Pain Management and Opioid Therapy: Persistent Knowledge Gaps Among Primary Care Providers

Abstract

Introduction: Given the opioid epidemic in the US, it is vital that clinicians who prescribe opioids for pain management to do so in an evidence-based manner, eg considering all pharmacologic and non-pharmacologic options, assessing risk of opioid use disorder prior to initiating opioids. Continuing education regarding the evidence-based prescribing of opioids is now required for US healthcare providers who prescribe opioids. A "blueprint" of the content to be included in continuing education programs was developed by the US Food and Drug Administration and updated in 2018.

Methods: To understand the baseline knowledge and confidence of healthcare professionals in prescribing opioids for pain management, we posed 27 unique knowledge-based questions and 1 confidence question to clinician participants before or during 2 continuing educational programs that were based respectively on the 2016 and 2018 FDA Risk Evaluation and Mitigation Strategy (REMS) educational blueprints for pain management.

Results: Overall, 5571 clinicians completed these programs, including 1925 physicians (1516 [79%] identifying as primary care), 1181 physician assistants, 737 advanced practice nurses, 719 nurses, and 479 pharmacists. Responses to pretest questions in both programs indicated profound and persistent gaps in knowledge, particularly in definitions and mechanisms of pain, general principles of pharmacologic analgesic therapy, and specific aspects of opioid analgesic therapy and addiction. Participants in both programs also expressed limited confidence in their abilities to incorporate patient engagement techniques into pain management or develop a treatment plan for a patient with chronic pain.

Discussion: These data support an ongoing need for comprehensive clinician-based education as outlined in the FDA REMS educational blueprint, especially given recent data of escalating overdose deaths during the COVID-19 pandemic.

Keywords: CME; REMS; analgesics; chronic pain; continuing medical education; opioid; opioid-related disorders; pain management; primary health care; risk evaluation and mitigation strategy.

Figure 1

Pretest questions and responses addressing definitions and mechanisms of pain. (Best evidence-based answers are noted with an asterisk.). Program 1: Which of the following statements is true about chronic pain? (n = 4453). Program 1: Which of the following statements defines chronic pain? (n = 3900). Program 2: Examples of nociceptive pain include which of the following? (n = 815).

Figure 2

Pretest questions and responses addressing assessments of patients in pain. (Correct answers are shown with an asterisk). Program 1: Assessing patients in pain: (n = 3445). Program 2: When assessing patients in pain, the main focus should be on: (n = 798).

Figure 3

Pretest questions and responses for components of an effective treatment plan. (Correct answers are shown with an asterisk). Program 1: Effective treatment of pain is determined by: (n = 3900). Program 1: The most effective and safe way to manage pain with medication is: (n = 3900). Program 2: The most effective and safe way to manage pain with medication is: (n = 842). Program 2: The treatment goals associated with acute pain include: (n = 714).

Figure 4

Pretest question and responses concerning nonpharmacologic approaches for pain. (Correct answer is shown with an asterisk). Programs 1 and 2: Nonpharmacologic therapies for pain: (n = 4701).

Figure 5

Pretest questions and responses addressing opioid and non-opioid analgesics. (Correct answers are shown with an asterisk). Program 1: Which of the following statements regarding drug-drug interactions with opioids is FALSE? (n = 6050). Program 1: The cytochrome P450 systems influence the metabolism of which of the following opioid analgesics? (n = 627). Program 2: Which pharmacokinetic properties contribute most to rewarding properties of a molecule? (n = 3900). Program 2: Looking at pharmacogenetic variability and response, what percentage of the general population has phenotype variability? (n = 901).

Figure 6

Pretest questions and responses concerning the prescription and management of opioid therapy. (Correct answers are shown with an asterisk). Program 1: Monitoring patients on opioids should include: (n = 625). Program 1: When counseling patients on the use of ER opioid formulations, which of the following is true? (n = 606). Program 1: Physicians should counsel the caregivers or patients to: (n = 548). Program 1: Upon considering the initiation of opioids, which of the following is true? (n = 4511). Program 1: Chronic opioid therapy is indicated when a patient is: (n = 3900). Programs 1 and 2: In converting patients from one ER opioid to another ER opioid: (n = 5394). Programs 1 and 2: When chronic opioid therapy is initiated: (n = 4702). Program 2: Patient/provider counseling strategies include all of the following except: (n = 787).

Figure 7

Continue.

Figure 7

Pretest questions and responses concerning the identification and management of OUD and addiction. (Correct answers are shown with an asterisk). Program 1: Which of the following screening tools is useful in identifying opioid misuse once therapy has begun? (n = 596). Program 1: Toxicity of methadone: (n = 683). Program 1: Examples of opioids that have been formulated to deter abuse include all of the following except? (n = 588). Programs 1 and 2: Which of the following is true? (n = 4697). Program 2: Co-prescribing of take-home naloxone should be considered for patients: (n = 771).

Figure 8

Pretest questions and responses regarding confidence in aspects of pain management. (N values of pretest participants exceed those of CME/CE completers). Program 1: Please rate your confidence in your ability to employ patient engagement techniques into pain management. (n = 4569). Program 2: Please rate your confidence in your ability to develop a treatment plan for a patient with chronic pain. (n = 908).