2 n = 48 |
Year 1 n = 51 |
Year 0 n = 70 |
P-valuea |
| 1. 10 mg of injected morphine is equivalent to 30 mg of oral morphine, n = 74 (43.8) | 32 (66.7) | 26 (51.0) | 16 (22.9) | <0.001 |
| 2. Of all long-term opioids, meperidine is more likely than morphine to cause addiction, n = 65 (38.5) | 28 (58.3) | 20 (39.2) | 17 (24.3) | 0.001 |
| 3. Long-term use of meperidine results in the accumulation of neurotoxic metabolites and causes tremors or convulsions, n = 71 (42.0) | 30 (62.5) | 21 (41.2) | 20 (28.6) | 0.001 |
| 4. Naloxone can be used to treat respiratory depression caused by opioids, n = 151 (89.3) | 43 (89.6) | 48 (94.1) | 60 (85.7) | 0.334 |
| 5. Consuming >4000 mg of acetaminophen can cause hepatic damage, n = 141 (83.4) | 42 (87.5) | 48 (94.1) | 51 (72.9) | 0.005 |
| 6. Constipation is a common side effect of opioids, n = 155 (91.7) | 43 (89.6) | 50 (98.0) | 62 (88.6) | 0.128 |
| 7. In patients with chronic non-cancer pain, oral opioids are more effective than injected opioids, n = 100 (59.2) | 32 (66.7) | 29 (56.9) | 39 (55.7) | 0.455 |
| 8. Regular narcotic prescription is preferable to pro re nata prescription for continual pain, n = 129 (76.3) | 41 (85.4) | 43 (84.3) | 45 (64.3) | 0.008 |
| 9. One-quarter of patients on long-term opioids may experience addiction or struggle with it, n = 71 (42.0) | 29 (60.4) | 17 (33.3) | 25 (35.7) | 0.009 |
| 10. Chronic non-cancer pain cannot be relieved only by opioids, n = 115 (68.0) | 36 (75.0) | 38 (74.5) | 41 (58.6) | 0.085 |
| 11. Fentanyl transdermal patches are not suitable for opioid-naïve patients, n = 103 (60.9) | 37 (77.1) | 36 (70.6) | 30 (42.9) | <0.001 |
| 12. Female patients may still experience breast pain following a mastectomy for breast cancer, n = 126 (74.6) | 39 (81.2) | 40 (78.4) | 47 (67.1) | 0.168 |
| Correct responses, %, 64.2 ± 26.1 | 75.0 ± 26.6 | 68.0 ± 20.4 | 53.9 ± 26.0 | <0.001b
η2 = 0.120 |
Data are presented as number (%) with correct responses or as mean ± standard deviation.
Effect size is presented as eta squared (η2).
aP-values estimated using the chi-squared test.
bP-values estimated using one-way analysis of variance.
Table 3 demonstrates overall negative attitudes towards opioid use for pain management. Approximately 78.1% of all respondents agreed with the statement ‘Opioids can have many side effects’, with the between-group difference being non-significant (p = 0.428). A larger percentage of the PGY2 (50.0%) and PGY1 (45.1%) groups agreed with the statement ‘Relieving the side effects of opioids is not easy’ compared with the PGY0 (24.3%) group (p = 0.008). Subgroup analyses revealed that gender, elective pain medicine curriculum at the medical school, pain-related courses at the hospital and rotation at the Department of Anesthesiology did not contribute to differences in knowledge correct responses and attitude negative responses in each training year (Supplement 2).
Table 3.
Negative attitude towards long-term use of opioids among physicians in postgraduate year training programme (N = 169).
