Skip to main content

Advertisement

Log in

Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices.

DESIGN: Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars.

MEASUREMENTS: Consecutive pharmacy and billing records of patients who were cared for by medical residents (n=733) and a comparison group of neurology and rehabilitative medicine patients (n=273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs).

MAIN RESULTS: The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline.

CONCLUSIONS: This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents’ opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Cleeland C, Gronin R, Hatfield A, Edmonson J, Blum R, Stewart J. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592–6.

    Article  PubMed  CAS  Google Scholar 

  2. Agency for Health Care Policy and Research. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. Rockville, MD: United States Department of Health and Human Services, Public Health Service; 1992. AHCPR Publication No. 92-0032.

    Google Scholar 

  3. Jacox A, Carr D, Payne R. Management of Cancer Pain. Clinical Practice Guideline No.9. Rockville, Md: Agency for Health Care Policy and Research, United States Department of Health and Human Services, Public Health Service; 1994.

    Google Scholar 

  4. Cherny N, Portenoy R. The management of cancer pain. CA Cancer J Clin. 1994;44:263–303.

    PubMed  CAS  Google Scholar 

  5. Foley K. The treatment of cancer pain. N Engl J Med. 1985;313:84–95.

    Article  PubMed  CAS  Google Scholar 

  6. Ingham J, Foley K. Pain and the barriers to its relief at the end of life: a lesson for improving end of life health care. Hosp J. 1998;13:89–100.

    PubMed  CAS  Google Scholar 

  7. Bressler LR, Geraci MC, Schatz BS. Misperceptions and inadequate pain management in cancer patients. DICP. 1991;11:1225–30.

    Google Scholar 

  8. Ferrell B, Wisdom C, Rhiner M, Alletto J. Pain management as a quality of care outcome. J Nurs Qual Assur. 1991;5:50–8.

    PubMed  CAS  Google Scholar 

  9. Portenoy R, Thaler H, Kornblith A. Symptom prevalence, characteristics and distress in a cancer population. Qual Life Res. 1994;3:183–9.

    Article  PubMed  CAS  Google Scholar 

  10. Oneschuk D, Fainsinger R, Hanson J, Bruera E. Assessment and knowledge in palliative care in second year family medicine residents. J Pain Symptom Manage. 1997;14:265–73.

    Article  PubMed  CAS  Google Scholar 

  11. Sees KL, Clark HW. Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage. 1993;8:257–64.

    Article  PubMed  CAS  Google Scholar 

  12. Weissman DE. Doctors, opioids, and the law: the effect of controlled substances regulations on cancer pain management. Semin Oncol. 1993;20:53–8.

    PubMed  CAS  Google Scholar 

  13. Hill CS. Pain management in a drug oriented society. Cancer. 1989;63:2383–6.

    Article  PubMed  Google Scholar 

  14. Field M, Cassel C. Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press; 1997:258–67.

    Google Scholar 

  15. Grossman S, Sheidler V. Skills of medical students and house officers in prescribing narcotic medications. J Med Educ. 1985;60:552–7.

    PubMed  CAS  Google Scholar 

  16. Ogle KS, Mavis B, Rohrer J. Graduating medical students’ competencies and educational experiences in palliative care. J Pain Symptom Manage. 1997;14:274–9.

    Article  Google Scholar 

  17. Weissman DE, Ambuel B, Norton AJ, Wang-Cheng R, Schiedermayer D. A survey of competencies and concerns in end-of-life care for physician trainees. J Pain Symptom Manage. 1998;15:82–90.

    Article  PubMed  CAS  Google Scholar 

  18. Billings AJ, Block S. Palliative care in undergraduate medical education. JAMA. 1997:278:733–8.

    Article  PubMed  CAS  Google Scholar 

  19. Weissman DE, Griffie J. Integration of palliative medicine at the Medical College of Wisconsin 1990–1996. J Pain Symptom Manage. 1998;15:195–201.

    Article  PubMed  CAS  Google Scholar 

  20. Jones JB. Assessment of pain management skills in emergency medicine residents: the role of a pain education program. J Emerg Med. 1999;17:349–54.

    Article  PubMed  CAS  Google Scholar 

  21. Dalton JA, Blau W, Carlson J, et al. Changing the relationship among nurses’ knowledge, self-reported behavior, and documented behavior of pain management: does education make a difference? J Pain Symptom Manage. 1996;12:308–19.

    Article  PubMed  CAS  Google Scholar 

  22. Von Roenn JH, Neely KJ, Curry RH, Weitzman SA. A curriculum in palliative care for internal medicine housestaff: a pilot project. J Cancer Educ. 1988;3:259–63.

    Article  Google Scholar 

  23. Sloan PA, Donnelly MB, Schwartz RW, Sloan DA. Cancer pain assessment and management by housestaff. Pain. 1996;67:475–81.

    Article  PubMed  CAS  Google Scholar 

  24. Janjan NA, Martin CG, Payne R, Dahl JL, Weissman DE, Hill CS. Teaching cancer pain management: durability of educational effects of a role model program. Cancer. 1996;77:996–1001.

