Transcript Ruff Oral 2015

Empowering residents to address chronic pain and
prescription opioid misuse in primary care
A.L. Ruff, M.D.1, D. P. Alford, M.D, M.P.H.2, R. Butler3, J.H. Isaacson, M.D.3
1. University of Michigan Medical School, Ann Arbor, MI
2. Boston University School of Medicine, Boston Medical Center, Boston, MA
3. Cleveland Clinic Foundation, Cleveland, OH
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Background
• Residents care for patients with chronic pain on long-term
opioid therapy; many who exhibit signs of prescription
opioid misuse.
• They often feel unprepared and lack confidence in caring
for these patients.
• Resident practice management deficiencies have been
seen in the areas of risk assessment and drug misuse
monitoring.
Colburn, J. L., D. R. Jasinski, and D. A. Rastegar. "Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and
attending physicians in a general medical clinic." Journal of opioid management 8.3 (2012): 153.
Yanni, L. M., et al. "Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic." Journal of opioid management 4.4 (2007):
201-211.
Objective
• Describe an educational intervention for Internal Medicine
residents designed to:
• Improve confidence in safe opioid prescribing for
chronic pain,
• Improve comfort communicating with patients with
chronic pain,
• Lead to self-reported practice change managing
patients taking chronic opioids, and
• Increase perceived support from preceptors for safe
opioid prescribing
Methods
• The intervention included 2 educational sessions for
Internal Medicine senior residents during an ambulatory
block.
• Session one (3 hours) included:
• Lecture on opioid use disorders and chronic pain
• Skills practice session covering patient-centered
communication skills
• Homework: Practice 1 newly-learned skill during at
least 1 patient encounter throughout the subsequent
week.
Methods continued
• Session two (1.5 hours) occurred one week later and
included:
• Debriefing of the patient encounters
• An overview of prescription opioid monitoring
strategies, treatment and resources for opioid use
disorders, and how to discontinue prescription opioids
when appropriate.
Curriculum
Methods: Outcomes
• Pre and post assessments evaluating resident confidence and selfreported practices were performed prior to and following all residents
completing the intervention including:
• Confidence in skills managing patients with chronic pain and
opioid use disorders
• Utilizing appropriate safe opioid prescribing monitoring strategies
including:
• Pill counts, urine drug screens, prescription drug monitoring
programs
• Knowledge of available resources for patients with chronic pain
and opioid addiction
• Perceived preceptor support for safe opioid prescribing practices
Results
• 91 senior residents completed the intervention
• 44 (48%) and 43 (47%) residents completed the pre- and postassessments respectively
• Utilizing a 4-point likert scale (1= strongly disagree, 2= disagree,
3=agree, 4=strongly agree), residents reported improved
confidence in:
• Skills managing patients with chronic pain (2.4 vs 3.0, p
<0.0001)
• Skills identifying which patients with chronic pain have
developed an opioid use disorder (2.4 vs 3.0, p<0.0001)
• Understanding monitoring benefit vs harm in patients on
chronic opioids (2.5 vs 3.0, p<0.0005)
• They noted improved ability to identify additional patient resources for
those with chronic pain and opioid addiction.
Results continued
• They did not report a significant increase in:
• Use of safe opioid prescribing monitoring strategies
• Feelings of being supported in their decisions by
precepting physicians.
• There was a non-significant trend toward improved
resident reported comfort talking to patients with chronic
pain about the need to discontinue opioids due to lack of
benefit or too much harm.
Discussion
• Resident skills in the management of chronic pain and
opioid use disorders can be taught with a brief, focused
intervention increasing:
• Confidence in skills managing patients with chronic
pain
• Confidence in determining which patients with chronic
pain have developed a prescription opioid use
disorder.
• Self-reported understanding of the risk/benefit
framework surrounding the use of these medications.
• Confidence in their knowledge of patient resources for
these disorders.
Discussion continued
• Despite these improvements, residents did not self-report
an increase in their use of opioid monitoring strategies.
