http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(1): 22– 2015 Informa UK, Ltd. DOI: 10.1080/00325481.2015.993572
ORIGINAL RESEARCH
Chronic noncancer pain management in primary care: family medicine physicians’ risk assessment of opioid misuse 1 & Mehmet Öner1 Ethem Kavukcu1, Melahat Akdeniz1, Hasan Huseyin Avci2, Mehmet Altug Department of Family Medicine, Akdeniz University Hospital, Antalya 07059, Turkey, and 2Ahmet Atmaca Primary Health Care Center, Antalya, Turkey
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1
Abstract
Keywords:
Objective: The majority of patients with chronic noncancer pain (CNCP) are managed in the primary care settings. The primary care family physician (PCFP) generally has limited time, training, or access to resources to effectively evaluate and treat these patients, particularly when there is the added potential liability of prescribing opioids. The aim of this study is to make a favorable change in PCFPs’ knowledge, attitudes, and practices about opioid use in CNCP via education on assessment of the risk of opioid misuse. Materials and methods: The universe of this crosssectional study comprised 36 family physicians working at Family Health Centers affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Initially, a survey on patients risk assessment was performed in both intervention and control groups; whereas the intervention group received education on assessment of the risk of opioid misuse, the control group did not. The survey was repeated after 6 months and the intervention group underwent a core examination. Data obtained were analyzed with Statistical Package for the Social Sciences 18.0 statistics program. Intervention and control groups were compared. Additionally, pre- and post-education results of the intervention group were also compared. Results: About 61.1% of family physicians reported concern and hesitation in prescribing opioids due to known risks, such as overdose, addiction, dependence, or diversion, and agreed that family physicians should apply risk assessment before opioid use in CNCP. Only 16.6% of PCFP reported that risk assessment is not so necessary, whereas 22.2% of PCFP were undecided. Although 47.2% of the family physicians expressed a willingness to apply risk assessment before starting opioids, the rate of eagerness increased markedly to 77.7% after the education, but the rate of increase in practicing was not statistically significant. Conclusion: Knowledge and competency of the family physicians in managing CNCP were improved as was expected. Although the rate of eagerness about risk assessment of opioid misuse was increased, expected increase in the rate of using risk assessment was not achieved. Further studies are needed to identify the reasons of the difficulties on changing the attitudes and practices of primary care physicians about this subject.
chronic pain, family medicine, risk assessment, opioids
Introduction Chronic noncancer pain (CNCP) is defined as a pain persisting beyond the normal healing time for a specific illness or injury when it persists >6 months by the International Association for the Study of Pain [1]. The problem of increasing opioid use in poorly controlled chronic pain is still a considerable global problem. In many cases, a physical cause of pain cannot be accurately determined and targeted during treatment. Almost one in every five adults suffers from continuous pain that seriously compromises the quality of their emotional, social, and working life. Opioid analgesics are the mainstay for pharmacological treatment of chronic moderate-to-severe pain, with their propensity to improve the quality of life. Although there is an agreement on their use in acute and cancer pain, long-term use for CNCP remains controversial [2-5]. Side effects, absence of any Correspondence: Ethem Kavukcu, Department of Family Medicine, Akdeniz University, Antalya, PC 07059, Turkey. E-mail: [email protected]
History Received 18 November 2014 Revised 26 November 2014 Accepted 27 November 2014 Published online 25 December 2014
improvement in physical function, misuse, abuse, and addiction are relatively common during chronic opioid use. Despite all these negativities, there has been a sharp increase in opioid prescriptions for chronic pain in recent years [6]. A recent analysis of data from the National Ambulatory Medical Care Survey indicates a 73% increase in opioid prescriptions for chronic pain occurring in the years 2000–2010. This growth seems to be specific to opioid treatment because the use of non-opioid treatments for chronic pain did not increase significantly over the same time frame [7]. Chronic pain represents a physically and psychologically complicated condition that can present a challenge to even the most skilled and specialized health professionals. Physicians practicing at tertiary care facilities often have focused training in pain management. Further, they may have established relationships with mental healthcare specialists who are able to complete opioid risk evaluations and make appropriate recommendations regarding the patient’s suitability for opioid treatment [7,8]. Primary care family physicians (PCFPs), in contrast to specialized providers, do not receive such focused