| Postgraduate year training |
||||
|---|---|---|---|---|
| Agreement with negative statement | Year 2 n = 48 |
Year 1 n = 51 |
Year 0 n = 70 |
P-valuea |
| 1. Adults should endure pain as much as possible, n = 20 (11.8) | 9 (18.8) | 5 (9.8) | 6 (8.6) | 0.211 |
| 2. Adults should not frequently request opioids, n = 63 (37.3) | 23 (47.9) | 13 (25.5) | 27 (38.6) | 0.067 |
| 3. Opioids are not good for the human body, n = 70 (41.4) | 23 (47.9) | 21 (41.2) | 26 (37.1) | 0.506 |
| 4. Opioids are not good for mental health, n = 63 (37.3) | 22 (45.8) | 15 (29.4) | 26 (37.1) | 0.240 |
| 5. Opioids can have many side effects, n = 132 (78.1) | 40 (83.3) | 37 (72.5) | 55 (78.6) | 0.428 |
| 6. Relieving the side effects of opioids is not easy, n = 64 (37.9) | 24 (50.0) | 23 (45.1) | 17 (24.3) | 0.008 |
| 7. Requiring more opioid analgesics compared to other patients is indicative of addiction onset, n = 82 (48.5) | 28 (58.3) | 21 (41.2) | 33 (47.1) | 0.223 |
| 8. Requiring additional opioid analgesics is indicative of a patient becoming addicted, n = 80 (47.3) | 26 (54.2) | 21 (41.2) | 33 (47.1) | 0.433 |
| 9. Patients with a history of substance abuse should not be prescribed opioids for pain because they are at a high risk of addiction, n = 51 (30.2) | 17 (35.4) | 16 (31.4) | 18 (25.7) | 0.516 |
| 10. Patients with chronic non-cancer pain require more opioids than those with acute pain do, n = 101 (59.8) | 28 (58.3) | 36 (70.6) | 37 (52.9) | 0.141 |
| Negative attitude responses, %, 43.0 ± 27.0 | 50.0 ± 31.8 | 40.8 ± 24.1 | 39.7 ± 24.9 | 0.274b |
Data are presented as number (%) or mean ± standard deviation of agreement responses.
aP-values estimated using the chi-squared test.
bP-values estimated using Kruskal–Wallis test.
Table 4 presents the clinical practice of pain management in the PGY physicians. Up to 75% of all the participants would immediately evaluate the post-operative pain intensity upon their patients’ arrival at the ward. Over 50% of all physicians would sometimes avoid prescribing opioid analgesics for post-operative patients because of the side effects and the potential for misuse and addiction.
Table 4.
Practice of pain management among physicians in postgraduate year training programme (N = 169).
| Postgraduate year training |
||||||
|---|---|---|---|---|---|---|
| All, N = 169 | Year 2 n = 48 |
Year 1 n = 51 |
Year 0 n = 70 |
P-valuea | ||
| 1. I immediately evaluate the post-operative pain intensity of my patients upon their arrival at the ward. | ||||||
| Always or frequently, n = 127 (75.1) | 37 (77.1) | 42 (82.4) | 48 (68.6) | 0.519b | ||
| Sometimes, n = 36 (21.3) | 9 (18.8) | 8 (15.7) | 19 (27.1) | |||
| Seldom or never, n = 6 (3.6) | 2 (4.2) | 1 (2.0) | 3 (4.3) | |||
| 2. I do not prescribe analgesics for patients with acute pain of unknown cause. | ||||||
| Always or frequently, n = 74 (43.8) | 28 (58.3) | 19 (37.3) | 27 (38.6) | 0.150b | ||
| Sometimes, n = 76 (45.0) | 16 (33.3) | 24 (47.1) | 36 (51.4) | |||
| Seldom or never, n = 19 (11.2) | 4 (8.3) | 8 (15.7) | 7 (10.0) | |||
| 3. I would avoid prescribing opioid analgesics for post-operative patients because of the potential for misuse and addiction. | ||||||
| Always or frequently, n = 13 (7.7) | 5 (10.4) | 2 (3.9) | 6 (8.6) | 0.028b | ||
| Sometimes, n = 98 (58.0) | 23 (47.9) | 26 (51.0) | 49 (70.0) | |||
| Seldom or never, n = 58 (34.3) | 20 (41.7) | 23 (45.1) | 15 (12.4) | |||
| 4. I would avoid prescribing opioid analgesics for post-operative patients because of their side effects. | ||||||
| Always or frequently, n = 11 (6.5) | 3 (6.2) | 2 (3.9) | 6 (8.6) | 0.114b | ||
