Teaching A Toolkit for All Levels of Expertise
Safe and Competent Opioid Prescribing: A Toolkit for All Levels of Expertise Phoebe Cushman, MD Christopher Shanahan, MD, MPH Daniel Alford, MD, MPH AMERSA Conference November 5, 2015 Phoebe Facilitated Discussion
What challenges have you experienced, or do you anticipate experiencing, in teaching (colleagues, students, faculty, staff) opioid prescribing for chronic pain? Phoebe, use flip chart Teaching A Toolkit for All Levels of Expertise
Safe and Competent Opioid Prescribing: A Toolkit for All Levels of Expertise Phoebe Cushman, MD Christopher Shanahan, MD, MPH Daniel Alford, MD, MPH AMERSA Conference November 5, 2015 Phoebe Faculty & Disclosures Phoebe Cushman, MD Christopher Shanahan, MD, MPH
General Internal Medicine Fellow Boston University Christopher Shanahan, MD, MPH Assistant Professor of Medicine Daniel Alford, MD, MPH Associate Professor of Medicine Phoebe Introduces self Chris introduces self Dan introduces self POLL THE AUDIENCE HERE? ASK FOR SHOW OF HANDS who is attending MD resident or student//NP or PA/RN/CSW or other Other? How many have prescribed opioids for chronic nonmalignant pain OR taken patients on chronic opioids in the outpatient setting? Faculty members have nothing to disclose with regards to commercial support. Faculty members indicate that they do not plan to discuss unlabeled/investigational uses of a commercial product. Workshop Aim To teach you how to instruct learners at your homeinstitution in opioid prescribing by applying conceptsfrom SCOPE of Pain:Safe and Competent OpioidPrescribing Education The aim is NOT to provide a comprehensiveunderstanding of managing opioids for chronic pain Instead, we recommend that you complete the 3modules of Your learners will also benefit from completing themodules prior to your teaching session Phoebe Workshop Objectives In your role as a teacher, educator, trainer
Recognize effective communication strategies for conversationswith patients who take opioids for chronic pain Develop a risk-benefit framework in which to evaluate patientswho take opioids for chronic pain Guide a peer learner through a patient conversation about opioids Identify challenges and facilitators to teaching opioid prescribingin your institution Create an Action Plan for incorporating SCOPE of Pain into yourcurriculum Phoebe Agenda What is SCOPE of Pain (ER/LA Opioid REMS training)?
What are the tools in the Trainers Toolkit? Demonstration of the SCOPE Trainers Toolkit: Video presentations teach key communication skills in opioidprescribing Skills practice helps learners practicetheir communicationskills Develop an Action Plan for your institution Phoebe DANstarts with What is Scope of Pain? What is ER/LA Opioids REMS?
Risk Evaluation and Mitigation Strategy:FDA- mandated program including prescriber education,patient education, package inserts, etc. July 2012, FDA required a class-wide REMS from the21 manufacturers of ER/LA Opioid Analgesics (REMSProgram Companies [RPC]) FDA created essential content (Blueprint) for prescribereducation RPC to fund accredited CME providers SCOPE of Pain is an ER/LA Opioid REMS program Dan ER/LA Opioids REMS Goal
to reduce serious adverse outcomes(addiction, unintentional overdose, death)resulting from inappropriate prescribing,misuse, and abuse of ER/LA opioidanalgesics while maintaining patient accessto pain medications Dan WHAT IS SCOPEOFPAIN.ORG? Three 1-hour Modules
How to: Determine when opioid analgesics are indicated Assess for pain, function and opioid misuse risk Talk to patients about opioid risks and benefits Monitor and manage patients on opioid therapy Case Study:Mary Williams 42 year old female Hypertension Type 2 diabetes with painful diabetic neuropathy Chronic low back pain Each module is a separate visit Dan What Are the Tools in the Trainers Toolkit? Flexible
All exercises can be completed a 45-minute grandrounds or pre-clinic meeting Which exercise(s) you choose will depend on How much time you have Size of your group of learners How interactive you want to make the session Dan SCREENSHOT IN CASE WE DO NOT HAVE INTERNET ACCESS What Are the Tools in the Trainers Toolkit? 7 video vignettes
