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Prescribers or Multidisciplinarians? An Evaluation of Brief Education for General Practitioners on Chronic Pain Management

Active pain self-management (PSM) for patients with chronic pain (CP) is assumed to require multidisciplinary care, leaving prescribing analgesics the most accessible option for general practitioners (GPs). As such, we sought to upskill GPs in multimodal PSM with a harm minimisation approach for any opioid prescribing. Having developed an educational training resource, a multidisciplinary team (MDT) delivered the program to attendees at a GP conference in 2017. The educational package comprised pre-readings, a six-hour interactive, skills-based workshop, and post-workshop resources. The single-group intervention was evaluated with an original and unvalidated pre-/post-test (three months) survey of four domains: knowledge, attitudes, utilisation of strategies involving PSM and opioid harm minimisation. Paired t-tests were conducted on each domain score and overall, with effect sizes assessed using Cohen’s d. A sensitivity analysis was performed on the data lacking a post-test survey response. Post-survey scores were imputed using chained regression equations, then paired t-tests analyses were conducted on imputed datasets using Rubin’s method to pool estimates. Of 99 participants, 33 returned both surveys for primary analysis. These were combined in the sensitivity analysis with 60 unpaired surveys with modest internal consistency (Cronbach’s alpha 0.736). Primary analysis demonstrated significant selfreported improvements in each educational domain, with the overall score increasing 10.54 points out of 130 (p < 0.001, Cohen’s d 1.11). Improvements were similar in a sensitivity analysis. This study found that a brief GP educational package might be a viable intervention for facilitating PSM and promoting safer prescribing strategies. Outcomes at three months, from this unvalidated survey instrument, suggest improvements in knowledge, attitudes and self-reported facilitation of PSM and opioid prescribing. As this study did not measure clinician behaviour or patient outcomes objectively, further Health Education in Practice: Journal of Research for Professional Learning Vol. 3 | No. 1 | 2020 Research & Evaluation article (double blind peer-review) Copyright is held by the authors with the first publication rights granted to the journal. Conditions of sharing are defined by the Creative Commons License Attribution-ShareAlikeNonCommercial 4.0 International Citation: Holliday, S, Hayes, C, Jones, L, Gordon, J, Fraser, C, Harris, N, Nicholas, M, Holder, C, Oldmeadow, C & Magin, P 2020, ‘Prescribers or Multidisciplinarians? An Evaluation of Brief Education for General Practitioners on Chronic Pain Management’, Health Education in Practice: Journal of Research for Professional Learning, vol. 3, no. 1 http://dx.doi.org/10.339 66/hepj.3.1.14146


