The Value of Patient Education

No randomized controlled trials have specifically evaluated the effect of patient education on treatment outcomes; however, Brox and colleagues (2006) studied 60 patients who had persistent low back pain at least a year after surgery for disc herniation. Patients were randomized to receive either lumbar fusion with transpedicular screws or cognitive intervention, which consisted largely of education on back hygiene and exercises. Outcomes were essentially the same for the two groups.

The potential value of patient education is also supported by ad hoc reviews in the medical literature. For instance, VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain (Department of Veterans Affairs & Department of Defense [VA/DoD], 2010) recommends both patient and family education, as do other pain treatment guidelines (Chou, Fanciullo, Fine, Adler, et al., 2009; Institute for Clinical Systems Improvement, 2007). Patient education is also necessary for truly informed consent. Geppert (2004, p. 163) defines informed consent as follows: “Informed consent encompasses the capacity to understand the risks, benefits, and alternatives of a treatment, to communicate a choice regarding therapy, to deliberate and reason about the consequences of the proposed medication, and to appreciate how the treatment will affect life and values.” Informed consent is particularly important when clinicians are prescribing potentially addictive medications to patients who have histories of substance use disorders (SUDs) and other behavioral health disorders.

Providing culturally sensitive and linguistically appropriate education can:

• Improve adherence.
• Help the patient understand medication responses that are expected and normal and those that are of concern and warrant a phone call.
• Allay fears about particular treatments or medications.
• Increase satisfaction with treatment by promoting realistic expectations.
• Provide an opportunity to discuss any concerns.
• Strengthen the clinician–patient relationship by demonstrating respect and enhancing patient feelings of self-efficacy.
• Improve health, well-being, and outcomes.

In addition, patient education provides a forum in which clinicians can ask patients about their perceptions of their condition and explore patients’ conceptions and misconceptions about their condition and its treatment. Clinicians should encourage patients to talk about their use of complementary and alternative medicine (CAM) and other non-pharmacological approaches to pain.

Providing education and soliciting questions require an initial time commitment; however, these efforts ultimately save time. A patient is less likely to make unnecessary emergency appointments when he or she clearly understands what to expect from a medication or treatment and has a specific plan for what actions to take when pain flares.

Providing Effective Education

Effective education is a process that begins at treatment initiation and continues throughout treatment. The treatment needs of patients who have chronic noncancer pain (CNCP) and SUD change over time, necessitating ongoing education. Family members, especially caregivers, frequently play important roles in pain treatment (Glajchen, 2001) and ought to be involved in educational efforts.

Educational approaches must be tailored to each patient’s needs. The clinician or other members of the treatment team should develop a repertoire of educational materials and approaches to meet the differing needs of patients. Approaches should consider:

• Primary languages spoken by patients.
• Culture, gender, race/ethnicity, and age of patients.
• Resources in the local community (e.g., availability of hospitals, pharmacies).
• Educational, general literacy, and health literacy levels of patients.
• Cognitive function of patients.

Health literacy has been defined as “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (U.S. Department of Health and Human Services, 2000, p. vi). Online sources for more information and training on health literacy are in Exhibit 5-1.

Exhibit 5-1

Selected Online Sources of Information on Health Literacy.

To enhance communication with a diverse patient population, HRSA recommends that the treatment team (http://www.hrsa.gov/healthliteracy):

• Use simple language and short sentences and define technical terms.
• Supplement instruction with appropriate materials (e.g., videos, models, pictures).
• Ask patients to explain or demonstrate the clinician’s instructions (teach-back method; see Exhibit 5-2).
• Ask open-ended questions that begin with “how” and “what,” rather than closed-ended, yes/no questions.
• Organize information so that the most important points stand out and repeat this information.
• Consider gender; age; and the cultural, ethnic, and racial diversity of patients when selecting or designing educational materials.
• Offer assistance with completing forms.

Exhibit 5-2

Talking With Patients Following a Teach-Back Approach.

Oral communication can be supplemented with charts, diagrams, and other visual aids. These can help patients with limited English proficiency or low-literacy skills as well as those who learn more efficiently from graphic representations. Patient education materials are available in several languages at http://www.healthinfotranslations.org. In some cases, a translator may be necessary.

Communication also can be enhanced by using the teach-back method (or “interactive communication loop”) (Schillinger et al., 2003). This method can be effectively used with any patient but may be particularly helpful with those who have low general knowledge or health literacy or who are in early recovery from an SUD.

