Provider/Patient Education and Change Management

The opioid crisis arose in the U.S. due to aggressive pharmaceutical marketing without fully warning of their addictive qualities, a clinical focus on alleviating pain allowing pain to be elevated to the fifth vital sign and lack of regulatory constraints to prescribing. In recent years, many hospitals and health systems have recognized that physician prescribing practices have unintentionally contributed to what is now an opioid epidemic and now are taking steps to reduce prescribing of opioids and thus shut down a pipeline to potential addiction. In the meantime, physicians may feel torn between an increased awareness of the risks of addiction and their desire to reduce patients’ pain and suffering.

The Centers for Medicare and Medicaid Services has stated “primary care providers account for nearly half of all dispensed opioid prescriptions and their prescribing rates have increased at high rates compared to other specialties.” For every 1 million Americans, almost 50,000 doses of opioids are taken every day. That’s four times the rate in the UK.

The previous chapters outlined how to create an Opioid Stewardship Committee and a robust dashboard to assess and monitor performance metrics tied to opioid prescribing practices. Healthcare systems described in Chapters 1 and 2 used their dashboards to establish baseline data, identify outliers and monitor change over time. As their success grew, they evolved their dashboards to conduct increasingly sophisticated and impactful analyses. But to reach those steps, they needed to modify physician prescribing patterns and temper patient expectations.

In this chapter, we provide strategies and resources for healthcare organizations to change physician behavior. We also offer a synthesis of the literature and lessons that an Opioid Steering Committee, Opioid Task Force and others can apply to educate and engage physicians and patients.

Framework of Proposed Solutions

By establishing an Opioid Stewardship Committee and developing a dashboard, you built the foundation to achieve the next steps of creating opioid provider and patient educational programs and ensuring adoption of best practices. The discussion points in the previous chapters touched on the outcomes that result when data and dashboards are used effectively to ignite change.

That alone may not suffice. The method to ensure permanent physician behavior change requires proven techniques based on influence and a bottom-up approach. In addition, a health system must provision for additional educational resources, content and content delivery methods for physicians who prescribe opioids to their patients and for patients wishing to understand and manage their treatment plans.

To bring a program forward, your organization will need to focus on:

• engagement with physicians and patients
• education
• behavior changes

Real behavior change can happen only when physicians truly understand their prescribing tendencies. This requires awareness of prescribing habits that is informed by trustworthy data clearly presented in the dashboard. This is the first step to performance assessment and eventually to performance improvement. Some physicians may be convinced when a physician leader puts the data in front of them. Others may resist, insisting their professional experience validates their prescribing practices. One way to disprove their misconceptions (see Table 1) is to counter the assertions made with verifiable information backed up by factual data.

A physician-written article in the Harvard Business Review stated that “physicians are mesmerized by data and cannot look away.” It cited a strategy by Brent James, MD, executive director at the Institute for Health Care Delivery at Intermountain Healthcare: “Rather than make a frontal attack on physicians’ autonomy, he wears down their resistance to change by showing them how their practice varies from the norm.”

Arming providers with data and appropriateness measures can help them determine whether their prescribing behavior for opioids is consistent with peer-developed guidelines. Making prescribing data available to physicians allows them to self-correct without bringing their clinical judgment into question.

Proven steps used to self-assess prescribing behaviors and how they may align with norms are:

• Assess clinician perception by getting data on the current state through surveys or interviews about how opioids are used across the system, whether they are overused, underused and used appropriately
• Determine the opinions on the effectiveness of opioids relative to other pain management options and the safety of opioid prescription
• Ensure that the data presented to physicians is uniform and reliable so that organizational leaders can push for standardization of best practices
• Have the Opioid Stewardship Committee identify pain management studies from the literature and present the findings to the relevant service lines
• Develop reports and dashboards that analyze prescribing data that can be used by medical directors to share with clinicians to identify improvement opportunities by service line

Recommendations

It is recommended that the Opioid Stewardship Committee, staffed with physician leaders, develop an educational program that:

