With a growing epidemic of opioid abuse, dependence and deaths, a team of doctors at Northwell Health is collaborating with colleagues at the University of Pennsylvania and the Mayo Clinic to study the effectiveness of two different educational tools that could ultimately lower the risk for opioid dependence among patients who receive these medicines for pain syndromes during a hospital visit. The study is being funded by the Patient Centered Outcomes Research Institute (PCORI), an independent nonprofit, nongovernmental organization based in Washington, DC. Northwell Health (formerly North Shore-LIJ Health System) will receive $350,000 over three years.
Karin Rhodes, MD, vice president of care management design and evaluation in the Office of Population Health Management at Northwell Health, and her colleagues plan to enroll 1,200 patients (400 at each institution) who arrive in emergency departments with pain from kidney stones or lower back pain. Patients with those conditions have been traditionally prescribed opioids for pain relief, but non-steroidal, anti-inflammatory medication has been shown to work equally well for pain management.
Dr. Rhodes, an emergency medicine physician, and the two other research teams will deliver the educational intervention in two different forms – a questionnaire that assesses and provides patient with their personal level of risk for opioid addiction (low, medium or high) or the same questionnaire that also includes a videotaped narrative from a patient who began abusing opioids after receiving a prescription. As a next step, the team will track whether patients and their emergency department (ED) providers choose prescription opioids or non-steroidal anti-inflammatory medication on discharge.
“While treatment with opioids for these conditions has been a standard treatment, patients can easily become dependent on these medications without realizing it,” said Dr. Rhodes. “We want to see whether people who understand the risk, and in particular their risk, will be less likely to choose an opioid as a pain reliever. We want to balance good pain management with engaging the patient in informed decision-making to help them opt for the best choice of therapy for them.”
While there are likely genetic predispositions, no one really knows who will go on to abuse opioids. But there are well recognized risk factors, including an individual or family history of alcohol or drug abuse that should be red flags. The team has designed a visual of an opioid risk tool to show patients where they fall on the spectrum of risk for opioid dependence. The second tool the researchers are testing is a video narrative from a people who became addicted to opioids after an ED visit during which they were prescribed opioids. The narratives are true stories that have the key components of good stories – but also provide valuable information.
“Our study was inspired by one of our own nurses who became addicted after being treated with an opioid in the University of Pennsylvania emergency department for a minor injury. He began stealing drugs from work and his life spiraled out of control until he ultimately sought treatment and recovered. He wanted to share his story to make sure others are warned of the risks; people learn by stories,” said Dr. Rhodes.
The researchers are planning to deliver the randomized intervention during the patient’s emergency visit. All patients will then be asked to respond to daily text messages regarding their medication use and level of pain for one week, then weekly for the next three months. During that time, they will also be asked questions about their functional status, including information about when they are able to resume their normal activities and return to work. At three months, they will have a follow-up assessment to determine their satisfaction with their overall pain management and functional status.
The primary outcome of the study is to see how much opioid pain medication patients take and how many days they take any opioids over the three months following their ED visit. Data from the two intervention groups will then be compared to see which approach was more effective. “The study hypothesis, which is supported by our pilot data, is that people exposed to the narrative story will take fewer doses of opioid medication for fewer days without an increase in pain,” said Dr. Rhodes. “I would also not be surprised if they return to work sooner, as you cannot drive to work if you are on opioids.”
Studies have shown that 42 percent of emergency department visits are related to pain. That means that the treatment decisions made in the ED can greatly influence the events that unfold when the patient goes home. “Because pain management is tracked as a hospital quality measure in patient satisfaction surveys, there has been tremendous pressure for providers to prescribe opioids,” said Dr. Rhodes. “Individualized prevention may be the key to addressing the opioid epidemic.”
“Patients must be informed about the risks around opioid use,” said Dr. Rhodes. “Narrative communication can be an easily scalable, low-cost, sustainable method for disseminating and promoting patient engagement around health information.”
For more information on The Comparative Effectiveness of Probabilistic vs. Patient Narrative Enhanced Risk Communication for Pain Management Following Acute Care study, contact Dr. Rhodes at [email protected]. The funding award for this study has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.