Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?
BACKGROUND
Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices.


METHODS
Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars.


METHODS
Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs).


RESULTS
The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline.


CONCLUSIONS
This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.
Ury
Wayne A
WA
Saint Vincent's Catholic Medical Centers of New York, Manhattan Campus, New York, NY 10011, USA. WURY@AOL.COM
Rahn
Maike
M
Tolentino
Victorio
V
Pignotti
Monica G
MG
Yoon
Janet
J
McKegney
Patrick
P
Sulmasy
Daniel P
DP
D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D002908:Chronic Disease; D003479:Curriculum / Q000592:standards*; D011307:Drug Prescriptions; D017723:Drug Utilization Review; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D016015:Logistic Models; D008297:Male; D008614:Meperidine / Q000009:adverse effects; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy*; D010166:Palliative Care; D019338:Polypharmacy
D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D008614:Meperidine