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
DOI: 10.1080/00325481.2015.993572
training but still are often responsible for managing a patient’s chronic pain in primary care. Despite lacking a specialized fellowship in pain, frequent appointments provide PCFPs with increased opportunities to evaluate patients, including followup of pain symptoms and evaluation of ongoing risk and side effects that can occur with opioid use [9]. Guidelines recommend that the use of opioids in patients with CNCP must be preceded by an assessment of potential benefits and risks of aberrant drug-related behaviors and should include a psychological and psychiatric assessment [2,10]. Different kinds of tools have been developed for this purpose in recent years [11,12]; Pain Medication Questionnaire [13] and Diagnosis Intractability Risk and Efficacy (DIRE) score [14] were created specifically for chronic pain patients. The Screener and Opioid Assessment for Patients with Pain-Revised, the Current Opioid Misuse Measure, Opioid Risk Tool, and the Screening Instrument for Substance Abuse Potential were the other validated measures developed for screening patients with chronic pain for misuse and addiction risk potential [14]. In the present study, guidelines for the use of opioids and risk evaluation tools were used for participants’ education and was primarily aimed at investigating whether PCFPs are aware of their knowledge and social requirements concerning CNCP treatment or not. Secondarily, it was investigated whether education given to the PCFPs on patients risk evaluation for opioid misuse in CNCP provided favorable improvement in family physicians’ knowledge and attitudes.
Materials and methods The universe of this cross-sectional study consists of PCFPs working at Family Health Care Centers (FHCCs) affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Study was planned with 36 PCFPs; 18 physicians constituted the intervention group and 18 physicians the control group. Using sample size calculation table, it was planned to reach to at least 30 physicians at the significance level of a 0.05 and with a 5% error. A 20-question survey including explanations and demographic data was structured to apply to the participants both before and after education to assess their knowledge, attitude, and opinions on risk assessment before opioid use. Education of the participant PCFPs were designed according to the “Clinical guidelines for the use of chronic opioid therapy in CNCP” [15] of the American Pain Society/American Academy of Pain Medicine and the use of pain medication questionnaire and DIRE [13,14]. The survey was consulted with the Department of Biostatistics and Medical Informatics for the validity and reliability of test results and the survey questions took their final form in line with the recommendations. It was approved by the ethics committee as being considered scientifically and ethically appropriate, and then necessary permissions were obtained. Statistical analysis Eighteen PCFPs in the intervention group received education on risk assessment before opioid use. The survey was then
Chronic noncancer pain management in primary care
23
Table I. Characteristics of the primary care family physician. Variable
Physicians in intervention group (n = 18)
Sex Female 33.3% Male 66.6% Age 30–45 44.5% 46–60 55.5% Year of graduation >2000 27.7% 3500, respectively. The rate of evaluation for the risk of opioid misuse decreases in correlation with the increase in population affiliated to family physician. The rate of physicians expressing that they performed adequate number of risk evaluation before opioid use was 52.7% in those working at primary care setting for > 15 years and 31.9% in those working at primary care setting £ 15 years; the difference was statistically significant (p = 0.009). In the present study, it was determined that the rate of correct answers given to all six case questions in the questionnaire increased after the education. The rate of 100% correct answer was achieved for one question; proportional increase in four questions was found to be statistically significant; however, increased proportions in one question were not statistically significant. The core examination, which was performed to measure family physicians’ skills in deciding to perform or not to perform risk evaluation before opioid use, consisted of six case questions. Whereas a success rate of 51.4% was obtained for one question in the
DOI: 10.1080/00325481.2015.993572
core examination, the success rates ranged between 75 and 100% for the other questions.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