| Sometimes, n = 95 (56.2) | 23 (47.9) | 26 (51.0) | 46 (65.7) | |||
| Seldom or never, n = 63 (37.3) | 22 (45.8) | 23 (45.1) | 18 (25.7) | |||
| 5. Because narcotics can cause respiratory depression, they should not be used in paediatric patients. | ||||||
| Strongly agree or agree, n = 68 (40.2) | 19 (39.6) | 19 (37.3) | 30 (42.9) | 0.825 | ||
| Uncertain, n = 67 (39.6) | 18 (37.5) | 20 (39.2) | 29 (41.4) | |||
| Strongly disagree or disagree, n = 34 (20.1) | 11 (22.9) | 12 (23.5) | 11 (15.7) | |||
| 6. Older patients cannot tolerate opioids for post-operative pain relief. | ||||||
| Strongly agree or agree, n = 35 (20.7) | 13 (27.1) | 11 (21.6) | 11 (15.7) | 0.102 | ||
| Uncertain, n = 60 (35.5) | 13 (27.1) | 14 (27.5) | 33 (47.1) | |||
| Strongly disagree or disagree, n = 74 (43.8) | 22 (45.8) | 26 (51.0) | 26 (37.1) | |||
| 7. Individuals with dementia cannot provide an accurate self-report of their pain. | ||||||
| Strongly agree or agree, n = 143 (84.6) | 41 (85.4) | 44 (86.3) | 58 (82.9) | 0.645b | ||
| Uncertain, n = 18 (10.7) | 4 (8.3) | 4 (7.8) | 10 (14.3) | |||
| Strongly disagree or disagree, n = 8 (4.7) | 3 (6.2) | 3 (5.9) | 2 (2.9) | |||
| 8. Individuals with dementia are at increased risk of respiratory depression and confusion caused by opioid analgesics. | ||||||
| Strongly agree or agree, n = 137 (81.1) | 40 (83.3) | 43 (84.3) | 54 (77.1) | 0.822b | ||
| Uncertain, n = 29 (17.2) | 7 (14.6) | 7 (13.7) | 15 (21.4) | |||
| Strongly disagree or disagree, n = 3 (1.8) | 1 (2.1) | 1 (2.0) | 1 (1.4) | |||
The data are presented as number (%) with correct responses.
aP-values were estimated by chi-square test.
bP-values were estimated by Fisher’s exact test.
As revealed in Table 5, only 92 (54.4%) of all the physicians were aware of the ongoing opioid crisis in the United States. Additionally, 28 (16.6%) of the physicians disagreed with the notion of a current opioid problem in Taiwan, with the intergroup difference being non-significant. The PGY2 and PGY1 groups were more confident in managing post-operative acute pain (66.7% vs. 64.7% vs. 12.9%, p < 0.001) and chronic cancer pain (43.8% vs. 47.1% vs. 14.3%, p < 0.001) compared with the PGY0 group (Figure 1). However, 47 (27.8%) of all the participants had never heard of multimodal analgesia. The experience of prescribing medications for multimodal analgesia was demonstrated. Larger percentages of the PGY2 and PGY1 groups than that of the PGY0 group agreed on the need for postgraduation pain medicine education regarding chronic pain management (91.7% vs. 94.1% vs. 77.1%, p = 0.012).
Table 5.
Perceptions of the current opioid crisis, pain management and barriers to long-term opioid prescription.
| Postgraduate year training |
||||
|---|---|---|---|---|
| All, N = 169 | Year 2 n = 48 |
Year 1 n = 51 |
Year 0 n = 70 |
P-value a |
| 1. The opioid crisis is a major ongoing concern in the United States. | ||||
| Strongly agree or agree, n = 92 (54.4) | 31 (64.6) | 29 (56.9) | 32 (45.7) | 0.090b |
| Uncertain, n = 75 (44.4) | 16 (33.3) | 21 (41.2) | 38 (54.3) | |
| Strongly disagree or disagree, n = 2 (1.2) | 1 (2.1) | 1 (2.0) | 0 (0.0) | |
| 2. The opioid crisis is a major ongoing concern in Taiwan. | ||||
| Strongly agree or agree, n = 45 (26.6) | 18 (37.5) | 11 (21.6) | 16 (22.9) | 0.055 |
| Uncertain, n = 96 (56.8) | 21 (43.8) | 28 (54.9) | 47 (67.1) | |
| Strongly disagree or disagree, n = 28 (16.6) | 9 (18.8) | 12 (23.5) | 7 (10.0) | |
| 3. I am confident in prescribing appropriate analgesics for post-operative acute pain. | ||||
| Strongly agree or agree, n = 74 (43.8) | 32 (66.7) | 33 (64.7) | 9 (12.9) | <0.001b |