The method involves the clinician’s explaining or demonstrating an instruction or concept to the patient, then asking the patient to repeat the instruction or information back in his or her own words (not verbatim) or to repeat the demonstration. When asking, the clinician takes responsibility for any misunderstanding (e.g., “I want to be sure I explained this well enough”). If the patient cannot demonstrate or does not appear to understand the instruction, the clinician tries again. This is repeated until the patient clearly understands what he or she is expected to do. Exhibit 5-2 offers a sample teach-back dialog.

Take-home handouts and pamphlets may aid recall and provide additional information. Clinicians can prepare their own handouts, but many can be found online. University medical centers and government Web sites are a good source of reliable patient education resources, and pharmaceutical companies almost always offer patient education sheets on specific medications. Professional associations also often have useful materials, such as patient communication aids (e.g., Pain Log, Quality of Life Scale). Clinicians should review these documents for appropriateness, print them out, go over them with patients, and allow patients to take them home.

The Internet as a Source of Patient Education

Many patients use the Internet as a source of health information. Although the Internet can be a useful adjunct to in-office education, it is also a source of much misinformation and marketing disguised as education.

Clinicians can offer guidance and recommend Web sites with reliable content on chronic pain management and SUDs. Exhibit 5-3 lists a few such Web sites with information on chronic pain, and Exhibit 5-4 lists Web sites with information on SUDs.

Exhibit 5-3

Reliable Web Sites With Information on Chronic Pain and Pain Treatment.

Exhibit 5-4

Reliable Web Sites With Information on Substance Use Disorders.

Education Content

Opioid Information

Use of opioids requires additional educational efforts. To give informed consent, patients must understand the expected benefits as well as the uncertainties of chronic opioid therapy. Specifically, they must understand that excellent analgesia can almost always be provided by starting opioids; however, long-term studies are limited and often of poor quality. They suggest that benefit diminishes with time; after 1½ years, about one-half of patients dropped out of opioid therapy because of side effects or the therapy’s loss of efficacy. Those continuing to take opioids had about 30-percent pain reduction (Kalso, Edwards, Moore, & McQuay, 2004).

Patients must also understand the risks of therapy, which include overdose (by patient, others, pets), constipation, sedation, and hormone changes, and the hazards of combining opioids with sedating drugs or alcohol. Finally, they should understand that tolerance and physical dependence are expected consequences of extended therapy, that these conditions do not necessarily indicate the presence of an addictive disorder, but that they do require that arrangements be made to prevent abrupt withdrawal when either the patient or clinician is out of town or the clinician is otherwise unavailable. Policies of the clinician or program (e.g., requirements for urine drug testing, responses to lost or stolen prescription reports, early refill requests) should be communicated in advance.

In addition, patients need to understand (VA/ DoD, 2010):

• The titration process, how soon the patient can expect maximum effectiveness, and why taking medications exactly as prescribed is important to the titration process.
• The risks of discontinuing the medication abruptly (e.g., withdrawal symptoms).
• How medication will be safely discontinued (e.g., tapering, managing withdrawal symptoms).
• That drowsiness is a common side effect during titration and that patients should not try to drive or operate heavy machinery until drowsiness is cleared.
• How to discuss pain therapy, analgesic needs, and recovery status with other health professionals (e.g., dentists, anes-thesiologists). (See Exhibit 5-5.)

Exhibit 5-5

Talking With Patients Before Surgery.

Patients also need to know about legal and regulatory issues (VA/DoD, 2010), including:

• The legal responsibilities of the clinician.
• That it is illegal to give away, trade, share, or sell prescription opioids.
• The potential effect of regulatory issues on occupation, lifestyle, and use (e.g., pilots, commercial drivers; Chou and colleagues [2009] provide more information).
• The responsibility of the patient to report stolen medications both to the police and to the clinician.

Methadone Maintenance Therapy Information

Patients on methadone maintenance therapy (MMT) for opioid dependence need to understand how pain treatment will affect their MMT and vice versa. Patients also need to understand that long-term use of opioids can bring tolerance, may cause them to become more sensitive to pain (to have opioid-induced hyperalgesia), and can cause the opioids to become ineffective over time. (Chapter 3 provides more information on opioid-induced hyperalgesia.)