Discussion PCFPs find themselves at an important junction concerning opioid treatment for CNCP. Surveys of PCFPs involved in the treatment and follow-up of patients with CNCP revealed that educational programs on chronic pain management are relevant and perceived as necessary by PCFPs [16]. In the literature, 12 studies assessed the effect of health professionals’ education-mediated interventions on health provider outcomes such as the changes in knowledge about pain and its management [17-19], clinical management [20,21], prescription behavior [22,23], confidence in therapy [24], and patient-related outcomes [25-27]. Physicians’ educationmediated interventions, such as electronic learning education based on clinical practice guidelines [20] and educational packages that involved the participation of educational leaders [21], were evaluated and study results did not show statistically significant effect on clinical pain management. In the current study, when the intervention and control groups were compared in terms of responses to the first survey, there were no statistically significant differences indicating that the groups had similar characteristics. The rate of those thinking that family physicians should perform risk evaluation for opioid misuse was 61.1%. Family physicians in the USA and Europe also agree that risk evaluation before opioid use is an important point in chronic pain management; however, the number of risk evaluation performed before opioid use is inadequate in routine practice [28]. Washington State Department of Health was the first jurisdiction to implement specific dosing guidance for opioids in the treatment of CNCP in 2007 [29]. In 2011, Morse et al. reported that they rarely used this guide, which was implemented in 2007, and thought that more guidance and community resources, including dosing guidance, were needed [30]. Starting from those years, concerns have never ended about opioid use in CNCP. Primary care physicians’ concerns about dependence, addiction, and diversion are consistent with surveys in different countries [31-33]. According to the results of AHRQ study ‘The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain’, in 10 uncontrolled studies, rates of opioid abuse were 0.6–8% and rates of dependence were 3.1–26% in primary care settings, but studies varied in methods used to define and ascertain outcomes. Rates of aberrant drug-related behaviors ranged from 5.7 to 37.1% [34]. In the present study, a large proportion of providers (80.5%) reported similar concerns, and they also highlighted the importance of risk assessment to be able to control these concerns; on the first survey, 80.5% of family physicians agreed about concerns about dependence, addiction, and diversion and reported that the purpose of risk evaluation before opioid treatment was ‘to assess the factors that threaten health and safety of the CNCP patients’, whereas this rate increased to 97.2% after the education. According to Geraud G and his friends study in 2009, electronic learning education based on clinical practice guidelines, did not show statistically significant effect on clinical
Chronic noncancer pain management in primary care
25
pain management [20], Similar to this study, when the intervention and control groups in terms of responses given to the second survey were compared, it was observed that education made a favorable change in the intervention groups’ knowledge but did not show statistically significant effect on the management of chronic pain in the current study. A total of 88.6% of the family physicians reported that individuals seeking solution for CNCP are over the age of 65 years. Kersnic [35] and Peppas et al. [36] found in their studies on patient home visits that chronic pain were more often a problem of the elderly over the age of 65 years. The reasons expressed by the physicians for not performing adequate number of risk evaluations before opioid use were lack of sufficient time, at a rate of 95.8%; inadequate salary and low motivation, at a rate of 68.1%; concern about malpractice, at a rate of 41.7%; lack of knowledge on risk evaluation before opioid use, at a rate of 40.3%; and opinion that risk evaluation before opioid use would not be beneficial, at a rate of 30.6%. According to the present study, physicians over the age of 45 years apply risk assessment more compared to the physicians under the age of 45 years (61.1 and 55.5% in intervention and control groups, respectively; p = 0.024). Although it was not statistically significant, male physicians performed more risk assessment before opioid use than female physicians. Whereas 61.1% of the physicians working at primary care for > 15 years thought that they performed adequate number of risk evaluation before opioid use, this rate was found to be 31.9% for the physicians working for < 15 years (p = 0.01). In the current study, it was found that education enhanced the physicians’ knowledge on risk assessment of opioid misuse. The core examination performed after the education revealed that the physicians had adequate skills to decide whether to perform risk assessment before opioid use and to manage the pain treatment. The physicians participating in the study expressed that their knowledge concerning risk evaluation was enhanced on the second survey compared to the first survey and that they became more skillful on this subject (p = 0.013). Eagerness of physicians in performing risk assessment were significantly increased after the education (p = 0.003). Nevertheless, physicians’ attitudes and the number of risk assessment applied in the primary care practice did not change significantly after the education (p = 1.000).