BACKGROUND
Pain is common, experienced in the last month by most (68%) adults in Australia, with 15% reporting recurrent or persistent pain in the previous six months (Miller et al. 2017). General practitioners (GPs) often manage chronic pain (CP) as if it were an acute condition and focus on elimination of pain rather than promotion of functional restoration (Schneiderhan, Clauw & Schwenk 2017;Semple & Hogg 2012;Sullivan & Ballantyne 2016). Historically, pain management education has been advocacy driven. Professor Emeritus John Bonica championed the multidisciplinary team (MDT) combined with interventional approaches (Loeser 2017), and Dame Cicely Saunders (1978), of the hospice movement, taught how the multifaceted nature of pain in terminal illness required attention to social, psychological and spiritual distress along with liberal access to opioid analgesics. Liberal access-appropriate in palliative care practice-was promoted for all patients for 'under-treated' non-cancer CP by pain specialists and commercial interests, despite a lack of clear scientific evidence (Sullivan & Ballantyne 2016). Pharmaceutical manufacturers underwrote pain advocacy organisations, medical societies, medical education and guideline development to influence prescribing culture (Davis & Carr 2016; Organisation for Economic Cooperation and Development [OECD] 2019). Continuing medical education (CME) for CP claimed that 'judicious' opioid prescribing strategies could prevent prescription opioid analgesic (POA) patients from being transformed into addicts (Dyer 2019; Kertesz & Gordon 2018;Kuehn 2017;Madras 2018;OECD 2019). A composite model of CP care soon emerged, highlighting specialist multidisciplinary and interventional care combined with opioids titrated to symptoms (Sullivan & Ballantyne 2016).
Consequently, over the last three decades, the availability of POAs has boomed across the Western world (OECD 2019). Iatrogenic harms such as opioid-related deaths (ORDs) increased an average of 20% across 25 OECD (2019) countries. In the United States (US), opioid prescribing escalated over 300% (Madras 2018), with over one-third (37.8%) of adults reporting POA use during 2015 (Han et al. 2017). In America, drug poisonings (predominantly ORDs) are now the leading contributor to reduced gains in life expectancy (Dowell et al. 2017;OECD 2019). The situation in Australia is similar, with POA dispensing increasing 15-fold from 1992 to 2012 (Blanch, Pearson & Haber 2014). An estimated 16% of adult Australians are being dispensed a POA annually (Lalic et al. 2019), with a 10-fold variation in prescribing rates across the nation (Australian Commission on Safety and Quality in Health Care 2015). Past or current POA misuse is common and, in 2016, was reported by 11% of adults (Australian Institute of Health and Welfare 2018). In the decade leading to 2016, the rate of ORDs almost doubled to three each day with over three-quarters involving POAs (Australian Institute of Health and Welfare 2018; Department of Health 2019). Tapering or termination of long-term POAs may actually increase ORDs without the introduction of active pain self-management (PSM) as well as strategies used for opioid maintenance in dependency (James et al. 2019).
The World Health Organization recently discontinued two CP guidelines due to the emerging science supporting non-pharmaceutical strategies, as well as reports of conflicts of interest involving the experts who developed the guidance (Dyer 2019). Evidence informed CP management emphasises non-pharmacological and noninvasive PSM (a multidisciplinary engagement with multimorbidity), the non-initiation or deprescribing of opioids, and a harm minimisation approach to addictive pharmacotherapies (Australian Commission on Safety and Quality in Health Care 2015; Department of Health 2019; Hogans et al. 2018;Holliday et al. 2018;Malfliet et al. 2019;Manhapra & Becker 2018). The shift away from POAs reflects concerns about harms including pre-clinical research that indicates opioids may intensify and prolong GP care may be less expensive than specialist MDTs, but considering the costs of lost earnings and productivity, GP care is less cost-effective (Deloitte Access Economics 2019; Lin et al. 2011;Semple & Hogg 2012). Cost-effectiveness may be improved with the addition of PSM, whether delivered by a GP or accessed by referral (Lin et al. 2011). To date, there have been no direct comparisons of multidisciplinary care against a biopsychosocial approach taken in a monodisciplinary setting (Malfliet et al. 2019), so we simply do not know which approach is more cost-effective. However, we can make some assumptions based on what we know. For example, the prevalence of CP and opioid consumption is higher in populations with demographics characterised by low levels of education, low income, rurality and complex psychosocial issues (Hardman, Lawn & Tsourtos 2018). Such populations are less willing or able to access specialist MDTs and are more likely to dropout from PSM (Hardman, Lawn & Tsourtos 2018). That said, GPs offer greater geographical and financial accessibility along with opportunistic and longitudinal care. This may explain why population-level research shows strengthening of the GP sector improves many health outcomes, including mortality (Basu et al. 2019).
In the US, the National Institutes of Health has committed to developing and disseminating non-addictive pain management strategies integrated with the prevention and treatment of addiction (Kuehn 2017). In Australia, the Department of Health (2019) has called for action to translate best practice CP management into primary care to make it accessible. The department identified a need for short training courses for GPs, which featured engagement activities such as webinars and workshops (Department of Health 2019). To equip GPs to address the biopsychosocial under-treatment of CP and to minimise the unsafe provision of POAs, our MDT developed training, compatible with standard CME scheduling, promoting strategies deliverable within routine clinical workflow. As the authors are not aware of any evaluations of similar training, we undertook this study.