| Uncertain, n = 75 (44.4) | 16 (33.3) | 14 (27.5) | 45 (64.3) | |
| Strongly disagree or disagree, n = 20 (11.8) | 0 (0.0) | 4 (7.8) | 16 (22.9) | |
| 4. I am confident in prescribing appropriate analgesics for chronic cancer pain. | ||||
| Strongly agree or agree, n = 55 (32.5) | 21 (43.8) | 24 (47.1) | 10 (14.3) | <0.001b |
| Uncertain, n = 84 (49.7) | 26 (54.2) | 21 (41.2) | 37 (52.9) | |
| Strongly disagree or disagree, n = 30 (17.8) | 1 (2.1) | 6 (11.8) | 23 (32.9) | |
| 5. Most patients with post-operative acute pain receive adequate pain management in this hospital. Agreement, n = 122 (72.2) | 37 (77.1) | 37 (72.5) | 48 (68.6) | 0.597 |
| 6. Most patients with chronic cancer pain receive adequate pain management in this hospital. Agreement, n = 108 (63.9) | 31 (64.6) | 31 (60.8) | 46 (65.7) | 0.850 |
| 7. I provide pain relief to patients after surgery on the basis of the multimodal analgesia principle. Agreement, n = 48 (28.4) | 17 (35.4) | 12 (23.5) | 19 (27.1) | 0.404 |
| 8. I have never heard of multimodal analgesia. n = 47 (27.8) | 16 (33.3) | 20 (39.2) | 11 (15.7) | 0.010 |
| 9. Ever prescribed for patients with post-operative acute pain | ||||
| 10. Oral non-steroidal anti-inflammatory drugs | 46 (95.8) | 47 (92.2) | 68 (97.1) | 0.438 |
| 11. Intravenous cyclooxygenase 2 inhibitor | 41 (85.4) | 48 (94.1) | 56 (80.0) | 0.089 |
| 12. Oral acetaminophen | 42 (87.5) | 49 (96.1) | 60 (85.7) | 0.168 |
| 13. Intravenous acetaminophen | 16 (33.3) | 15 (29.4) | 19 (27.1) | 0.769 |
| 14. Weak opioids, such as tramadol and nalbuphine… | 42 (87.5) | 50 (98.0) | 56 (80.0) | 0.012 |
| 15. Strong opioids, such as morphine and fentanyl for patient-controlled analgesia… | 30 (62.5) | 36 (70.6) | 40 (57.1) | 0.319 |
| 16. Peripheral nerve blockade | 10 (20.8) | 12 (23.5) | 17 (24.3) | 0.905 |
| 17. Local anaesthetic infiltration | 6 (12.5) | 11 (21.6) | 12 (17.1) | 0.489 |
| 18. Additional education on the pathophysiology and management of chronic pain is essential after graduation. Agreement, n = 146 (86.4) | 44 (91.7) | 48 (94.1) | 54 (77.1) | 0.012 |
| 19. Perceived barriers to long-term opioid prescription | ||||
| Physician’s concern of opioid side effects, n = 116 (68.6) | 34 (70.8) | 37 (72.5) | 45 (64.3) | 0.581 |
| Physician’s concern of patient addiction, n = 97 (57.4) | 27 (56.2) | 27 (52.9) | 43 (61.4) | 0.636 |
| Patient’s multiple comorbidities, n = 87 (51.5) | 27 (56.2) | 20 (39.2) | 40 (57.1) | 0.110 |
| Patient reluctance to consume opioids, n = 64 (37.9) | 17 (35.4) | 15 (29.4) | 32 (45.7) | 0.173 |
| Physician reluctance to prescribe opioids, n = 67 (39.6) | 14 (29.2) | 24 (47.1) | 29 (41.4) | 0.177 |
The data are presented as number (%) with correct responses.
aP-values were estimated by chi-square test.
bP-values were estimated by Fisher’s exact test.
Figure 1.
The postgraduate year-2 (PGY2) and year-1 (PGY1) physicians were more confident in managing post-operative acute pain and chronic cancer pain compared with those who just started the postgraduate training programme (PGY0).
4. Discussion
4.1. Major findings
According to the findings of our questionnaire survey, the postgraduate 2-year training programme in Taiwan enhanced postgraduates’ knowledge of opioids, familiarity with narcotics regulations, confidence in acute and chronic pain management and willingness to receive further pain education after graduation. One in four of the physician participants had never heard of multimodal analgesia. Additionally, only half of the physicians were aware of the ongoing opioid crisis in the United States, while merely one-sixth accurately recognized that Taiwan did not have an opioid problem.