Conclusion The education given to the PCFPs provided statistically significant increase in the physicians’ knowledge on risk evaluation before starting opioid use. With regard to the results of core examination, it was observed that the physicians found it necessary to perform risk evaluation before opioid use and manage the pain treatment, and also to make recommendations on the use of opioids. However, they did not apply it in practice. Although physicians were willing to practice risk evaluation after the education in a statistically significant manner (p = 0.003), this did not increase the number of risk evaluation in the practice as much as expected. In other words, it was not significantly projected on their attitudes about this subject (p = 1.000). This result highlights the need to integrate routine
26
E. Kavukcu et al.
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clinical evaluation with the use of tools specifically created to assess the risk of opioid misuse in the CNCP patients.
Postgrad Med, 2015; 127(1):22–26
[17]
Acknowledgement
[18]
Ethics committee approval was received from the ethics committee of Akdeniz University School of Medicine.
[19]
Declaration of interest: The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents, received or pending, or royalties.
[20]
References
[23]
` re M, et al. Knowledge, [1] Lalonde L, Leroux-Lapointe V, ChoiniO attitudes and beliefs about chronic noncancer pain in primary care: a Canadian survey of physicians and pharmacists. Pain Res Manag 2014;19:241–50. [2] Ferrari R, Duse G, Capraro M, Visentin M. Risk assessment of opioid misuse in Italian patients with chronic noncancer pain. Pain Res Treat 2014;2014:584986. [3] Moulin DE, Clark AJ, Speechley M, Morley-Forster PK. Chronic pain in Canada- prevalence, treatment, impact and the role of opioid analgesia. Pain Res Manag 2002;7:179–84. [4] Gouvernement du Quebec. Portrait de sante du Quebec et de ses regions 2006: Publications du Quebec; 2006. [5] Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333. [6] Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician 2014;17:E1–E10. [7] Fink-Miller E, Long D, Gross R. Comparing chronic pain treatment seekers in primary care versus tertiary care settings. J Am Board Fam Med 2014;27:594–601. [8] Cheatle M, Barker C. Improving opioid prescription practices and reducing patient risk in the primary care setting. J Pain Res 2014;7:301–11. [9] Nishimori M, Kulich RJ, Carwood CM, et al. Successful and unsuccessful outcomes with long term opioid therapy: a survey of physicians opinions. J Palliat Med 2006;9:50–6. [10] Chou R, Ballantyne JC, Fanciullo GJ, et al. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009;10:147–59. [11] Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain 2007;11:490–518. [12] Ferrari R, Capraro M, Visentin M. Risk factors in opioid treatment of chronic non-cancer pain: a multidisciplinary assessment. In Pain management-current issues and opinions. ISBN: 978-953307-813-7. InTech. 2011. p 419–58. [13] Adams L, Gatchel RJ, Robinson RC, et al. Development of a selfreport screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Managem 2004;27:440–59. [14] Belgrade MJ, Schamber CD, Lindgren BR. The DIRE score: predicting outcomes of opioid prescribing for chronic pain. J Pain 2006;7:671–81. [15] Gudin JA. The changing landscape of opioid prescribing: longacting and extended-release opioid class-wide risk evaluation and mitigation strategy. Ther Clin Risk Manag 2012. 8:209–17. [16] Murphy L, Isaac P, Kalvik A, et al. Safer Opioids: a structured approach to identifying key information and drug therapy