    Article  PubMed  CAS  Google Scholar 

  25. Bordage G. The curriculum: overloaded or too general. Med Educ. 1987;21:183–8.

    PubMed  CAS  Google Scholar 

  26. Bordage G, Lemieux M. Semantic structures and diagnostic thinking of experts and novices. Acad Med. 1991;66:S70–2.

    Article  PubMed  CAS  Google Scholar 

  27. Chapman C, Foley K. eds. Current and Emerging Issues in Cancer Pain: Research and Practice. New York: Raven; 1993:321–30.

    Google Scholar 

  28. Neely J. The effects of analgesic drugs on gastro-intestinal motility in man. Br J Surg. 1969;56:925–9.

    Article  PubMed  CAS  Google Scholar 

  29. Forman WB. Opioid analgesic drugs in the elderly. Clin Geriatr Med. 1996;12:489–500.

    PubMed  CAS  Google Scholar 

  30. Benson MJ, Roberts JP, Wingate DL, et al. Small bowel motility following major intra-abdominal surgery: the effects of opiates and rectal cisapride. Gastroenterology. 1994;106:924–36.

    PubMed  CAS  Google Scholar 

  31. Ury W, Reznich C, Weber C. A needs assessment for a palliative care curriculum. J Pain Symptom Manage. 2000;20:408–16.

    Article  PubMed  CAS  Google Scholar 

  32. Expert Working Group of the European Association for Palliative Care. Morphine in cancer pain: modes of administration. BMJ. 1996;312:823–6.

    Google Scholar 

  33. American Pain Society. Practice Guidelines for the Treatment of Cancer Pain. Glenview, Ill: American Pain Society; 1996.

    Google Scholar 

  34. Sherman S, Lehman GA. Opioids and the sphincter of oddi. Gastrointest Endosc. 1994;40:105–6.

    Article  PubMed  CAS  Google Scholar 

  35. Elta GH, Barnett JL. Meperidine need not be proscribed during sphincter of oddi manometry. Gastrointest Endosc. 1994;40:7–9.

    Article  PubMed  CAS  Google Scholar 

  36. Sherman S, Gottlieb K, Uzer MF, et al. Effects of meperidine on pancreatic and biliary sphincter. Gastrointest Endosc. 1996;44:239–42.

    Article  PubMed  CAS  Google Scholar 

  37. Harper AC, Roy WB, Norman GR, Rand CA, Freightner JW. Difficulties in clinical skills evaluation. Med Educ. 1983;17:24–7.

    Article  PubMed  CAS  Google Scholar 

  38. Ury WA, Tesar CM, Burton WB. Brief case-based inpatient palliative care teaching modules: an effective method of introducting new medical topics. J Gen Intern Med. 1999;16:29.

    Google Scholar 

  39. Wakeford R, ed. Directions in Clinical Assessment. Cambridge, England: Cambridge University School of Medicine; 1985:97–104.

    Google Scholar 

  40. Landy FJ, Farr JL, Performance rating. Psychol Bull. 1980;87:72–107.

    Article  Google Scholar 

  41. Mash EJ, McElwee JD. Situational effects on observer accuracy: behavior prediction, prior experience, and complexity of coding categories. Child Dev. 1974;45:367–77.

    Article  Google Scholar 

  42. Joint Commission Resources, Inc. Pain Assessment and Management: An Organizational Approach. Oakbrook Terr., Ill: the Joint Commission on Accreditation of Healthcare Organizations; 2000.

    Google Scholar 

  43. Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA 2000;284:428–9.

    Article  PubMed  CAS  Google Scholar 

  44. Donabedian A. Promoting quality through evaluating the process of patient care. Med Care. 1968;6:181–202.

    Article  Google Scholar 

  45. Rutala PJ, Stillman PL, Sabers DL. Housestaff evaluation using patient instructors: a brief report. Ariz Med. 1981;38:531–2.

    PubMed  CAS  Google Scholar 

  46. Stillman PL, Burpeau-Di Gregorio MY, Nicholson GI, et al. Six years of experience using patient instructors to teach interviewing skills. J Med Educ. 1983;58:941–6.

    PubMed  CAS  Google Scholar 

  47. Cook TD, Campbell DT. Quasi-Experimentation. Design and Analysis Issues for Field Settings. Boston: Houghton Mifflin; 1979.

    Google Scholar 

  48. Ray WA. Policy and program analysis using administrative databases. Ann Intern Med. 1997;127:712–8.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Wayne A. Ury MD.

Additional information

Support for this research was received from The Altman Foundation, Wayne A. Ury is a Faculty Scholar of the Open Society Institute and the Project on Death in America.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ury, W.A., Rahn, M., Tolentino, V. et al. Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?. J GEN INTERN MED 17, 625–631 (2002). https://doi.org/10.1046/j.1525-1497.2002.10837.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2002.10837.x

Key words

Navigation