Opioid Prescribing: Interventions to Improve Guideline Adherence
Opioid analgesics are commonly prescribed to treat chronic noncancer pain, despite limited evidence indicating that opioids are safe and effective for this modality.
Opioid analgesics are commonly prescribed to treat chronic noncancer pain (CNCP), despite limited evidence indicating that opioids are safe and effective for this modality.1,2 In Australia, approximately 70% of opioid prescriptions are dispensed to patients to address CNCP.1 Prescription of opioids to manage CNCP is also inconsistent with current guidelines, which advise against their use in routine care.1,2
A team of Australian researchers recently developed a training program on opioid prescribing for general practice registrars (GPRs) to improve adherence to guidelines on opioid prescribing for CNCP.1 Registrars are physicians at the early stage of their career who work under the supervision of more experienced practitioners. This program aimed to decrease the number of initial opioid prescriptions and encourage deprescribing for patients already taking opioids. The training activity started with an online reading session of relevant material, which was followed by a 90-minute in-person educational workshop. After the workshop, participants had access to a variety of online resources, including videos and information sheets for patients.
Approximately 250 GPRs participated in the training activity, and 600 practitioners were used as controls. The training activity had no significant effect on GPRs' overall opioid prescribing. In fact, the study observed a nonsignificant increase in opioid prescribing during the study. However, when GPRs were presented with clinical vignettes and asked about opioid prescribing, the proportion willing to initiate opioids for a patient with CNCP declined significantly from 74.5% before the training activity to 51.1% afterward. The proportion of GPRs who said they would deprescribe opioid maintenance for the CNCP patient in the vignette significantly increased from 80.4% before training to 95.7% afterward.
The authors wrote, "Our interpretation of the discordant results of these concurrent 'hypothetical' and 'actual' prescribing studies of the same training activity is that the translation of changes in knowledge, attitude, and clinical judgment from a theoretical paper-based setting to actual practice is problematic." They noted that data showed newer practitioners often reported difficulty managing patients with CNCP, who, in desperation, may resort to intimidation, humiliation, or threats to harm themselves. "The distress or shame from a threatened or received complaint engenders more defensive medicine," the authors wrote. Many GPRs also struggle with their own compassionate desire to ease their patients' suffering. A limitation of the study is the possible influence of supervisors on the GPRs' decisions about opioid prescribing. "Their supervisors, senior colleagues, or specialists may have initiated or regularly prescribed the medication, and, seemingly, mandated their continuation," the authors explained.
The obstacles in translating knowledge about the risks of inappropriate opioid prescribing into practice suggests the need for interventions to better educate GPRs on how to handle difficult conversations with patients with CNCP. The authors said practice-level interventions may also be needed to reduce inappropriate opioid prescribing for CNCP. They proposed improving patient education, prescription monitoring, mandatory documentation of guideline adherence, and disciplinary action for unethical prescribing of opioids.
Summary and Clinical Applicability
Opioids are frequently prescribed for chronic noncancer pain (CNCP) despite a lack of evidence supporting their use. An educational intervention for general practice registrars in Australia failed to reduce real-world opioid prescribing for CNCP. Conversely, when hypothetical patient vignettes were used with the same educational intervention, the registrars indicated a willingness to reduce opioid prescriptions. The authors of the study concluded that educational interventions may need to include components that instruct new practitioners on how to handle difficult conversations about opioids with patients who have CNPC.
Limitations and Disclosures
A limitation of the study is the authors' inability to distinguish reliably between opioid prescriptions for CNCP and prescriptions for acute or end-of-life pain, which may have biased the results. Another limitation is that registrars stay only 6 to 12 months at a practice, which may not allow sufficient time to explore tapering and cessation. The study may also have been underpowered on the endpoint of opioid initiation.
One of the authors (Chris Hayes) has consulted for Mundipharma, Janssen, and Pfizer. No other conflicts of interest were reported.
- Holliday SM, Hayes C, Dunlop AJ, et al. Dose brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners. Pain. 207;158:278-288. doi: 10.1097/j.pain.0000000000000755
- Franklin GM; American Academy of Neurology. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83:1277-1284. doi: 10.1212/WNL.0000000000000839