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problems in chronic noncancer pain patients using opioid therapy. Can Pharm J (Ott) 2013;146:26–9. Harris JM Jr, Elliott TE, Davis BE, et al. Educating generalist physicians about chronic pain: Live experts and online education can provide durable benefits. Pain Med 2008;9:555–63. Smits PB, Verbeek JH, Van Dijk FJ, et al. Evaluation of a postgraduate educational programme for occupational physicians on work rehabilitation guidelines for patients with low back pain. Occup Environ Med 2000;57:645–6. Jones KR, Fink R, Pepper G, et al. Improving nursing home staff knowledge and attitudes about pain. Gerontologist 2004;44:469–78. Geraud G, Valade D, Meric G, Troy S, Lanteri-Minet M. Study of the impact of a general practitioner educational program in managing migraine according to the French guidelines (FAST study). 4th Congress of the Int. Headache Society; 10 – 13 September 2009; Philadelphia. p 50–1. Stevenson K, Lewis M, Hay E. Does physiotherapy management of low back pain change as a result of an evidence-based educational programme? J Eval Clin Pract 2006;12:365–75. Figueiras A, Sastre I, Tato F, et al. One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. Med Care 2001;39:158–67. Rahme E, Choquette D, Beaulieu M, et al. Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population. Am J Med 2005;118:1262–70. Keijsers JF, Bouter LM, Meertens RM, Kessels AG, Knipschild PG. The impact of back school research on the beliefs of health care professionals: a randomised survey of general practitioners and physiotherapists. Physiother Theory Pract 1992;8:79–83. Becker A, Leonhardt C, Kochen MM, et al. Effects of two guideline implementation strategies on patient outcomes in primary care: a cluster randomized controlled trial. Spine 2008;33:473–80. Bekkering GE, van Tulder MW, Hendriks EJ, et al. Implementation of clinical guidelines on physical therapy for patients with low back pain: Randomized trial comparing patient outcomes after a Standard and active implementation strategy. Phys Ther 2005;85:544–55. Smelt A, Blom J, Dekker F, et al. A proactive approach towards migraine patients in general practice: a pragmatic randomized controlled trial. 2nd European Headache and Migraine Trust International Congress – EHMTIC. 28 – 31 October 2010; Nice. S27. Franklin GM, Fulton-Kehoe D, Turner JA, et al. Changes in opioid prescribing for chronic pain in Washington state. J Am Board Fam Med 2013;26:394–400. Washington Agency Medical Director’s Group. Opioid dosing guideline for chronic noncancer pain. Available from http://www.agencymeddirectors.wa.gov/opioiddosing.asp. Accessed 5 September 2012. Morse JS, Stockbridge H, Egan KB, Mai J, Wickizer T, Franklin GM. Primary care survey of the value and effectiveness of the Washington state opioid dosing guideline. J Opioid Manag 2011;7:427–33. Leverence RR, Williams RL, Potter M, et al. Chronic non-cancer pain: a siren for primary care–a report from the PRImary care multiethnic network. J Am Board Fam Med 2011;24:551–61. Wenghofer F, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician 2011;57:324–32. Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med 2008;9: 564–71. Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-201200014-I.) AHRQ Publication No. 14-E005-EF Agency for Healthcare Research and Quality, Rockville, MD; September 2014. Available from www.effectivehealthcare.ahrq.gov/reports/final.cfm. Kersnic J. Observational study of home visits in Slovene general practice: patient characteristics, practice characteristics and health care utilization. Fam Pract 2000;17:389–93. Peppas G, Theocharis G, Karveli EA, Falagas ME. An analysis of patient house calls in the area of Attica, Greece. BMC Health Serv Res 2006;6:112.
