A clinician training intervention to improve pain-related communication, pain management and opioid prescribing in primary care Project Summary / Abstract Increasing rates of prescription drug abuse and opioid-related deaths have led clinicians and policymakers to re-evaluate the use of opioids to treat chronic non-cancer pain. Clinicians thus face the challenge of promoting safe prescribing while also meeting their obligation to address patients' pain and maintaining positive therapeu- tic relationships, which are critical for achieving optimal medical outcomes in primary care. Communication plays a key role in both opioid prescribing (e.g., opioid dosing and tapering decisions) and in maintaining ther- apeutic relationships. Yet patients and primary care clinicians (who prescribe 65% of all opioids) report that poor communication and difficult clinical interactions are among the most important barriers to safe prescribing and effective pain management. The overall goal of this K23 proposal is to develop and pilot test a clinician training intervention that uses standardized patients (trained actors playing patient roles) as instructors who impart communication skills to primary care clinicians. The PI has collected a library of video-recorded primary care visits involving patients on opioids for chronic pain and is systematically coding and analyzing pain-related statements made during these visits. This library is a unique resource for identifying effective communication strategies to inform the design of an intervention that fosters effective pain-related communication (operational- ized as absence of high-risk prescribing and high patient agreement with treatment plans).
Aim 1 of this project is to develop an empirically-based, scalable clinician training intervention to promote effective communication about pain and opioids in primary care. To accomplish this, findings from the video library will be reviewed to identify video clips showing instances of putatively effective and ineffective communication. Primary care clini- cians and patients with chronic pain will then be interviewed to elicit their reactions to these video clips and ob- tain feedback on causes of poor communication and strategies to make communication more effective. Inter- view findings will be used to confirm key patient-centered and pain-specific communication skills that will be targeted by the standardized patient instructor intervention.
Aim 2 is to conduct a pilot RCT of the intervention developed in Aim 1 in order to evaluate intervention feasibility and estimate treatment effects to plan a subse- quent fully-powered, multisite RCT. Primary care clinicians will be randomized to receive either the intervention or control; 48 patients (2 per clinician) will then be recorded during clinic visits with study clinicians and will provide data on post-visit perceptions and health outcomes. Study hypotheses are that visits with clinicians who receive the intervention (versus control) will be associated with more frequent use of targeted communica- tion skills, lower probability of high-risk opioid prescribing, higher patient-reported agreement with treatment plan, and lower pain interference 3 months later. The planned research and training activities in this proposal will equip the PI with the skills required to become an independent investigator focused on improving patient- clinician communication about pain and decreasing high-risk opioid prescribing in primary care.
This proposal is relevant to public health because it will design and pilot test a communication intervention to improve communication about pain and decrease high-risk opioid prescribing in primary care. Therefore, it has potential to positively impact the current epidemic of opioid-related overdoses and deaths. This project advances the part of NIH's mission that relates to promoting prevention of drug abuse and addiction by supporting scientific research and discovery across a broad range of disciplines.