METHODS
This paper describes a questionnaire-based evaluation of a pragmatic educational intervention, using a pre-/post-test design without a control group. Our working group included a pain physician (CHa), a pain physiotherapist (LJ), a clinical psychologist (MN) and a psychiatrist (NH)-all of whom specialise in CP-as well as three non-pain specialised GPs. All the GPs worked in private practice-two with special interests in mental health (CF and JG) and one as a rural GP and addiction physician (SH).
The project was named 'Time-efficient Management of Pain in the Office' (TEMPO). It was designed to promote positive, active pain care involving multiple PSM micro-interventions delivered longitudinally during standard GP consultations. Reliance on safety strategies, derived from a non-pain dependency model, was recommended for any provision of POAs. Content advice was also received from the pain and addiction specific interest groups within the Royal Australian College of Holliday et al. General Practitioners (RACGP). During 2016-2017, the TEMPO package was delivered and refined in a webinar and at four conferences, and was specifically accredited by the RACGP as an 'active learning module' (ALM). Every three years, Australian GPs are required to obtain CME credits from such a module in which two-thirds of a six-hour workshop involves active learning exercises. Participants in this study were emailed readings before the workshop (Holliday & Jammal 2015;Lack 2016;Schneiderhan, Clauw & Schwenk 2017), directed to relevant websites such as the NSW Health ACI Pain Management Network (https://www.aci.health.nsw.gov.au/chronic-pain) or the Hunter Integrated Pain Service (http://www.hnehealth.nsw.gov.au/Pain/Pages/Health professionals.aspx). Online CME and patient education resources were provided subsequently as published in detail previously (Holliday et al. 2018) and cited in the Australian National Strategic Action Plan for Pain Management (Department of Health 2019). The content is summarised in Box 1.

BOX 1: WORKSHOP CONTENT
• The history of pain and opioid management: acute analgesia, palliative care and dependency treatments • Opioid-related harms in chronic pain including how prescribing volume correlates with overdoses and addiction • The regulators' view: identifying misprescribers • The non-initiation and de-prescribing of opioid analgesics • Management or prevention of the various opioid-related harms including dependency, naloxone rescue provision, and avoiding co-consumption with benzodiazepines The six-hour skills-based workshop was presented by an MDT and included 16 learning activities. Participants undertook role-plays and small group discussions covering patient education, outcome assessments, deprescribing and the provision of PSM.
Most of the workshop involved non-pharmacological management with less than an hour allocated to discussing POAs and other pharmacotherapy.
The ALM ran during the RACGP national annual conference in Sydney, Australia, on 25 October 2017. Registrants were invited to participate in the research study and provided with hard copy or electronic forms of the study questionnaire.
No previously published CP education evaluation instruments covered nonpharmacological PSM, as they related predominantly to opioid-focused paradigms of care. Therefore, we developed an instrument specifically for this study, informed by an evaluation of the US Risk Evaluation and Mitigation Strategy (REMS) program (Alford et al. 2016). Our instrument (Box 2) covered four domains: knowledge, attitudes, current utilisation of PSM strategies, and last-month use of pharmaceutical REMS strategies. The questionnaire was not validated, though piloted in two TEMPO workshops during 2016.
Demographic factors elicited included age, gender, Prescription Shopping Information Service registration status and main practice site postcode (to describe rural versus urban status) (Department of Health 2018). A unique identifier allowed pairing of pre/post data.
Questionnaires were emailed one month before the workshop. Participants could return the pre-workshop form by email, fax or post, or else hand-deliver it at the workshop. Participants were able to indicate consent for their responses to be used for educational research. The presenters were blind to these evaluations at the time of the workshop.
The post-workshop questionnaire was delivered to all delegates at 12 weeks postworkshop and included an invitation for qualitative feedback. There was a $20 shopping voucher offered for the first 10 responses, and all registrants were emailed two reminders. Ethics approval was given by the RACGP National Research and Evaluation Ethics Committee (NREEC 16-005).

Holliday et al.
Eleven multiple-choice questions assessed knowledge of assessment, PSM and REMS, with one question derived from previous work (Alford et al. 2016). Each question gave 4-6 options with the one correct answer scoring two points. Other domains utilised a five-point Likert scale from 0-4, with approximately one-third of items being reverse scored. Attitudes were assessed based on participants' level of agreement with 11 statements, with four of these items based on previous work (Alford et al. 2016). Current utilisation of PSM was assessed with nine items, and past-month REMS with seven. Domain sums were calculated to give maximum scores of 22, 44, 36 and 28, respectively, and totalled to give an overall maximum score of 130.
Internal consistency of the instrument domains, and of the overall instrument, was assessed with Cronbach's alpha. Paired t-tests were conducted on each domain score and on the overall score. Effect sizes for domain scoring changes were assessed with Cohen's d.
For sensitivity analysis, each domain's item scores underwent multiple imputation. The pre-survey section scores, along with the respective section items, were used to predict the imputed post-survey section scores. The imputations were also adjusted for gender, Prescription Shopping Information Service registration status, age and practice location. The chained regression equations method was used to impute 30 completed datasets, and results of the paired t-test were produced over the datasets using Rubin's method. Paired t-tests were performed on the imputed data, as for the primary analysis. All analyses were conducted using SAS Version 9.4 (SAS Institute Inc, Cary, NC, USA).