4.2. Postgraduate pain education in Taiwan
In Taiwan, pain medicine education is not offered as a standalone course in the 2-year postgraduate training programme. Instead, it is primarily integrated into internal medicine, elective anaesthesia and elective rehabilitation courses. At Tri-Service General Hospital, the Department of Anesthesiology offers an elective 1-month rotation training course to three PGY trainees every month, and 72 out of 121 (59.5%) of the PGY physicians had completed the course in the preceding 2 years. The department also provides an elective 2-week anaesthesia clerkship for medical students with two lectures, namely those on pain measurement with recording and appropriate pain treatment prescriptions, focusing on 80 undergraduate basic clinical skills. In this study, the PGY2 and PGY1 groups were found to be more familiar than the PGY0 group with the WHO analgesic ladder and were more confident in prescribing appropriate analgesics for post-operative acute pain. Hence, conducting a longitudinal survey of the PGY0 group, combined with a prospective pre- and post-course survey of those rotating through the Department of Anesthesiology, could further assess the cohort effects of the 2-year training programme on pain management.
4.3. Overdose deaths involving prescription opioids
In the United States, more than one in five adults report experiencing chronic pain [20]. From 1996, emphasis on pain as the fifth vital sign spurred initiatives such as the ‘Towards a Pain-Free Hospital’ project [21]. However, these initiatives resulted in the overprescription of opioids for both inpatients and outpatients. Managing acute pain versus chronic pain requires distinct approaches and interventional procedures that carefully weigh the benefits of analgesia against potential risks, including the risks of opioid side effects and opioid use disorder. Multiple initiatives based on the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain [3] have successfully reduced the prescription and dispensation of opioids, particularly among primary care clinicians [22]. Nevertheless, during the COVID-19 pandemic, limitations on opioid prescriptions for medically necessary cases, enforced tapering or cessation of opioid prescriptions during lockdowns and reduced access to interventional techniques contributed to an increase in illicit narcotic use, leading to a fourth wave of the opioid epidemic [23]. According to the U.S. National Center for Health Statistics, 14,716 (13.6%) of the 107,941 drug overdose deaths in 2022 involved prescription opioids [5]. Further research is required to properly distinguish the roles of illicit and prescription opioids in the current opioid crisis in the United States [23]. In Taiwan, long-term opioid prescriptions for managing chronic non-cancer pain are strictly regulated [24]. Two studies using official patient lists from the Taiwan Food and Drug Administration have reported that only 114 and 328 registered patients with chronic non-cancer pain received long-term opioid therapy in 2001 and 2010, respectively [25,26]. According to a prevalence survey of opioid prescriptions from 2008 to 2018 in Taiwan, opioids were predominantly used for managing acute pain (98.7%) and minimally used for managing chronic pain (1.3%) in patients without cancer [27]. Additionally, the Taiwan Cause of Death Statistics listed intentional self-harm or suicide as the 11th most common cause of death (n = 3,656 or 15.5 per 100,000 people) in 2020 [28], though the report did not specify the drugs involved in these overdose deaths. These findings sharply contrast with those obtained in high-opioid-consuming countries such as the United States [29]. In this study, only 54.4% of the PGY physician participants were aware of the ongoing opioid crisis in the United States, whereas 16.6% were aware that Taiwan does not have an opioid problem. Future pain management education should therefore be tailored to local evidence in Taiwan, consistent with the practices outlined by the CDC guidelines in the United States.
4.4. Opioid-free anaesthesia and opioid-sparing multimodal analgesia
According to a systematic review of pain management in graduate medical education, the majority of studies published up to November 2020 focused on chronic pain management interventions (69%). These studies largely evaluated learner reactions (Kirkpatrick level 1, 24%), learner knowledge (Kirkpatrick level 2, 48%) and learner behaviour (Kirkpatrick level 3, 20%), and they rarely evaluated patient or healthcare outcomes (Kirkpatrick level 4, 8%) [15]. Generally, the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain provides updated recommendations for managing acute (<1 month), subacute (1–3 months) and chronic (>3 months) pain [7]. Over 80% of surgical patients in the United States experience acute post-operative pain, and approximately 75% of those with post-operative pain report its severity as being moderate, severe or extreme [30]. Similar trends were observed in Taiwanese patients undergoing surgery [31]. Acute post-operative pain is a major risk factor for chronic post-operative pain syndrome, and discharge opioid prescriptions are identified as contributors to persistent opioid use and diversion [9]. To mitigate opioid exposure and post-operative consumption in surgical patients, researchers have been particularly interested since 2012 in the effects of enhanced recovery after surgery, various types of anaesthesia and multimodal analgesia [32]. Opioid-free anaesthesia and analgesia may be feasible, implementable and transferable for the reduction of opioid-related adverse effects (e.g. nausea, vomiting, sedation, ileus and respiratory depression) [10]. However, no evidence currently exists regarding whether opioid-free strategies offer additional benefits beyond opioid-sparing strategies, influence the risk of persistent post-operative opioid use or prevent post-operative opioid overprescription [9]. Consequently, multimodal opioid-sparing strategies, which involve avoiding high doses of opioids rather than eliminating them entirely, are considered rational [33]. These strategies can aid in mitigating the complexity of non-opioid anaesthetic or analgesic regimes, potentially avoiding additional harm in routine clinical practice [34]. In this study, 58% of the physician participants reported sometimes managing post-operative pain on the basis of the principle of multimodal analgesia, with the between-group differences being non-significant. By contrast, 27.8% were unaware of multimodal analgesia. Therefore, we recommend emphasizing the inclusion of multimodal analgesia and a multidisciplinary approach in the management of both acute and chronic pain within postgraduate training.