7 video vignettes 2 video/power point presentations 1 case discussion 1 skill practice session (role play) DANdelete this slide and insert real toolkit slide 7 VIDEOS:There are seven videos available for your use.Materials include learner/facilitator handouts with background information about the patient in each scenario; clinician tasks, for learners to think about, and discussion questions for after youve shown the video. 2 VIDEO/POWERPOINT PRESENTATIONS:This exercise, designed to be presented over two consecutive sessions, takes one of the longer videos above (the High dose opioids/inherited patient video), and interweaves it into a powerpoint presentation with integrated questions and pauses for reflection during the video. 1 CASE DISUSSION:This is an in-depth facilitator-led case discussion about one complex case.Materials include the case with facilitator notes for you, as well as handouts for your learners. 1 INTENSIVE ROLE PLAY:This exercise is designed as a single demonstrated role play, to be presented in front of the larger group.The facilitator takes the role of patient, and a volunteer from the learner group plays the clinicians.Detailed instructions for both roles, as well as follow up questions, are provided. Case 1: Mr. Robinson (new patient)
62 year old male with chronic lower back, hip, and kneepain after a MVC 15 years ago, new to your practice. Past medical history MVC in 1999 required multiple orthopedic surgeries course complicated by post-op infections, resulting in 2months in ICU followed by 3 months in inpatient rehab COPD, HTN (well-controlled) Social history Recently moved from FL to MA to live with his elderly mother Former electrician, single Unemployed and on disability since his accident in 1999 PhoebeNow lets move into a demo of one of the tools in the toolkit. For the purposes of this exercise, please consider yourself a learner and not a teacher.As you watch the video Case 1: Mr. Robinson Substance use history Family history
Smokes 1-2 ppd (50 pack year history) Drinks ETOH 2-3 x per year No illicit drug use Family history No known family history of substance use disorder Physical exam Ambulates using 2 canes Trouble getting on/off exam table Multiple well healed scars from his prior trauma/surgeries Otherwise WNL Phoebe Video:Mr. Robinson Please note, video is available at SCOPEOFPAIN.ORG Case 1: Mr. Robinson How would you assess the patients level of pain?
Phoebe The PEG Scale Pain on average? Pain interfered with Enjoyment of life?
In the past week, how much: 8 1 2 3 4 5 6 7 9 10 Pain on average? No pain As bad as you can imagine 8 Does not interfere Completely interferes 1 2 3 4 5 6 7 9 10 Pain interfered with Enjoyment of life? Phoebe explain PEG Explain that this is an example of the way the teaching of key concepts is incorporated into viewing the videos And that the module goes on to show how Dr Alford inquires about the patients pain and then uses shared decision making to together come up with goals However, in order to give you another example from our toolkit, we will now skip to Mr. Russo 8 1 2 3 4 5 6 7 9 10 Does not interfere Completely interferes Pain interfered with General activity? Krebs EE, et al. J Gen Intern Med. 2009;24(6):733-8. Case 2: Mr. Russo (established patient at follow-up)
48 yo man with chronic posttraumatic right knee andankle pain s/p infected compound fractures from amotorcycle accident 5 years ago.He always reports hispain as 4-5 out of 10. SH: Lives with girlfriend, no children.His cashier job in his friendsstore allows him to sit most of the day.+ past history of marijuanause disorder > 10 years ago, denies other illicit drug use, no historyof tobacco or alcohol use disorder. Current pain medications: Hydrocodone 5 mg/acetaminophen500 mg 2 tabs po TID, Ibuprofen 800 mg po TID Physical exam:Right knee and ankle are severely deformed withvery limited range of movement. He walks with a cane. Phoebe Again, for the purposes of this next exercise, you are a learner Case 2: Mr. Russo Urine drug testing from his previous visit was positive for hydrocodone and cocaine.This is confirmed with gas chromatography. How would you bring this up with Mr. Russo at hisvisit? Practice how you would frame the discussion. Video: Mr. Russo Please note, video is available at SCOPEOFPAIN.ORG
What did you find effective or ineffective about the way Dr Alford discussed the utox results with the pt? What is your role? Not This brings us to the risk-benefit framework, which is very helpful in thinking about opioids for chronic pain, and, in particular, how to talk about opioids with your patients. Nicolaidis C. Pain Med. 2011;12(6):890-7. Use a Health-Oriented, Risk/Benefit Framework