Total (n = 91)
Chi square Degrees of freedom for chi square P Missing 6 The instrument sub-scales assessing attitudes and utilisation of PSM and REMS had Cronbach's alphas of 0.57, 0.73 and 0.41, respectively. Overall, the entire survey had good overall internal consistency with a Cronbach's alpha of 0.736.
There were 40 comments about the beneficial aspects of training. For example, one respondent stated 'it empowered me to think I can do it and gave me tools to start using to achieve this' (Participant 4), while another acknowledged the 'use of objective measure for function (e.g., sit-to-stand test and online resources for patients to understand chronic pain)' (Participant 5). Participant 16 expressed 'how increasing physical activity and providing psychoeducation may decrease a need for analgesic medications', therefore, 'providing the rationale of moving from opioids and providing clear alternatives to manage chronic pain' (Participant 22). Others simply 'enjoyed it', particularly as the 'case examples and role-plays work well' (Participant 28), including the 'simple strategies and a common-sense approach to management' (Participant 32).
There were also 27 comments about areas to improve. For example, one thought that 'not enough time [was] spent discussing modes to reduce dosing' (Participant 7), while another requested 'extension ALMs to build on skills' (Participant 30). One Nonetheless, some participants shared no criticisms about the training, believing 'it was a good session and every GP should be required to undertake the course', particularly 'GP registrars' (Participant 40).

DISCUSSION
Various allied health providers have successfully trained in PSM (Nicholas & Blyth 2016) and this evaluation suggests that GPs may do so as well. Three months after brief training, scores for knowledge, attitudes and self-reported practice improved for each measure, with moderate to large effect sizes.
Previous evaluations of pain education for GPs have focused on the under-or overuse of opioids (Hogans et al. 2018;Ospina et al. 2013). Reviews indicate they lack consensus on content, or on how outcome measures are defined or gauged (Davis & Carr 2016;Hogans et al. 2018). A diversity of findings with differing evaluation methods was demonstrated by dual evaluations of opioid REMS training for Australian GP registrars. The pre-/post-test survey showed improved knowledge and reported practice, but the objective prescribing data revealed no reduction in total opioid prescription (Holliday, Hayes, Dunlop, Morgan, Tapley, Henderson, Larance, et al. 2017;Holliday, Hayes, Dunlop, Morgan, Tapley, Henderson, van Driel, et al. 2017). In 2015, over 7,000 Australian GPs received academic detailing, led by specialists and GPs, that recommended a transition from opioid prescribing to non-pharmacological care (NPS MedicineWise 2017). One year afterwards, a questionnaire found improved knowledge about prescribing, but none regarding non-pharmacological care (Deloitte Access Economics 2019; NPS MedicineWise 2017). In 2016, 19 GPs in New South Wales, Australia, and other primary health clinicians were invited to two workshops. These aimed to encourage deprescribing of POAs and referral to local MDTs to deliver regimes similar to specialist MDTs (White et al. 2019). Eleven attitudinal items were assessed with an unvalidated questionnaire within a pre-/post-test design. At the conclusion of the second two-hour workshop, six attitudinal items had improved. Since 2012, US pharmaceutical manufacturers have been mandated to fund REMS education, despite the risks for conflicts of interest (Davis & Carr 2016). Two months after the voluntary 2-3 hours of training, clinician knowledge and confidence had improved, with 86% reporting changes in practice (Alford et al. 2016). Of previously evaluated CP education interventions, none have focused on upskilling and empowering GPs to provide psychobehavioural care.
The National Strategic Action Plan considers it vital to upskill time-poor GPs in early interventions, including PSM, to prevent the chronification of acute pain (Department of Health 2019). This study indicates such training may be considered viable. One report estimated that a nationwide CP education program for GPs would be cost-effective based solely on the reduction of ORDs (Deloitte Access Economics 2019). Another goal of the National Strategic Action Plan is the addressing of barriers to safer pharmacotherapy (Department of Health 2019), a major one of which is a perceived lack of effective alternatives (White et al. 2019). If further evaluations show TEMPOlike education is effective, then the initiation, or re-triggering, of opioid-related harms may be reduced (Nicholas & Blyth 2016). Variability in healthcare provision also may be reduced as higher rates of opioid provision and overdoses are found rurally, in lower socio-demographic areas and among Aboriginal and Torres Strait Islander populations (Australian Commission on Safety and Quality in Health Care 2015; Penington Institute 2017). These are demographic factors shared with CP and multimorbidity (Barnett et al. 2012;Lujic et al. 2017).
The facilitation of PSM is now considered a core GP competency in the management of chronic disease (Rochfort et al. 2018). As such, the dissemination of PSM skills through primary care should reduce healthcare disparities and the burden of non-communicable disease (Bruggink et  This interprofessional collaboration developed an innovative approach to a common and complex clinical conundrum. Such non-commercial educational research partnerships will be unlikely without financial support from health funding bodies (Hogans et al. 2018). Since discontinuation of POAs (particularly if non-consensual) risks increased harm, more resourcing is required for addiction training and management (Kertesz & Gordon 2018). Should regulators mandate periodic training in pain and addictions, TEMPO-like education may provide a template (Davis & Carr 2016).
To appraise effectiveness, investment in development and validation of an educational assessment instrument will be necessary, potentially involving interrogation of GP electronic health records and patient-reported functional outcome measures (Hogans et al. 2018;Sullivan & Ballantyne 2016). Improved outcomes from training may require repeated training exposures, with scaleability enhanced by the utilisation of webbased formats (Hogans et al. 2018).
These data reflect real-world GP education, delivered at a mainstream conference. Individually matched outcomes were sustainable; the three-month, post-workshop gap exceeds most other evaluations of similar interventions.
A major limitation of the study is the lack of a control group. This workshop occurred four months before codeine was 'up-scheduled', making it unavailable over the counter (Holliday et al. 2018). A control group would have helped to identify bias from concurrent training. There is also a risk of sampling bias due to the ALM registrants being self-selected. However, the matching of individualised results may ameliorate this bias. We also relied on a pragmatic uncontrolled mode of evaluationthe pre-/post-test, which is the most commonly used instrument evaluating CP education (Ospina et al. 2013). Our evaluation instrument was original with moderate internal validity. As with the majority of educational evaluations, lack of instrument reliability and validity data and modest response rates limits the strength of our conclusions (Hogans et al. 2018). That said, our response rate was consistent with many surveys of GPs (Bonevski et al. 2011).
Our pre-readings may have boosted pre-test scores, reducing the apparent effect of the package. Further, we did not observe objective clinical behaviour, which may be discordant with paper-based self-report (Holliday, Hayes, Dunlop, Morgan, Tapley, Henderson, Larance, et al. 2017;Holliday, Hayes, Dunlop, Morgan, Tapley, Henderson, van Driel, et al. 2017). Finally, pain and opioid education is ultimately designed to improve patient and societal health, neither of which was measured in this evaluation (Hogans et al. 2018).