• Engages all physicians no matter what their prescription patterns are; the educational program should be developed to create change using face-to-face, one-on-one conversation
• Includes examples or patient stories to highlight the historical pain management culture that you are trying to change
• Engages naysayers and those who resist with additional personal training, providing them time to talk in person
• Includes analytics to drive discussions on standards, guidelines and reduce variability; reports should include benchmarking data about prescribing practice compared to physician peers
• Incorporates training into annual compliance/training program for all staff to ensure awareness
• Includes not just physicians but all clinical workforce; the educational program should include the organization’s vision and commitment to ending the opioid crisis
• Makes it local and personal; engage frontline staff about the opioid epidemic and how your health system can play a role in reversing it
• Takes a wide approach to education, offering training through online training modules, system-wide forums, peer-to-peer discussions, educational podcasts and lunch and learns
• Understands and addresses barriers by administering a “culture assessment” survey to attending physicians, residents and fellows, pharmacists and pharmacy residents, and advanced practice providers to identify issues, barriers and where prescribers need support the most
• Adds awareness and alerts into the EHR so standards are integrated into the physician’s workflow
• Launches an opioid awareness campaign focused on providers to boost engagement and awareness; campaign should partner with marketing to include newsletters, intranet communication, email blasts and community partners
• Provides CMEs and is disseminated at medical staff meetings, executive medical meetings, grand rounds

How to Achieve Permanent Behavior Change 

Education often is not enough. Real changes require permanent behavior modification, especially in physician practices where concepts and practices have remained in place for years and have become habitual. Even now with the opioid crisis fully recognized, physicians may lack awareness and familiarity with the most recent guidelines or may lack confidence to execute change. Many practicing physicians were trained in an era with set clinical methods in place with an emphasis on adequate treatment of pain and have valid concerns about harming patients by failing to prescribe sufficient analgesics.

“Educating physicians is less likely to alter their practice if it contradicts patients’ preferences. Physicians may indeed oppose any mechanism that they perceive as threatening their sense of competence or autonomy, but such threats may be overcome if the patient is the agent of change.” James L. Wofford, M.D., M.S. Wake Forest University, Winston-Salem, NC 27157-1051

“Doctors have historically seen themselves as their patients’ sole advocates, with the rest of the world divided into those who are helping and those who are in the way. Resistance in the pursuit of patients’ interests was acceptable behavior. ”

Source: “Turning Doctors into Leaders,” Harvard Business Review

To effectively change prescribing behavior, physicians must believe that the action is good for their patients, is based on best practices and can be incorporated into their practice without significant barriers. The Theory of Planned Behavior is a good model for understanding physician clinical behaviors. (See Resources for more on the Theory of Planned Behavior.)

This theory recommends using a bottom-up approach that engages physicians. The approach emphasized influence rather than authority by not threatening the physician clinical and personal autonomy. Unlike a top-down approach that needs groups of physicians to reach a consensus on new approaches to care, the bottom-up approach involves leaders using their influence to construct a vision and build a case for change that doctors can buy into. It is a more inspirational method requiring participation of the Opioid Stewardship Committee rather than imposed by administration and senior leaders. This approach coupled with data analysis brings positive behaviors that enable the outliers to achieve success. Healthy competition method stimulates physicians to work toward goals and avoids the frustration of asking physicians to reach consensus. Research demonstrates that most physicians undergo stages of change in adopting new behaviors. (See Table 4)

Guidelines and Prescribing Standards

Many professional and governmental organizations have published guidelines that reflect the most up-to-date research on pain management with best practices for opioid prescribing. The list in the Resources section provides material that assists providers through the various phases of pain management, suggests alternative therapies and recommends appropriate types and levels of medication when needed. Adoption of nationally recognized standards of care will enable clinicians to align their prescribing patterns with industry-wide best practices.

There are many resources available. including the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry, CDC Opioid Guidelines and toolkits from the American Hospital Association to assist with content development for an educational program. In addition, educational material and programming should equip physicians to engage patients who may be in different phases of addiction.   Though most patients likely will never go past phase 1 and 2, there remain too many who are at risk as they progress to addiction and possibly death.

Phase 1: No opioid use, “opioid-naïve”
Phase 2: Acute pain treatment with opioids
Phase 3: Tolerance
Phase 4: Dependence
Phase 5: Recovery

Education should not only include treatment plans and guidelines but should include scripts and advice on how to have crucial conversations with patients about their expectations for pain, options for management and need for weaning off opioids. Pain management training consists of many topics as seen in Table 5.

In addition, providers should be trained to avoid the stigma of substance disorder that could discourage patients from seeking appropriate treatment.