ORIGINAL RESEARCH
Chronic noncancer pain management in primary care: family medicine physicians’ risk assessment of opioid misuse 1 & Mehmet Öner1 Ethem Kavukcu1, Melahat Akdeniz1, Hasan Huseyin Avci2, Mehmet Altug Department of Family Medicine, Akdeniz University Hospital, Antalya 07059, Turkey, and 2Ahmet Atmaca Primary Health Care Center, Antalya, Turkey
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
1
Abstract
Keywords:
Objective: The majority of patients with chronic noncancer pain (CNCP) are managed in the primary care settings. The primary care family physician (PCFP) generally has limited time, training, or access to resources to effectively evaluate and treat these patients, particularly when there is the added potential liability of prescribing opioids. The aim of this study is to make a favorable change in PCFPs’ knowledge, attitudes, and practices about opioid use in CNCP via education on assessment of the risk of opioid misuse. Materials and methods: The universe of this crosssectional study comprised 36 family physicians working at Family Health Centers affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Initially, a survey on patients risk assessment was performed in both intervention and control groups; whereas the intervention group received education on assessment of the risk of opioid misuse, the control group did not. The survey was repeated after 6 months and the intervention group underwent a core examination. Data obtained were analyzed with Statistical Package for the Social Sciences 18.0 statistics program. Intervention and control groups were compared. Additionally, pre- and post-education results of the intervention group were also compared. Results: About 61.1% of family physicians reported concern and hesitation in prescribing opioids due to known risks, such as overdose, addiction, dependence, or diversion, and agreed that family physicians should apply risk assessment before opioid use in CNCP. Only 16.6% of PCFP reported that risk assessment is not so necessary, whereas 22.2% of PCFP were undecided. Although 47.2% of the family physicians expressed a willingness to apply risk assessment before starting opioids, the rate of eagerness increased markedly to 77.7% after the education, but the rate of increase in practicing was not statistically significant. Conclusion: Knowledge and competency of the family physicians in managing CNCP were improved as was expected. Although the rate of eagerness about risk assessment of opioid misuse was increased, expected increase in the rate of using risk assessment was not achieved. Further studies are needed to identify the reasons of the difficulties on changing the attitudes and practices of primary care physicians about this subject.
chronic pain, family medicine, risk assessment, opioids
Introduction Chronic noncancer pain (CNCP) is defined as a pain persisting beyond the normal healing time for a specific illness or injury when it persists >6 months by the International Association for the Study of Pain [1]. The problem of increasing opioid use in poorly controlled chronic pain is still a considerable global problem. In many cases, a physical cause of pain cannot be accurately determined and targeted during treatment. Almost one in every five adults suffers from continuous pain that seriously compromises the quality of their emotional, social, and working life. Opioid analgesics are the mainstay for pharmacological treatment of chronic moderate-to-severe pain, with their propensity to improve the quality of life. Although there is an agreement on their use in acute and cancer pain, long-term use for CNCP remains controversial [2-5]. Side effects, absence of any Correspondence: Ethem Kavukcu, Department of Family Medicine, Akdeniz University, Antalya, PC 07059, Turkey. E-mail: [email protected]
History Received 18 November 2014 Revised 26 November 2014 Accepted 27 November 2014 Published online 25 December 2014
improvement in physical function, misuse, abuse, and addiction are relatively common during chronic opioid use. Despite all these negativities, there has been a sharp increase in opioid prescriptions for chronic pain in recent years [6]. A recent analysis of data from the National Ambulatory Medical Care Survey indicates a 73% increase in opioid prescriptions for chronic pain occurring in the years 2000–2010. This growth seems to be specific to opioid treatment because the use of non-opioid treatments for chronic pain did not increase significantly over the same time frame [7]. Chronic pain represents a physically and psychologically complicated condition that can present a challenge to even the most skilled and specialized health professionals. Physicians practicing at tertiary care facilities often have focused training in pain management. Further, they may have established relationships with mental healthcare specialists who are able to complete opioid risk evaluations and make appropriate recommendations regarding the patient’s suitability for opioid treatment [7,8]. Primary care family physicians (PCFPs), in contrast to specialized providers, do not receive such focused
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
DOI: 10.1080/00325481.2015.993572
training but still are often responsible for managing a patient’s chronic pain in primary care. Despite lacking a specialized fellowship in pain, frequent appointments provide PCFPs with increased opportunities to evaluate patients, including followup of pain symptoms and evaluation of ongoing risk and side effects that can occur with opioid use [9]. Guidelines recommend that the use of opioids in patients with CNCP must be preceded by an assessment of potential benefits and risks of aberrant drug-related behaviors and should include a psychological and psychiatric assessment [2,10]. Different kinds of tools have been developed for this purpose in recent years [11,12]; Pain Medication Questionnaire [13] and Diagnosis Intractability Risk and Efficacy (DIRE) score [14] were created specifically for chronic pain patients. The Screener and Opioid Assessment for Patients with Pain-Revised, the Current Opioid Misuse Measure, Opioid Risk Tool, and the Screening Instrument for Substance Abuse Potential were the other validated measures developed for screening patients with chronic pain for misuse and addiction risk potential [14]. In the present study, guidelines for the use of opioids and risk evaluation tools were used for participants’ education and was primarily aimed at investigating whether PCFPs are aware of their knowledge and social requirements concerning CNCP treatment or not. Secondarily, it was investigated whether education given to the PCFPs on patients risk evaluation for opioid misuse in CNCP provided favorable improvement in family physicians’ knowledge and attitudes.