CONCLUSION
GPs manage the vast majority of CP and do so without the resources and interventions of specialist MDTs. Therefore, an alternative is needed to allow GPs to transition from biomedical medication management towards a multifaceted approach. We showed that it is feasible to assemble an MDT involving specialist pain practitioners and GPs to deliver brief CP training as standard CME to disseminate competencies appropriate for a GP's clinical workflow. Our unvalidated instrument showed modest evidence that the training had sustainable value. Three months following the workshop, GPs selfreported improved knowledge and attitudes as well as increased utilisation of multimodal PSM and less reliance on addictive pharmacotherapy. Further studies are needed to explore whether PSM training for GPs improves access to affordable holistic pain care. Intriguingly, such training may improve outcomes for the common and intersecting problems of CP, addictive pharmacotherapy, disadvantage and multimorbidity.

PRE-WORKSHOP SURVEY
Thank you for participating in the pre-assessment survey for the Time-efficient Management of Pain in the Office (TEMPO) program. It should take you about 15 minutes to complete. We request that you please answer all questions, so that, with the post-assessment survey, we can measure the effectiveness of this educational activity. Ethical approval for this evaluation has been given by the RACGP National Research and Evaluation Ethics Committee (NREEC) 16-005.
Please complete the following.

Q1
For

threequarters
All or just about all a) discussing their side effects b) prescribing a benzodiazepine for insomnia (reverse scored) c) starting a conversation about opioid reduction d) seeking regulatory approval (where required) e) warning patients that anyone who misuses their analgesics will be fired from the practice (reverse scored) f) considering naloxone prescription g) assessing suicide risk Q20 Please tick the appropriate box: I understand these results will be de-identified and analysed to evaluate this educational project. Are you willing for your responses to be used for research purposes?

No
Please return this survey prior to the workshop. See over for details. Thank you.