Evaluation of the Impact of an Online Opioid Education Program for Acute Pain Management.

OBJECTIVE: The University of Washington instituted a policy requiring all credentialed clinicians who prescribe opioids to complete a one-time education activity about safe and responsible opioid prescribing. A scenario-based, interactive online learning module was developed for opioid management of acute pain in hospitalized adults. This study examined the impact of the education module on learners' knowledge, perceived competence, and use of guideline-adherent practices. METHODS: Clinicians who completed the education module participated in a voluntary de-identified online survey approximately six months after the learning activity. Survey questions were related to 1) the perception of improved knowledge; 2) impact on learner's use of three guideline-adherent practices; and 3) perceived competence in managing opioids for acute pain. Descriptive statistics were generated, and multiple linear regression models were used for analysis. RESULTS: Clinicians (N = 167) reported improvement in knowledge and perceived competence. Controlling for other aspects of knowledge evaluated, learning to construct a safe opioid taper plan for acute pain, distinguishing between short- and long-acting opioids, and safely initiating opioids for acute pain were significantly associated with increased self-reported likelihood of incorporating the Washington state Prescription Monitoring Program (P = 0.003), using multimodal analgesia (P = 0.022), and reducing the duration of opioids prescribed (P = 0.016). Only improvement in knowledge of how to construct a safe opioid taper plan was significantly associated with increased perceived competence (P = 0.002). CONCLUSIONS: Our findings suggest that this online education module about safe opioid prescribing for acute pain management was effective at improving knowledge, increasing the likelihood of using guideline-adherent clinical practices, and increasing perceived competence.

Evaluation of an interprofessional active learning session on acute pain and opioid use disorder using the interprofessional collaborative competency attainment scale.

Pain is complex and best managed using an interprofessional approach. A complicating factor is the high prevalence of co-existing opioid use disorder (OUD). Interprofessional education (IPE) may be an important strategy for transforming pain and OUD care. The objective of this study was to evaluate the impact of an interactive, case-based IPE session related to acute pain management in persons with OUD on pre-licensure health science students' perceived achievement of core competencies for interprofessional collaborative practice. Students completed a self-assessment of competency before and after the IPE session, using the Interprofessional Collaborative Competency Attainment Scale. Paired samples t-tests determined differences between pre- and post-session assessments and Cohen's d effect sizes evaluated the magnitude of change. Learners (n = 160) included students from pharmacy (30.9%), social work (21.9%), dentistry (16.3%), nursing (14.4%), medicine (9.4%), and other professional schools (7.4%). Learners showed significant improvement in perceived competency for all items (all p ≤ 0.002). Using a Collaborative Patient-Centered Approach and Team Functioning demonstrated the greatest overall improvement (Cohen's d > 0. 80). Findings suggest that an interactive IPE session is associated with perceived achievement of core interprofessional competencies for acute pain management in persons with OUD.

Use of Self-management Interventions for Chronic Pain Management: A Comparison between Rural and Nonrural Residents.

Individuals with chronic pain who live in rural communities often lack access to pain specialists and rely on primary care providers who may be less prepared. Research has indicated that rural residents with chronic pain are more likely to receive an opioid prescription than nonrural residents. Although self-management approaches are available for chronic pain management, it is unclear to what extent rural residents use these interventions. This study compares usage of self-management interventions and opioid-based analgesics for chronic pain management between rural and nonrural residents. This study is a secondary analysis of baseline data from a randomized controlled trial evaluating a telehealth intervention for chronic pain management. Participants, recruited from primary care clinics, were 65 rural residents and 144 nonrural residents with similar demographic characteristics. Differences in the use of self-management interventions, pain intensity, and opioid dose were evaluated between rural and nonrural residents. Rural residents (n = 50, 77%) were less likely to use self-management interventions compared with nonrural residents (n = 133, 92%) (p = .019). Opioids were taken for pain relief by 76% of the rural residents compared with 52% of the nonrural residents. A disparity exists in the use of self-management interventions for chronic pain management by rural residents compared with nonrural residents. Further study is needed to determine if this is related to the lack of access to specialists and/or pain management training of primary care providers. Nurses can play an essential role in addressing this disparity by educating patients about self-management interventions.

A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.

OBJECTIVES: With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth. METHODS: Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified. RESULTS: Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth. CONCLUSIONS: U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.

Lessons from the implementation of a trauma center-based program to support primary care providers in managing opioids and pain after trauma hospitalization.

Background: Decreasing exposure to prescription opioids is critical to lowering risk of opioid misuse, overdose and opioid use disorder. This study reports a secondary analysis of a randomized controlled trial implementing an opioid taper support program directed to primary care providers (PCPs) of patients discharged from a level I trauma center to their homes distant from the center, and shares lessons for trauma centers in supporting these patients. Methods: This longitudinal descriptive mixed-methods study uses quantitative/qualitative data from trial intervention arm patients to examine implementation challenges and outcomes: adoption, acceptability, appropriateness, feasibility, fidelity. In the intervention, a physician assistant (PA) contacted patients after discharge to review their discharge instructions and pain management plan, confirm their PCP's identity and encourage PCP follow-up. The PA reached out to the PCP to review the discharge instructions and offer ongoing opioid taper and pain management support. Results: The PA reached 32 of 37 patients randomized to the program. Of these 32, 81% discussed topics not targeted by the intervention (eg, social/financial). The PA identified and reached a PCP's office for only 51% of patients. Of these, all PCP offices (100% adoption) received one to four consults (mean 1.9) per patient (fidelity). Few consults were with PCPs (22%); most were with medical assistants (56%) or nurses (22%). The PA reported that it was not routinely clear to patients or PCPs who was responsible for post-trauma care and opioid taper, and what the taper instructions were. Conclusions: This level I trauma center successfully implemented a telephonic opioid taper support program during COVID-19 but adapted the program to allow nurses and medical assistants to receive it. This study demonstrates a critical need to improve care transition from hospitalization to home for patients discharged after trauma. Level of evidence: Level IV.

