When Samuel Ofei-Dodoo, Ph.D., started looking into the opioid crisis, he learned it isn’t unusual for patients addicted to the powerful narcotics to act aggressively toward their physicians.

“Patients who are dependent on opioids often become agitated and desperate if their requests for opioids for noncancer pain are denied. There are reports where physicians, especially those working in emergency departments, have been physically assaulted at work,” said Ofei-Dodoo, associate professor and director of research administration at KU School of Medicine-Wichita.

That type of behavior sometimes contributes to physicians prescribing opioids without following proper procedures. But a training program for first-year KU Wichita residents appears to better prepare physicians to manage patients seeking opioids.

Ofei-Dodoo and four colleagues recently published a peer-reviewed article about the program in Family Medicine, an official journal of the Society of Teachers of Family Medicine. The chronic pain management educational program “was associated with improvements in perceived sense of comfort, knowledge and concerns in assessing and managing patients who use opioids for chronic noncancer pain,” the paper concluded. The article’s four co-authors were Sheryl Beard, M.D., chief medical officer at Ascension Via Christi; Amy Curry, M.D., clinical associate professor with KU School of Medicine-Wichita Family Medicine Program at Ascension Via Christi Hospitals; Tiffany Shin, Pharm.D., clinical assistant professor with KU School of Pharmacy-Wichita; and Ruth Nutting, Ph.D., director of behavioral health at Ascension Via Christi.

Ofei-Dodoo said the CPM training grew out of a conversation he had with Beard about the opioid crisis in the United States. One of the first pieces of data he came across was the reported 254 million opioid prescriptions dispensed in the nation during 2014, accompanied by spikes in overdoses and deaths. It was estimated that nearly a third of patients were misusing opioids, Ofei-Dodoo said. “About 30% of patients who are prescribed opioids to manage chronic pain use it for nonchronic purposes.”

In 2016, the U.S. Centers for Disease Control and Prevention came out with best practices guidelines for safe opioid prescribing. But, as Ofei-Dodoo noted, “physician utilization of the guidelines was very low. We decided let’s find why that is.”

That same year, KU Wichita Family Medicine Residency at Ascension Via Christi did a needs assessment of residents with respect to opioid prescribing.

“We were surprised at the results,” Ofei-Dodoo said. “Lack of confidence in managing patients seeking opioids for pain, lack of knowledge regarding how to appropriately prescribe opioids, and fear of denying analgesics to patients in pain were found to be the major concerns for residents regarding the assessment and management of ambulatory patients requesting opioids for chronic pain.”

“These findings got our attention,” he said. “So, we decided to come out with a skill-based educational program to train our residents on how to safely prescribe opioids, especially to noncancer patients.”

Several physicians and a pharmacist were consulted in designing the CPM training. It started with reading assignments regarding the CDC guidelines for prescribing opioids and information regarding risks and benefits of opioid therapy and lectures that cover things like the requirement that physicians must first prescribe nonopioids for chronic noncancer pain; must check K-TRACS, Kansas’ prescription drug monitoring program, before prescribing an opioid to make sure a patient isn’t attempting to get the drug from more than one physician; and must negotiate a “controlled substance agreement” with a patient who is prescribed an opioid. The residents then see standardized patients mimicking patients who are seeking opioids for non-medical purposes.

Residents were assessed on their level of knowledge, confidence and comfort level in CPM at three different time periods in the program. Ofei-Dodoo said there was clear improvement in perceived sense of comfort, knowledge and concerns in assessing and managing patients who use opioids for chronic noncancer pain.

“We saw that the residents comfortably negotiated a controlled substances agreement with a patient, as well as denied analgesics to those who did not need controlled substances.”

Family medicine resident Holly Burt, M.D., called the chronic pain management training “one of the best skills labs I had.” Residents regularly see chronic pain patients in their clinical rounds and Burt knows they will eventually be part of her family medicine practice.

“It helps us gauge how best to help them,” she said. “It helps us also see if there are some other pathologies like depression or substance abuse, which we need to address.”

One technique that residents are taught is to have patients rate on a scale of 1 to 10 how pain affects their daily activities. Comparing scores from subsequent visits allows the patient and physician to see where there’s been improvement and what needs attention.

Burt said the training made her more sensitive.

“Oh, absolutely. Pain is a very subjective thing. Everybody’s pain is different. That’s hard to understand.”

Seeing standardized patients was part of the training. One woman portrayed a patient who became emotional when Burt suggested alternatives to opioids.

Burt said such conversations are sometimes difficult, but the training better prepared her to handle them.

“They were excellent playing that emotional role. I think it’s natural for people to get defensive. They’re trying to figure out how best to help themselves, but addiction is a big concern.”

Some patients are unaware of alternatives such as nonopioid medications, physical therapy, osteopathic manipulation and acupuncture, Burt said. They also may not realize that opioids come with side effects.

“These conversations usually go over well once you step back and explain your concerns to the patient,” she said. “Also, to verify that you hear their concerns and feelings.”

Burt added, “I think our chronic pain management training serves as a way to focus on patient-centered care as well as teaching us to develop our boundaries in medicine, which is also very important.” 

The CPM training was completed by 72 first-year residents over four years and is now an established part of the Family Medicine Residency program's curriculum. The full article that appeared in Family Medicine can be found at Improving First-Year Family Medicine Residents’ Confidence in Safe Opioid Prescribing Through a Multiactivity Educational Program (stfm.org).