Patient Education with Joint Decision Making and Treatment Agreements

Prescribers should engage patients in a conversation about their expectation for pain and options for management. This requires patient education. Education should include considerations that address biopsychosocial factors with pain care:

• Defining and understanding contributing factors associated with pain
• Education on types of pain and factors that can influence or impact pain
• Differentiation of pain management strategies for acute and persistent or chronic pain
• Education on treatment options including non-pharmacological alternative methods for reducing and managing pain

It is important for care team members to direct patients to credible sources of health information, as an uninformed patient can be easily misdirected by divergent and sometimes false information available from noncredible sources. See the Resources section for a list of credible sources.

Shared decision making and use of treatment agreements will assist providers to review realistic benefits, risks and side effects (both common and serious), as well as alternative treatment options with the patient (See Table 6). Health systems and hospitals must fully support providers in helping connect patients to resources, appropriate treatment, social support and the help they need.

Table 6.

Measuring Success

The outcome of physician education and change management for opioid management would be that healthcare providers would have substantial knowledge of the current best practices for pain management.  They would begin a therapy regimen by first establishing treatment goals with all patients, including realistic goals for pain and function.  Providers would prescribe non-opioids and non-pharmacologic alternative and adjuvant treatments as first line therapies and conduct regular reviews with patients of the effectiveness of the treatment plans.  If opioid therapy is later identified as a need, providers would discuss the known risks and potential benefits of opioid therapy with their patients. The provider and patient would also consider how opioid therapy will be tapered and discontinued if its benefits do not continue to outweigh risks. Providers would begin by prescribing the lowest effective dosage of an immediate-release opioid and would avoid any extended-release formulations. Providers would conduct regular and regimented reviews of the effectiveness of the dose regimen and would monitor for adverse effects.

Key Takeaways

• Initiatives to improve opioid prescribing patterns must engage all providers. Expand access and awareness of non-opioid, opioid-sparing and non-pharmacological approaches.
• Do not develop a one-size-fits-all approach. Instead, a tailored approach based on patient type or archetypes and local needs should be utilized. This approach needs to consider differences in the types of patients being treated.
• Educate and engage physicians to use data to determine risk factors for abuse before prescribing and determine most effective care pathways and interventions to mitigate risk.
• Engage physicians to use patient-specific risk profile.
• Educate physicians on opioid use disorders.
• Determine what treatment programs are available and appropriate for each archetype. Effectively categorize patients stratified by risk and match them to the most effective treatment protocol.
• Educate providers on how to use their EHR, including using electronic prescribing for controlled substances, and equip providers with more information about the patients to whom they are prescribing pain medications.
• Use advanced analytics to define common patterns in your community and design local responses and engage local physicians. Demonstrate to providers their prescribing rate relative to their peers and how their pain management practices apply to specific episodes of care.
• Engage provider associations and state health agencies to develop and clarify guidelines and best practices.
• Explore local and community ways to educate providers and patients on appropriate disposal practices and prevent misuse.

Resources

• Healthcare professionals intentions and behaviours: A systematic review of studies based on social cognitive theories. Godin, G, Bélanger-Gravel, A, Eccles, M, Grimshaw, J. Implent Sci. 2008; 3.

The following industry-recognized and public organizations have helped to establish industry accepted guidelines and prescribing standards:

• Centers for Disease Control and Prevention (CDC) developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients in primary care settings. Recommendations focus on:
  • The use of opioids in treating chronic pain
  • Treatment options (not including cancer, palliative care, and end-of-life care)
  • Guidelines on when to initiate or continue opioids for chronic pain
  • Opioid selection, dosage, duration, follow-up and discontinuation
  • Assessing risk and addressing adverse impact of opioid use
• SAMHSA, TIP 63 MEDICATIONS FOR OPIOID USE DISORDER
  • Medications for Opioid Use Disorder treatment
  • Addressing Opioid Use Disorder in general medical settings
  • Pharmacotherapy for Opioid Use Disorder
• AMA, Stem the Tide Addressing the Opioid Epidemic
  • Clinician education on prescribing practices
  • Non-opioid pain management
  • Addressing stigma
  • Patient, family and caregiver education
  • Safeguarding against diversion
  • Collaborating with communities

Listed here are examples of credible sources of reliable patient educational content:

• National Center of Biotechnology Information
• Turning the Tide: For Patients – a website with education material for patients by former U.S .Surgeon General Vivek Murthy, MD
• The S. Food and Drug Administration website provides information on opioids, a consumer’s Guide to Safe Use of Pain Medication, as well as a List of Questions patients should ask their provider. Safe disposal instructions can also be found on the website
• Lock Your Meds Campaign is an opioid safety campaign including educational focus on adult awareness prescription medications storage and safety.
• What Patients Should Ask Prescribers Before Taking Opioids is a good educational tool for Patients.
• The FDA has guidance on Disposal of Unused Medications including DEA-Authorized Take Back Programs, and how to dispose of medication.