Telementoring for improving primary care provider knowledge and competence in managing chronic pain: A randomised controlled trial.

Introduction: Primary care providers are frequently unprepared to manage chronic pain adequately due in part to insufficient professional training. This study evaluated the effect of a telementoring intervention on knowledge and perceived competence related to chronic pain management. Methods: The study design was a cluster randomised controlled trial. Primary care clinics that were part of the University of Washington Medicine Telehealth network were the unit of randomization. Primary care providers comprised the intervention group (n = 23) and the control group (n = 18). Providers in the intervention group attended telementoring sessions through the TelePain programme and presented patient cases at the beginning and end of their enrolled patients' 12-week study period. TelePain sessions included a didactic presentation and telementoring for specific patient cases by a panel of pain specialists from the disciplines of pain medicine, internal medicine, anaesthesiology, rehabilitation medicine, psychiatry, addiction medicine, nursing and complementary and integrative pain management. Providers' baseline and end-of-study knowledge and perceived competence in managing chronic pain were assessed by three questionnaires: Knowledge and Attitudes Survey Regarding Pain, the KnowPain-12 and the Perceived Competence Scale. Results: Knowledge (Z = ­0.34, p = 0.97 (Knowledge and Attitudes Survey Regarding Pain) and Z = 0.49, p = 0.62 (KnowPain-12)) and perceived competence (Z = ­0.74, p = 0.46) did not increase for providers in the intervention group compared with providers in the control group. These providers attended on average 12.5 sessions (range 0­31) while participating in the study. Discussion: Further research is recommended to establish the effectiveness of this telementoring intervention.

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain.

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n = 4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, "numbness/detachment" was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD. PERSPECTIVE: We present evidence that PTSD symptoms are significantly related to a broad set of pain-related patient-reported outcomes. These findings highlight the need to evaluate for PTSD symptoms in patients with chronic pain, especially feelings of numbness or detachment from others, to improve understanding and management of chronic pain.

TelePain: Primary Care Chronic Pain Management through Weekly Didactic and Case-based Telementoring.

Chronic pain is a significant problem among military personnel and a priority of the military health system. The U.S. Army Surgeon General's Pain Management Task Force recommends using telehealth capabilities to enhance pain management. This article describes the development and evaluation of a telehealth intervention (TelePain) designed to improve access to pain specialist consultation in the military health system. The study uses a wait-list controlled clinical trial to test: 1) effectiveness of the intervention, and 2) interviews to assess barriers and facilitators of the intervention implementation. The intervention involves a didactic presentation based on the Joint Pain Education Curriculum followed by patient case presentations and multi-disciplinary discussion via videoconference by clinicians working in the military health system. A panel of pain specialists representing pain medicine, internal medicine, anesthesiology, rehabilitation medicine, psychiatry, addiction medicine, health psychology, pharmacology, nursing, and complementary and integrative pain management provide pain management recommendations for each patient case. We use the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to measure patient outcomes, including pain, sleep, fatigue, anxiety, and depression. This article reports some of the challenges and lessons learned during early implementation of the TelePain intervention. Weekly telephone meetings among the multisite research team were instrumental in problem solving, identifying problem areas, and developing solutions. Solutions for recruitment challenges included additional outreach and networking to military health providers, both building on.

Pain education at the University of Washington School of Medicine.

UNLABELLED: Contemporary medical education is inadequate to prepare medical students to competently assess and design care plans for patients with acute and chronic pain. The time devoted to pain education in most medical school curricula is brief and not integrated into case-based clinical experiences, and it is frequently nonexistent during clinical clerkships. Medical student pain curricula have been proposed for over 30 years and are commonly agreed upon, though rarely implemented. As a consequence of poor undergraduate pain education, postgraduate trainees and practicing physicians struggle with both competency and practice satisfaction; their patients are similarly dissatisfied. At the University of Washington School of Medicine, a committee of multidisciplinary pain experts has, between 2009 and 2011, successfully introduced a 4-year integrated pain curriculum that increases required pain education teaching time from 6 to 25 hours, and clinical elective pain courses from 177 to 318 hours. It is expected that increased didactic and case-based multidisciplinary clinical training will increase knowledge and competency in biopsychosocial measurement-based pain narrative and risk assessment, improve understanding of persistent pain as a chronic complex condition, and expand the role of patient-centered interprofessional treatment for medical students, residents, and fellows, leading to better prepared practicing physicians. PERSPECTIVE: Strategies for improving multidisciplinary pain education at the University of Washington School of Medicine are described and the preliminary results demonstrated.

Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States.

The Pacific Northwest of the US is a large, sparsely populated region. A telehealth programme called Project ECHO (Extension for Community Health Outcomes) was tested in this region in 2009. Weekly videoconferences were held in the areas of hepatitis C, chronic pain, integrated addictions and psychiatry, and HIV/AIDS. Rural clinicians presented cases to a panel of experts at an academic medical centre and received management advice and access to best practices. During the trial, more than 900 clinicians participated, and more than 700 patient cases were presented. At the end of June 2012, a total of 23 videoconference clinics for hepatitis C had been held, 16 clinics in addiction and psychiatry, 97 in chronic pain and 13 in HIV/AIDS. The Project ECHO model improves access to health care. It may provide a way to bring specialist care to rural areas in developing countries.