NOT Do the benefits of opioid treatment outweigh the untoward effects and risks for this patient (or society)? RATHER Is the patient good or bad? Does the patient deserveopioids? Should this patient bepunished or rewarded? Should I trust the patient? Phoebe In terms of a viable framework, this all makes sense if we always think about issues around opioids as health-related issues.So, its not is the patient good or bad, or does the patient deserve to have opioids, whether we should reward them if they behave well and punish them if they might be aiming towards misuse. We need to frame this instead as a risk/benefit assessment for an individual patient.So, if a patient has a history of substance misuse or mental health disorders that may make them more at risk, we are implementing these strategies in order to keep them safe.And when issues arise, we need to think of what might be driving them in terms of the patients health.So, these strategies are for the benefit of the individual patient and for the benefit of society or the public health. Judge the opioid treatment NOT the patient Nicolaidis C. Pain Med. 2011;12(6):890-7. Health-Oriented, Risk/Benefit Framework
Do the benefits of opioid treatment outweigh theuntoward effects and risks for this patient (or society)? I am concerned that your cocaine use puts you atincreased risk for misusing the opioids. I am concerned for your safety because taking higherdoses than I prescribe puts you at risk for anunintentional overdose. I am concerned that you are losing control of youropioid use and that you have developed a new problem,an addiction. I think the pills are causing more harmthan good. Phoebe Small Groups Skills Practice Session
Guide a peer learner through a patient conversation about opioids Create an Action Plan Incorporating SCOPE of Pain into your curriculum CHRIS Skills Practice Session
Your group should be composed of three people: the patient the health professional (e.g. nurse/physician/social worker) the observer Allow about 1-2 minutes of dialogue until the health professional achieves the tasks; the specific tasks are outlined in the materialsfor the health professional and observer rolesOR appears to be developing a confrontational relationship with thepatient OR gets stuck and asks for help Once someone has stopped the session, observer comments on what went well and what was challenging health professional and patient comment on the conversationfrom their points of view CHRIS Health-Oriented, Risk/Benefit Framework
Do the benefits of opioid treatment outweigh theuntoward effects and risks for this patient (or society)? I am concerned that your cocaine use puts you atincreased risk for misusing the opioids. I am concerned for your safety because taking higherdoses than I prescribe puts you at risk for anunintentional overdose. I am concerned that you are losing control of youropioid use and that you have developed a new problem,an addiction. I think the pills are causing more harmthan good. Chris Weve put the slide from earlier up here to help you come up with the right language to guide your conversations Create an Action Plan Define Analyze WHO are you teaching?
WHAT will you teach? Which aspects of opioid prescribing will be most relevant & will most challenge the learners? Which parts of SCOPE of Pain Toolkit will you use? Other resources you will use? HOW will you teach? How much time? Where & when? Analyze Challenges How to overcome them? Resources Who and/or what can help accomplish the project? CHRIS Debrief What did you learn from using the toolkit?
What worked and what did not? Questions? THANK YOU! Phoebe.Cushman@bmc.org Dan.Alford@bmc.org
Please fill out the paper evaluations Please sign in (near door) if did have not already Provide youron both if we can follow up with you regarding your opioid teaching Phoebe END OFPRESENTATION (AFTER THIS ARE EXTRA SLIDES ONLY) How to Teach When Not theExpert? How to Teach When Not the Expert?
Not being the worlds leading authority on a topiccan make you more effective Impress or Inspire? BIGGEST authority or ACCESSIBLE authority? How to Teach When Not the Expert?
Review the material Dont pretend to know everything Be a resource Teach what you know- and then learn more You know your audience and what they need toknow How to Teach When Not the Expert?
Problems you might face: Strong feelings Be ready to make the distinction between FACT and FANCY Agree to disagree Make a note and do the research You dont know the answer Say you dont know the answer Say you arent sure, that sounds right but Dont be bulldozed by certainty in others How to Teach When Not the Expert?
Talk about why this is important to you: Context iseverything Dont apologize Use your audience and their expertise to guide thediscussion (what do they want to know?)