4.5. Limitations
This study has some limitations. First, despite a high response rate of 85.8%, the questionnaire survey may have introduced potential selection and non-response biases, particularly among individuals with either a strong interest in or lack of willingness to participate in a survey on pain management. Second, this cross-sectional study could only compare physician groups at different stages of postgraduate training. A longitudinal survey of the PGY0 group, combined with a prospective pre- and post-course survey among those rotating in the Department of Anesthesiology, could further assess the cohort effects of the 2-year training programme on pain management. Third, the gender ratio of female postgraduate physicians in the current study (17.2%) is lower than that in the general population of Taiwanese medical graduates, which is close to 40%. According to the Taiwan Ministry of Education’s ‘Higher Education Institution Affairs Information Disclosure Platform’,’ 618 (38.2%) of 1,618 medical graduates in 2021 and 643 (39.5%) of 1,629 medical graduates in 2022 were female [35]. Female physicians in the emergency department were more likely to prescribe opioids to female patients [36] and to prescribe ancillary examinations for patients with acute low back pain [37]. In the current study, we did not observe any gender differences in knowledge and attitude responses in the subgroup analysis (Supplement 2). Nevertheless, potential biases may limit the generalizability of these findings to other hospitals. Fourth, this questionnaire survey assessed opioid knowledge, clinical experience and confidence in managing acute and chronic pain across different physician groups. However, it did not evaluate participants’ clinical competencies, stress levels and patient satisfaction. Future studies could incorporate case-based clinical scenarios and compare practice behaviours before and after anaesthesia department rotations to gain deeper insights into the effectiveness of postgraduate training programmes. Fifth, given the relatively low intra-class correlation coefficients (<0.55) for test–retest reliability observed in several questions (Supplement 1), we conducted further analysis of internal consistency reliability. Cronbach’s α values were 0.85 for the knowledge scale, 0.83 for the attitude scale and 0.63 for the practice scale (<0.7). Consequently, the results are presented descriptively rather than as scale scores for comparison.
5. Conclusions
This questionnaire survey offers valuable insights into the current landscape of Taiwanese PGY physicians’ pain management experience. The 2-year postgraduate training programme in Taiwan positively affects postgraduates’ knowledge of opioids, familiarity with narcotic regulations, confidence in acute and chronic pain management, and willingness to pursue further pain education after graduation. However, only one-sixth of PGY physicians are aware that Taiwan has no opioid problem, and one in four PGY physicians is unaware of multimodal analgesia. Further postgraduate pain management education should emphasize integrating local evidence on prescription opioids from Taiwan with U.S. CDC guidelines, as well as incorporating multimodal analgesia in the management of both acute and chronic pain.
Supplementary Material
Acknowledgment
The authors would like to sincerely thank Huei-Han Liou for her contribution to the statistical analysis.
Funding Statement
This work was supported by Tri-Service General Hospital (TSGH-D-112175).
Authors’ contributions
Conceptualization, methodology, investigation, data curation, formal analysis, and writing – original draft: JLC and TCL; Writing – review and editing, and validation: JLC, STH, CCY, CWF, CHH and TCL; Funding acquisition: JLC. All authors have read and agreed on the published version of the article.
Ethical statement
This questionnaire study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Tri-Service General Hospital Institutional Review Board (TSGHIRB-A202105015) with a waiver of written informed consent.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data presented in this study are available upon reasonable request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data presented in this study are available upon reasonable request from the corresponding author.