Comparing Two Approaches to Help Patients and Doctors Talk about Chronic Pain Treatments -- Voices in Pain Care

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What was the research about?

Chronic pain is pain that lasts for months or years. Medicines called opioids can treat chronic pain. But patients who use opioids for a long time are at risk for health problems, such as addiction, overdose, and injuries. Doctors and patients don’t always talk about these risks when choosing pain treatments.

In this study, the research team compared two approaches to help patients and doctors talk about chronic pain treatments and reduce high-risk opioid use and effects of pain on patients’ lives:

• Doctors received an alert in patients' health records when prescribing opioids. The alert reminded doctors about the correct use of opioids and to offer education to patients.
• Patients received materials, including handouts and a video, online or by email before their visit. Materials encouraged patients to talk with their doctors about treatment preferences.

The research team looked at patients’ satisfaction in talking with their doctor and other health outcomes.

What were the results?

Because of study limitations, it’s hard to draw conclusions about the results.

Compared with patients whose doctors received alerts, patients who received materials were more likely to be satisfied in talking with their doctor. But they were also more likely to get an opioid prescription with a high dose.

After one year, with the available data, the two approaches didn’t differ in:

• How pain interfered with patients’ lives
• Patients’ ability to do daily activities, such as walking or dressing
• Patients’ symptoms of depression
• How likely patients were to have prescriptions for both an opioid and an anxiety medicine

Who was in the study?

The study included 951 patients who received care from one of 82 primary care doctors in a California health system. Among patients, 63 percent were White, 22 percent were Black, 6 percent were Asian, less than 1 percent were American Indian or Native Hawaiian, and 8 percent didn’t report a race; 11 percent were Hispanic. The average age was 54, and 58 percent were women. All had one or more prescriptions for opioids.

What did the research team do?

The research team assigned doctors by chance to one of the two approaches.

After each visit, the health system sent patients a survey about their satisfaction with talking to their doctor. Each month, the research team sent patients surveys about pain and their daily activities. The team compared responses before and after the health system started using each approach. For data about depression and prescriptions, the team looked at health records.

Patients with chronic pain, patient advocacy groups, and doctors helped design and carry out the study.

What were the limits of the study?

At the start of the study, patients assigned to the two approaches differed in satisfaction and opioid prescriptions. Also, less than 40 percent of patients responded to surveys. These limitations make it hard to be certain about the results.

Future research could use other methods for looking at these approaches to help patients and doctors talk about chronic pain treatments.

How can people use the results?

Researchers can consider this study’s limitations when designing future research.

Objective

To compare the effectiveness of two communication strategies on improving satisfaction with patient-physician communication and pain interference and reducing high-risk medication use among patients with chronic pain and opioid medication prescriptions

Study Design

This pragmatic, cluster randomized trial compared the effectiveness of two strategies to improve patient-provider communication for chronic pain management:

• Clinician Decision Support (CDS). Physicians received an alert in the electronic health record when they prescribed a high-dose opioid or opioids and benzodiazepines together. Alerts included links to prescribing guidelines and suggestions for providing education to patients.
• Patient Education and Activation Tools (PEAT). Patients received education materials by email two days before their scheduled visits. Education materials helped patients prepare for visits and encouraged discussion with their physician about their treatment preferences and goals.

Researchers randomly assigned physicians to one of the two strategies; patients received the intervention assigned to the physician.

The study included 951 patients who received an opioid prescription from one of 82 primary care physicians in the Cedars-Sinai Medical Network. Of these patients, 63% were White, 22% were Black, 6% were Asian, less than 1% were American Indian or Native Hawaiian, and 8% did not report a race or race was missing; 11% were Hispanic. The average age was 54, and 58% were female.

Patients received satisfaction surveys by mail one month after each physician visit. Researchers also sent patients monthly surveys via email that asked about pain interference and physical function. Researchers compared responses pre- and post-intervention implementation. To assess satisfaction outcomes, researchers examined the change before and after the intervention in the percentage of top-box responses, which is the percentage of respondents who gave the highest possible satisfaction score. Researchers collected data about depression and prescriptions from patients’ electronic health records.

Patients with chronic pain, patient advocacy groups, and doctors helped design and carry out the study.

Results

After one year, the two strategies did not differ significantly in patients’ pain interference, physical function, depression symptoms, or rates of prescriptions for both opioids and benzodiazepines. The PEAT strategy was nearly three times more likely to have a greater increase in the top-box response for patient-physician communication than the CDS strategy (odds ratio [OR]=2.65; 95% confidence interval [CI]: 1.03, 6.8). However, patients who received PEAT were nearly two times more likely to have a high-dose opioid prescription in the post-intervention period (OR=1.90; 95% CI: 1.3, 2.78).

Limitations

At the start of the study, patients in the two strategies differed significantly on satisfaction and opioid prescription doses. Less than 40% of patients responded to satisfaction surveys, and less than 20% responded to pain and physical function surveys. Of the 82 physicians, only 52 had complete pre- and post-intervention satisfaction data. These limitations make it difficult to draw conclusions about the comparison.

Conclusions and Relevance

Although use of PEAT and CDS was associated with some improved outcomes, study limitations make results equivocal.

Future Research Needs

Future research could use other methods to evaluate these patient-physician communication strategies about use of opioid pain medications.