Chronic Opioid Therapy for Chronic Pain: An e-Learning Program to Develop Shared Decision-making and Communication Skills

Impact of Informed Consent and Education on Care Engagement After Opioid Initiation in the Veterans Health Administration

Objective

To ensure all patients receiving long-term opioid therapy (LTOT) understand the risks, benefits and treatment alternatives, the Veterans Health Administration (VHA) released a national policy in 2014 to standardize a signature informed consent (SIC) process. We evaluated the impact of this policy on medical follow-up after LTOT initiation, a guideline recommended practice.

Methods

Using VHA administrative data, we identified patients initiating LTOT between May 2013 and May 2016. We used an interrupted time series design to compare the monthly rates of medical follow-up within 30 days and primary care visits within 3 months after LTOT initiation across three periods: 12 months before the policy (Year 1); 12 months after policy release (Year 2); and 12-24 months after policy release, when the SIC process was mandatory (Year 3).

Results

Among the 409,895 patients who experienced 758,416 LTOT initiations, medical follow-up within 30 days and primary care engagement within 3 months increased by 4% between Year 1 and Year 3. Compared to Year 1, patients in Year 3 were 1.12 times more likely to have any medical follow-up (95% CI: 1.10, 1.13) and 1.13 times more likely to have a primary care visit (95% CI: 1.12, 1.15). Facilities with a greater proportion of patients receiving SIC had increased medical follow-up (RR: 1.04, 95% CI: 1.01, 1.07) and primary care engagement (RR: 1.06, 95% CI: 1.03, 1.10).

Conclusion

The VHA's SIC policy is associated with increased medical follow-up among patients initiating LTOT, which may result in improved patient safety and has implications for other healthcare settings.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training

OBJECTIVE

Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills.

SUBJECTS

The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles.

METHODS

Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum.

RESULTS

Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03).

CONCLUSIONS

Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.