Listed here are examples of credible sources of reliable patient educational content:

• National Center of Biotechnology Information
• Turning the Tide: For Patients – a website with education material for patients by former U.S .Surgeon General Vivek Murthy, MD
• The S. Food and Drug Administration website provides information on opioids, a consumer’s Guide to Safe Use of Pain Medication, as well as a List of Questions patients should ask their provider. Safe disposal instructions can also be found on the website
• Lock Your Meds Campaign is an opioid safety campaign including educational focus on adult awareness prescription medications storage and safety.
• What Patients Should Ask Prescribers Before Taking Opioids is a good educational tool for Patients.
• The FDA has guidance on Disposal of Unused Medications including DEA-Authorized Take Back Programs, and how to dispose of medication.

Anne Arundel Medical Center in Maryland made physician education a key component in its effort to reduce opioid prescribing. Their strategy included:

• departmental grand rounds
• service meetings with data review
• circulation of medical journal articles with information on overprescribing

Their dashboard displayed individual clinician prescribing compared with peers, which created a foundation for medical directors to have one-on-one discussions with prescribers to reinforce the key points of the education and review individual prescribing data and comparison with peers. The data points initially were blinded, which created a nonthreatening environment in which clinicians could strive to change. At the same time, the benchmarking and tracking data fed into some physicians’ competitive spirit, prompting them to make deliberate changes in their prescribing behavior to improve their ranking.

To address physicians’ concern about patient satisfaction, Anne Arundel Medical Center presented internal and published data showing no diminishment in patient satisfaction with lower opioid prescribing. Physicians who embraced lower prescribing strategies early on shared anecdotes of grateful patients who appreciated discussions about nonopioid alternatives, which eased other clinicians’ concerns.

“Opioid overprescribing is falling in multiple areas of our health system, with no decline in patient satisfaction with pain management, or return visits to the Emergency Department due to under treatment. This success is based on concerted efforts of hundreds of physicians who altered their customary mode of practice over hundreds of thousands of patient visits, surgeries and hospital discharges.”

Barry Meisenberg, MD, lead on Anne Arundel Medical Center’s Opioid Taskforce

Source: Living Healthier Together, a publication of the Anne Arundel Medical Center

Keys to Success

• Begin by making sure all stakeholders are educated about the program and its goals.
• Review data periodically to discuss progress and opportunities for improvement. Hold one-on-one discussions between a medical director and physician to review the physician’s performance compared to peers.
• Using blinded data at first creates a nonthreatening environment.

Community Health Center Inc. is a multisite federally qualified health center in Connecticut that provide primary care services for more than 140,00 medically underserved patients. The health center has a fully integrated EHR for medical, dental and behavioral healthcare. They recognized that their patient population was impacted by chronic pain and that their primary care providers had limited resources and faced time constraints for dealing with patients receiving chronic opioid therapy. To help clinicians adhere to practice guidelines, they developed a dashboard to support opioid management based on current practice guidelines. The guidelines required patients receiving chronic opioid therapy have:

• an opioid treatment agreement
• routine urine drug screening
• routine reassessments of pain and functional status
• recommended co-management with a behavioral health provider

Providers were required to review Community Health Center’s opioid management policy at employment annual review of this policy. Providers had access to a dashboard that displayed their rate of guideline adherence as well as other statistics and the ability to drill down by patient. Each week physicians and their teams received a Missed Opportunity Report listing patients who in the week prior had not received one of the guideline recommendations.

Based on study data collected before and after implementation of the dashboard, Community Health Center observed increased use in each of the recommendations. They also noted a decline in the percentage of patients prescribed opioids over the one-year period. They attributed the program’s success to several possible factors, including:

• Clear and actionable data presented in the dashboard
• Team review of the data, which motivated support staff and physicians to adhere to the guidelines
• Continual performance feedback, which may have sparked competitive desire to improve

Keys to Success:

• Making the opioid management guideline transparent and available online for providers to easily access it.
• Designing a dashboard with clearly presented data.
• Giving providers the ability to use dashboards to identify gaps in patents’ and plan care.
• Use of Missed Opportunities Report.
• Using the dashboard as a collaborative tool for support staff and physicians to foster a team approach to patient care.