Materials and methods The universe of this cross-sectional study consists of PCFPs working at Family Health Care Centers (FHCCs) affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Study was planned with 36 PCFPs; 18 physicians constituted the intervention group and 18 physicians the control group. Using sample size calculation table, it was planned to reach to at least 30 physicians at the significance level of a 0.05 and with a 5% error. A 20-question survey including explanations and demographic data was structured to apply to the participants both before and after education to assess their knowledge, attitude, and opinions on risk assessment before opioid use. Education of the participant PCFPs were designed according to the “Clinical guidelines for the use of chronic opioid therapy in CNCP” [15] of the American Pain Society/American Academy of Pain Medicine and the use of pain medication questionnaire and DIRE [13,14]. The survey was consulted with the Department of Biostatistics and Medical Informatics for the validity and reliability of test results and the survey questions took their final form in line with the recommendations. It was approved by the ethics committee as being considered scientifically and ethically appropriate, and then necessary permissions were obtained. Statistical analysis Eighteen PCFPs in the intervention group received education on risk assessment before opioid use. The survey was then
Chronic noncancer pain management in primary care
23
Table I. Characteristics of the primary care family physician. Variable
Physicians in intervention group (n = 18)
Sex Female 33.3% Male 66.6% Age 30–45 44.5% 46–60 55.5% Year of graduation >2000 27.7% 3500, respectively. The rate of evaluation for the risk of opioid misuse decreases in correlation with the increase in population affiliated to family physician. The rate of physicians expressing that they performed adequate number of risk evaluation before opioid use was 52.7% in those working at primary care setting for > 15 years and 31.9% in those working at primary care setting £ 15 years; the difference was statistically significant (p = 0.009). In the present study, it was determined that the rate of correct answers given to all six case questions in the questionnaire increased after the education. The rate of 100% correct answer was achieved for one question; proportional increase in four questions was found to be statistically significant; however, increased proportions in one question were not statistically significant. The core examination, which was performed to measure family physicians’ skills in deciding to perform or not to perform risk evaluation before opioid use, consisted of six case questions. Whereas a success rate of 51.4% was obtained for one question in the
DOI: 10.1080/00325481.2015.993572
core examination, the success rates ranged between 75 and 100% for the other questions.
Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
Discussion PCFPs find themselves at an important junction concerning opioid treatment for CNCP. Surveys of PCFPs involved in the treatment and follow-up of patients with CNCP revealed that educational programs on chronic pain management are relevant and perceived as necessary by PCFPs [16]. In the literature, 12 studies assessed the effect of health professionals’ education-mediated interventions on health provider outcomes such as the changes in knowledge about pain and its management [17-19], clinical management [20,21], prescription behavior [22,23], confidence in therapy [24], and patient-related outcomes [25-27]. Physicians’ educationmediated interventions, such as electronic learning education based on clinical practice guidelines [20] and educational packages that involved the participation of educational leaders [21], were evaluated and study results did not show statistically significant effect on clinical pain management. In the current study, when the intervention and control groups were compared in terms of responses to the first survey, there were no statistically significant differences indicating that the groups had similar characteristics. The rate of those thinking that family physicians should perform risk evaluation for opioid misuse was 61.1%. Family physicians in the USA and Europe also agree that risk evaluation before opioid use is an important point in chronic pain management; however, the number of risk evaluation performed before opioid use is inadequate in routine practice [28]. Washington State Department of Health was the first jurisdiction to implement specific dosing guidance for opioids in the treatment of CNCP in 2007 [29]. In 2011, Morse et al. reported that they rarely used this guide, which was implemented in 2007, and thought that more guidance and community resources, including dosing guidance, were needed [30]. Starting from those years, concerns have never ended about opioid use in CNCP. Primary care physicians’ concerns about dependence, addiction, and diversion are consistent with surveys in different countries [31-33]. According