Although opioid prescribing and opioid overdose are very important topics in pain management medicine, there are not enough pain management specialists to handle all the patients in need. For a paper published in The Clinical Journal of Pain, my colleagues and I examined a program (Pain E-Consult Program [PEP]) that was developed to educate non-pain management specialist opioid prescribers on how to treat patients with these medications. Dubbed the “ECHO Model,” the education formula used was derived from the United States military for care of Veterans Administration beneficiaries and service members in all branches of the military. This type of education had not been widely used in non-military healthcare settings.
We sought to determine if opioid use decreased among patients seen by clinicians who received education through PEP. We also wanted to determine if patients had other utilization increases in non-opioid pain management medications and they were receiving relief from non-medication care that was related to their pain.
Assessing Patients With Pain Consults
We conducted a retrospective, matched, cohort study in an integrated healthcare delivery system and identified the patients of clinicians who had received education through the PEP (observation group). We then identified other patients who had pain consults with non-PEP primary care providers (control group/usual care). Adult patients (125 in the observation group and 540 in the control group) without cancer and with a 90-day morphine milligram equivalent (MME) of 30 mg/day or greater between April 1, 2016 and June 30, 2017 were included.
Patients were primarily female, white, and Medicare beneficiaries. The observation group had a greater decrease in median MME/day during the 6-month (-7.4 mg vs 1.5 mg) and 12-month (-15.1 mg vs -2.8 mg) follow-up periods and higher rates of patients with at least a 20% decrease in MME/day (6-month, 41.6% vs 24.6%; 12-month, 48.0% vs 32.6%; Table). We observed no differences in rates of initiation of non-opioid alternative medications.
Nearly Double the Reduction in Opioid Use
Based on our observations, my colleagues and I concluded that it was not necessary for pain management specialists to directly see patients for whom opioid medications have been prescribed. Instead, they can educate other prescribers—such as primary care physicians and advanced nurse practitioners—about using opioids more appropriately in the sense that these prescribers can reduce opioid use and try other non-opioid medications or non-medication therapies. As aforementioned, there are not enough pain management specialists, specifically non-cancer pain specialists, to manage all the patients who require pain management care, nor non-pain specialists who can safely prescribe opioids and help reduce their overuse.
For this study, we had to identify non-military patients and their physicians who had and had not received education from the PEP, which created the potential for confounding issues. In addition, we were not able to obtain pain scale measurements on these patients, assessing only opioid reductions, and, thus, were unable to address whether their pain was better managed by clinicians in the observation group. We would ideally like to see a trial conducted where patients are randomized to prescribers who did and did not receive education from the PEP to remove potential confounders and assess pain control.
The reduction of opioid use and the safe prescribing of opioids is of great importance to the field of pain management. For pain management specialists, perhaps being more involved in case-based learning and the telemonitoring of other clinicians may allow them to increase access to pain management resources.
Martta Kelly