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Papers of the Week

Papers: 17 Jun 2023 - 23 Jun 2023

Clinical, Methodology, Psychology

Human Studies


2023 Jun 15

J Pain


Cluster-Randomized Comparative Effectiveness Trial of Physician-Directed Clinical Decision Support vs. Patient-Directed Education to Promote Appropriate Use of Opioids for Chronic Pain.


Spiegel BMR, Fuller G, Liu X, Dupuy T, Norris T, Bolus R, Gale R, Danovitch I, Eberlein S, Jusufagic A, Nuckols T, Cowan P


We compared the effectiveness of physician-directed clinical decision support (CDS) administered via electronic health record (EHR) vs. patient-directed education to promote appropriate use of opioids by conducting a cluster-randomized trial involving 82 primary care physicians and 951 of their patients with chronic pain. Primary outcomes were satisfaction with patient-physician communication (CG-CAHPS) and pain interference (PROMIS®). Secondary outcomes included physical function (PROMIS®), depression (PHQ-9), high-risk opioid prescribing (>90 morphine milligram equivalents per day [≥90 MME/day]), and co-prescription of opioids and benzodiazepines. We used multi-level regression to compare longitudinal difference-in-difference scores between arms. The odds of achieving the maximum CG-CAHPS score was 2.65 times higher in the patient education vs. CDS arm (P=.044; 95% CI 1.03-6.80). However, baseline CG-CAHPS scores were dissimilar between arms, making these results challenging to interpret definitively. No difference in pain interference was found between groups (Coef=-0.64, 95% CI -2.66-1.38). The patient education arm experienced higher odds of Rx≥90 MME/day (OR=1.63; P=.010; 95% CI 1.13,2.36). There were no differences between groups in physical function, depression, or co-prescription of opioids and benzodiazepines. These results suggest that patient-directed education may have potential to improve satisfaction with patient-physician communication, whereas physician-directed CDS via EHR may have greater potential to reduce high-risk opioid dosing. More evidence is needed to ascertain relative cost-effectiveness between strategies. PERSPECTIVE: This article presents the results of a comparative-effectiveness study of two broadly used communication strategies to catalyze dialogue between patients and PCPs around chronic pain. The results add to the decision-making literature and offer insights about the relative benefits of physician-directed vs. patient-directed interventions to promote appropriate use of opioids.