In general, when patients receiving MMT have inadequate pain control, options include non-opioid therapies and dividing the daily methadone dose into three-times-a-day dosing. If a decision is made to increase the dose of methadone by the pain-treating clinician, it should be done only in concert with the MMT program. The patient must be monitored for continued participation in an aggressive recovery program and for evidence that the increased dose of methadone leads to demonstrable reductions in pain or improvements in function.

Treatment Agreements

As with patient education, opioid treatment agreements (contracts) have had no randomized controlled trials that have specifically evaluated their effect on treatment outcomes. Such agreements are, however, recommended in clinical guidelines and are frequently used in practice. Although written agreements specific to prescribed opioids are most frequently discussed, agreements can be used for other treatment modalities (e.g., exercise regimens).

Disagreement exists about the use of agreements when prescribing opioids (Heit, 2003). Some guidelines recommend opioid agreements only when the patient has or is at risk for an SUD. Others are concerned that “opioid contracts may diminish patient autonomy; autonomy and adherence may sometimes represent conflicting values in chronic opioid therapy” (Arnold, Han, & Seltzer, 2006, p. 294).

These concerns can be mitigated somewhat by the way in which treatment agreements are established. Patients can be informed that treatment agreements are mutually agreed-on plans and courses of action. Providing education on options and involving the patient in planning and writing treatment agreements can preserve patient autonomy while establishing necessary guidelines. Arnold and colleagues (2006) suggest that, if a clinician chooses to use an opioid agreement, it should:

• Use neutral, nonconfrontational language.
• Be written so that the patient can understand it.
• Emphasize opioids as a part of a comprehensive pain management plan that also includes physical therapy, counseling, and other medications for co-occurring disorders, as needed.
• Emphasize the clinician’s responsibility to work with the patient to alleviate his or her symptoms.
• Explain that the agreement protects the patient’s access to scheduled medications and protects the clinician’s license to prescribe them.
• Describe behaviors that are incompatible with chronic opioid therapy (e.g., getting prescriptions from other clinicians, losing medications).
• Describe the actions the clinician may take in response to these behaviors up to and including cessation of opioid prescribing.

As when treating all patients, the clinician can assess the ability of the patient with or in recovery from an SUD to make an informed decision (Longo, Parren, Johnson, & Kinsey, 2000). If the clinician becomes aware of limitations, he or she can (in addition to or instead of having a written agreement) involve the patient’s family in treatment, with the patient’s permission (Geppert, 2004).

Treatment agreements vary considerably from practice to practice and from patient to patient. However, some common elements of agreements include the following (Fishman, 2007; Heit, 2003; Jacobson & Mann, 2004; VA/DoD, 2010; Ziegler, 2007):

• Timeframe of the agreement
• Goals of therapy
• Risks and benefits of chronic opioid therapy
• Requirement for obtaining prescriptions from a single clinician and a named pharmacy
• Activities for pain management (e.g., exercise, CAM)
• Risk and benefit statement, including lists of possible side effects
• Proscription against changing medication dosage without permission
• Schedule for regular medical visits for evaluation of the agreed-on treatment
• Requirement of complete, honest self-report of pain relief, side effects, and function at each medical visit
• Limits on medication refills
• Limits on replacing lost medications or prescriptions
• Consent for random urine drug testing and other specified testing
• Required pill counts
• Consent for appropriate release of information (e.g., from family members, other clinicians, counselors, substance abuse treatment programs)
• Participation in agreed-on SUD recovery activities (e.g., treatment, continuing care, mutual-help groups)
• Requirements of the clinician
• Participation in agreed-on psychiatric treatment activities
• Possible consequences of not following the treatment agreement

A useful treatment agreement should be revised as the patient’s needs and circumstances change. An opioid agreement by American Academy of Pain Management is online at http://www.aapainmanage.org. Exhibit 5-6 presents another sample pain treatment agreement for a woman in recovery from an SUD.

Exhibit 5-6

Sample Pain Treatment Agreement.

Key Points

• Patient education is necessary for informed consent, and it equips patients to take an active role in their pain management.
• Education must be tailored to the individual patient. More research is needed on tailoring education to patients who have CNCP.
• Clinicians should take time to educate their patients and make sure patients understand how to help themselves.
• People learn in different ways; clinicians should have a variety of learning materials at their disposal.
• Treatment agreements document the treatment plan and the responsibilities of the patient and the clinician.