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Intervention Summary

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COPE: Collaborative Opioid Prescribing Education

COPE: Collaborative Opioid Prescribing Education is a free online training course that is designed to increase physicians' knowledge, competence, and satisfaction regarding the use of opioid medications in managing chronic noncancer pain experienced by outpatients. Based on the chronic care model, whereby health care providers and patients make treatment decisions collaboratively to achieve positive health outcomes, COPE teaches physicians communication skills for collaborative physician-patient goal setting in relation to decisions about starting, stopping, or continuing chronic opioid therapy.

The COPE course takes 2-3 hours to complete and has six interactive chapters, which consist of exercises that provide comprehensive background information on recent research in relevant areas of pain care; videotaped clinical scenarios to illustrate and reinforce learning goals, such as how to support communication skills development and promote shared decisionmaking; and quizzes to test information retention. The course also includes a resources section, which provides information for the physician taking the course and informational handouts that can be given to patients.

The COPE course has been approved for a maximum of 3 American Medical Association Physician's Recognition Award Category 1 Credits through the University of Washington School of Medicine, which is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The research reviewed for this summary was conducted with internal medicine residents from five residency programs.

Descriptive Information

Areas of Interest Substance abuse prevention
Substance abuse treatment
Outcomes Review Date: March 2012
1: Knowledge of the role of opioids in chronic noncancer pain management
2: Competence in managing outpatients' chronic noncancer pain
3: Satisfaction with recent encounters with patients experiencing chronic pain
Outcome Categories Drugs
Treatment/recovery
Ages 18-25 (Young adult)
Genders Male
Female
Races/Ethnicities Data were not reported/available.
Settings Outpatient
Geographic Locations Urban
Suburban
Implementation History COPE was first implemented in 2007 as an online, accredited continuing medical education course through the University of Washington. Since 2010, COPE has averaged a minimum of 3,000 users per year.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Indicated

Quality of Research
Review Date: March 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Clark, M. R. (2011). Chronic opioid therapy for chronic pain: An e-learning program to develop shared decision-making and communication skills. Current Pain and Headache Reports, 15(2), 88-90.  Pub Med icon

Sullivan, M. D., Gaster, B., Russo, J., Bowlby, L., Rocco, N., Sinex, N., et al. (2010). Randomized trial of Web-based training about opioid therapy for chronic pain. Clinical Journal of Pain, 26(6), 512-517.  Pub Med icon

Supplementary Materials

Between-group knowledge quiz data, by residency year and gender [Table]

Guidelines for Negotiating a Patient Care Agreement for Chronic Non-Malignant Pain Management

Physician-Patient Pain Treatment Agreement--Follow-Up Version

Suchman, A. L., Roter, D., Green, M., Lipkin, M., Jr., & the Collaborative Study Group of the American Academy on Physician and Patient. (1993). Physician satisfaction with primary care office visits. Medical Care, 31(12), 1083-1092.  Pub Med icon

Sullivan, M. D., Leigh, J., & Gaster, B. (2006). Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain. Journal of General Internal Medicine, 21(4), 360-362.  Pub Med icon

Outcomes

Outcome 1: Knowledge of the role of opioids in chronic noncancer pain management
Description of Measures Knowledge of the role of opioids in the management of chronic noncancer pain in outpatients was assessed using a 9-item multiple-choice quiz. The measure was developed for the study and included the topics of opioid pharmacology, controlled substance regulations, and diagnostic challenges. Participants responded to each item (e.g., "The average percent pain relief for chronic non cancer pain achieved in randomized trials is approximately: a. 10%, b. 30% [correct answer], c. 50%, or d. 80%"); incorrect responses were scored as 0, and correct responses were scored as 1. Total scores ranged from 0 to 9, with higher scores indicating greater knowledge. Assessments occurred before training (baseline) and immediately after training (posttraining).
Key Findings In a clinical trial, internal medicine residents from five residency programs were recruited by email and randomly assigned in blocks according to gender and year of residency to receive COPE or the Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The VA/DoD guideline is a 26-chapter document, released in 2003, that uses a modular approach to provide key points and a treatment algorithm flowchart with recommendations for the use of opioids to treat outpatients who have chronic noncancer pain. From baseline to posttraining, internal medicine residents who received COPE had a greater increase in knowledge scores relative to internal medicine residents who received the VA/DoD guideline (5.9 to 8.4 vs. 5.7 to 6.1; p < .00001).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)
Outcome 2: Competence in managing outpatients' chronic noncancer pain
Description of Measures Competence in managing outpatients' chronic noncancer pain, both in general and with the use of opioids, was assessed by two self-rated items developed for the study: "I feel competent in the overall management of outpatients with chronic non-cancer pain" and "I feel competent in the use of opioids for the management of outpatients with chronic non-cancer pain." Using a Likert scale ranging from 0 (not competent) to 10 (completely competent), respondents rated their perceived level of competence on each of the two items. Assessments occurred before training (baseline) and 45-60 days after training (follow-up).
Key Findings In a clinical trial, internal medicine residents from five residency programs were recruited by email and randomly assigned in blocks according to gender and year of residency to receive COPE or the VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The VA/DoD guideline is a 26-chapter document, released in 2003, that uses a modular approach to provide key points and a treatment algorithm flowchart with recommendations for the use of opioids to treat outpatients who have chronic noncancer pain. From baseline to follow-up, compared with internal medicine residents who received the VA/DoD guideline, internal medicine residents who received COPE had greater improvements in self-rated levels of competence in the general management of outpatients' chronic noncancer pain (3.2 to 3.7 vs. 3.1 to 3.5; p = .01) and in the use of opioids for managing chronic noncancer pain (3.2 to 3.8 vs. 3.2 to 3.5; p = .02).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)
Outcome 3: Satisfaction with recent encounters with patients experiencing chronic pain
Description of Measures Satisfaction with recent encounters (i.e., past 45-60 days) with patients experiencing chronic pain was assessed by a modified version of the 20-item Physician Satisfaction Questionnaire. The items cover six subscale domains of physician-patient interactions:

  • General satisfaction (e.g., "This was a very satisfying visit for me")
  • Adequately trained (e.g., "I felt adequately trained and confident in treating this patient")
  • Quality of the patient-physician relationship (e.g., "I established effective rapport with this patient")
  • Adequacy of the patient data collection process during the visit (e.g., "I didn't get all the detail I wanted on the patient's problem and symptoms")
  • Appropriate use of office visit time (e.g., "My time was NOT well spent in the visit")
  • Cooperative, nondemanding nature of the patient during the office visit (e.g., "This patient demands a lot of personal attention")
Using a 5-point Likert scale ranging from "strongly agree" to "strongly disagree," respondents rated each item. Higher ratings across subscales indicate greater satisfaction. Assessments occurred before training (baseline) and 45-60 days after training (follow-up).
Key Findings In a clinical trial, internal medicine residents from five residency programs were recruited by email and randomly assigned in blocks according to gender and year of residency to receive COPE or the VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The VA/DoD guideline is a 26-chapter document, released in 2003, that uses a modular approach to provide key points and a treatment algorithm flowchart with recommendations for the use of opioids to treat outpatients who have chronic noncancer pain. From baseline to follow-up, compared with internal medicine residents who received the VA/DoD guideline, internal medicine residents who received COPE had greater improvements in self-rated levels of satisfaction on two subscale domains of the Physician Satisfaction Questionnaire: adequately trained (2.7 to 3.4 vs. 2.7 to 3.2; p = .03) and quality of the patient-physician relationship (12.1 to 13.1 vs. 12.2 to 12.5; p = .02).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult) 54.9% Male
45.1% Female
Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Knowledge of the role of opioids in chronic noncancer pain management 1.5 1.8 1.5 3.0 2.5 3.0 2.2
2: Competence in managing outpatients' chronic noncancer pain 1.5 1.5 1.5 3.0 2.5 3.0 2.2
3: Satisfaction with recent encounters with patients experiencing chronic pain 1.5 1.5 1.5 3.0 2.5 3.0 2.2

Study Strengths

Intervention fidelity was strengthened by the online delivery format of the training course, and the online assessment of outcome measures provided for a systematic and unbiased data collection protocol. The inclusion of an active comparison condition and the use of random assignment by blocks according to gender and year of residency controlled for many potential confounding variables. Study participants who completed both assessments were compared with those who were missing one or both assessments. The investigators analyzed the data in two ways: first, statistical modeling was carried out only for study participants with complete outcome assessment data, and second, a more sophisticated statistical modeling was carried out with an intent-to-treat approach that analyzed data from all randomized participants (including those participants with missing outcome assessments).

Study Weaknesses

There was no well-developed conceptual framework for the nine multiple-choice items that made up the knowledge outcome quiz, which compromised the reliability and validity of this study-created outcome measure. The self-rated competence outcome measure, also created for this study, consisted of only two items with no reliability or evidence of validity. There was no direct measurement of the intervention dosage received by each participant, such as time logged in to the training site or which of the six course chapters were accessed and in what order. The frequency of using the course while logged in and the attention given to the various course chapters varied by each participant and were uncontrolled by the investigators. There was a large amount of assessment data with one or both assessments missing across participants (33%).

Readiness for Dissemination
Review Date: March 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

COPE brochure

COPE online course, http://elearning.talariainc.com/default.aspx?pagekey=49581

Program Web site, http://www.cope-pain.org/

University of Washington School of Medicine's Continuing Medical Education Web site, http://depts.washington.edu/cme/online/course/EN0903

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 2.5 2.0 2.6

Dissemination Strengths

The interactive course is thorough, detailed, and easy to navigate. The individual chapters within the course contain specific learning objectives. Videos depict realistic patient-physician interactions that demonstrate shared decisionmaking skills. The online nature of the course allows users to access it at their convenience. The University of Washington regularly monitors completion rates and participant feedback for use in ongoing course improvement.

Dissemination Weaknesses

No summary of the course material is provided, and course-specific support materials for physician use are limited. It appears that the only technical assistance available during and after taking the course is via phone or email, with no structured consultation or supervision options available to strengthen fidelity to the intervention. Pre- and posttests of knowledge acquisition are available, but their use is not required for the successful completion of the course.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
COPE: Collaborative Opioid Prescribing Education (online course) Free Yes
Phone and email technical assistance through the University of Washington School of Medicine's Office of Continuing Medical Education Free No

Additional Information

Physicians who seek written certification from an institution accredited by the Accreditation Council for Continuing Medical Education may apply for credit through the University of Washington School of Medicine's Office of Continuing Medical Education for a fee of $45. The University of Washington also designates the successful completion of COPE for a total of 3 American Medical Association Physician's Recognition Award Category 1 Credits.

Contact Information

To learn more about implementation, contact:
Laura Cooley, M.A.
(206) 685-5181
lcooley1@uw.edu

To learn more about research, contact:
Mark D. Sullivan, M.D., Ph.D.
(206) 685-3184
sullimar@u.washington.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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