to the results of AHRQ study ‘The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain’, in 10 uncontrolled studies, rates of opioid abuse were 0.6–8% and rates of dependence were 3.1–26% in primary care settings, but studies varied in methods used to define and ascertain outcomes. Rates of aberrant drug-related behaviors ranged from 5.7 to 37.1% [34]. In the present study, a large proportion of providers (80.5%) reported similar concerns, and they also highlighted the importance of risk assessment to be able to control these concerns; on the first survey, 80.5% of family physicians agreed about concerns about dependence, addiction, and diversion and reported that the purpose of risk evaluation before opioid treatment was ‘to assess the factors that threaten health and safety of the CNCP patients’, whereas this rate increased to 97.2% after the education. According to Geraud G and his friends study in 2009, electronic learning education based on clinical practice guidelines, did not show statistically significant effect on clinical
Chronic noncancer pain management in primary care
25
pain management [20], Similar to this study, when the intervention and control groups in terms of responses given to the second survey were compared, it was observed that education made a favorable change in the intervention groups’ knowledge but did not show statistically significant effect on the management of chronic pain in the current study. A total of 88.6% of the family physicians reported that individuals seeking solution for CNCP are over the age of 65 years. Kersnic [35] and Peppas et al. [36] found in their studies on patient home visits that chronic pain were more often a problem of the elderly over the age of 65 years. The reasons expressed by the physicians for not performing adequate number of risk evaluations before opioid use were lack of sufficient time, at a rate of 95.8%; inadequate salary and low motivation, at a rate of 68.1%; concern about malpractice, at a rate of 41.7%; lack of knowledge on risk evaluation before opioid use, at a rate of 40.3%; and opinion that risk evaluation before opioid use would not be beneficial, at a rate of 30.6%. According to the present study, physicians over the age of 45 years apply risk assessment more compared to the physicians under the age of 45 years (61.1 and 55.5% in intervention and control groups, respectively; p = 0.024). Although it was not statistically significant, male physicians performed more risk assessment before opioid use than female physicians. Whereas 61.1% of the physicians working at primary care for > 15 years thought that they performed adequate number of risk evaluation before opioid use, this rate was found to be 31.9% for the physicians working for < 15 years (p = 0.01). In the current study, it was found that education enhanced the physicians’ knowledge on risk assessment of opioid misuse. The core examination performed after the education revealed that the physicians had adequate skills to decide whether to perform risk assessment before opioid use and to manage the pain treatment. The physicians participating in the study expressed that their knowledge concerning risk evaluation was enhanced on the second survey compared to the first survey and that they became more skillful on this subject (p = 0.013). Eagerness of physicians in performing risk assessment were significantly increased after the education (p = 0.003). Nevertheless, physicians’ attitudes and the number of risk assessment applied in the primary care practice did not change significantly after the education (p = 1.000).
Conclusion The education given to the PCFPs provided statistically significant increase in the physicians’ knowledge on risk evaluation before starting opioid use. With regard to the results of core examination, it was observed that the physicians found it necessary to perform risk evaluation before opioid use and manage the pain treatment, and also to make recommendations on the use of opioids. However, they did not apply it in practice. Although physicians were willing to practice risk evaluation after the education in a statistically significant manner (p = 0.003), this did not increase the number of risk evaluation in the practice as much as expected. In other words, it was not significantly projected on their attitudes about this subject (p = 1.000). This result highlights the need to integrate routine
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Postgraduate Medicine Downloaded from informahealthcare.com by Nyu Medical Center on 06/13/15 For personal use only.
clinical evaluation with the use of tools specifically created to assess the risk of opioid misuse in the CNCP patients.
Postgrad Med, 2015; 127(1):22–26
[17]
Acknowledgement
[18]
Ethics committee approval was received from the ethics committee of Akdeniz University School of Medicine.
[19]
Declaration of interest: The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents, received or pending, or royalties.
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