• Possible reasons why rates may not have increased
include:
• Only residents underwent training
• Unreliable patient continuity in resident clinic
• Limited survey design
Lum, Paula J., et al. "Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings." JAIDS Journal of Acquired Immune Deficiency
Syndromes 56 (2011): S91-S97.
Wenghofer, Elizabeth Francis, et al. "Survey of Ontario primary care physicians’ experiences with opioid prescribing." Canadian Family Physician 57.3 (2011): 324-332.
Dobscha, Steven K., et al. "Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates." Pain Medicine9.5 (2008): 564-571.
Chaudhry, Sarah R., et al. "Primary Resident Physician: Improving Continuity of Care." Journal of Graduate Medical Education 7.2 (2015): 291-292.
Neher, Jon O., Gary Kelsberg, and Drew Oliveira. "Improving continuity by increasing clinic frequency in a residency setting." FAMILY MEDICINE-KANSAS CITY- 33.10 (2001): 751-755.
Garfunkel, Lynn C., et al. "Resident and family continuity in pediatric continuity clinic: nine years of observation." Pediatrics 101.1 (1998): 37-42.
Discussion continued
• Lack of improvement in resident comfort discussing the
need to discontinue opioids with their patients may be the
result of
• Skill difficulty
• Limited time allotted in this short intervention
• In the future, more time will need to be devoted to allowing
learners to practice their skills in this area and the addition
of a second role play may be beneficial.
Nestel, Debra, and Tanya Tierney. "Role-play for medical students learning about communication: Guidelines for maximising benefits." BMC Medical Education 7.1 (2007): 3.
Manzoor, Iram, Fatima Mukhtar, and Noreen Rahat Hashmi. "Medical students’ perspective about role-plays as a teaching strategy in community medicine." J Coll Physicians
Surg Pak 22.4 (2012): 222-5.
Discussion continued
• It was our hypothesis that educating residents would
“trickle up” to preceptors, resulting in residents feeling
increasingly supported by their preceptors in utilizing
newly learned decision making skills.
• No change was noted following the teaching intervention.
• More focus will need to be placed on including preceptors
in this type of educational intervention.
Limitations
• Response rate was below 50% (48% and 47%
respectively).
• It is unknown if residents who did not complete the
survey had a similar experience to those that did.
• All data was self-reported and may differ from actual skills
and practices.
• Social desirability bias may have led residents to overreport “good” behavior.
Limitations continued
• Study did not evaluate how improvement in resident
confidence affects patient care and patient experience
and further study will be needed in this area.
• Study also did not evaluate preceptor opinions and
impressions regarding the resident’s changed approach.
Conclusion
• A brief, focused educational intervention can improve
residents’ confidence in safe opioid prescribing for chronic
pain but did not lead to self-reported practice change
managing patients taking chronic opioids.
• Residents did not perceive increased support in their
decision making by precepting physicians despite the
intervention.
• How this change in confidence affects patient care
requires further study.
• This model can be adapted to trainees in many areas.
References
Colburn, J. L., D. R. Jasinski, and D. A. Rastegar. "Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients
treated by resident and attending physicians in a general medical clinic." Journal of opioid management 8.3 (2012): 153.
Yanni, L. M., et al. "Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic." Journal of
opioid management 4.4 (2007): 201-211.
Lum, Paula J., et al. "Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings." JAIDS
Journal of Acquired Immune Deficiency Syndromes 56 (2011): S91-S97.
Wenghofer, Elizabeth Francis, et al. "Survey of Ontario primary care physicians’ experiences with opioid prescribing." Canadian Family
Physician 57.3 (2011): 324-332.
Dobscha, Steven K., et al. "Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates." Pain
Medicine9.5 (2008): 564-571.
Chaudhry, Sarah R., et al. "Primary Resident Physician: Improving Continuity of Care." Journal of Graduate Medical Education 7.2 (2015): 291-292.
Neher, Jon O., Gary Kelsberg, and Drew Oliveira. "Improving continuity by increasing clinic frequency in a residency setting." FAMILY MEDICINEKANSAS CITY- 33.10 (2001): 751-755.
Garfunkel, Lynn C., et al. "Resident and family continuity in pediatric continuity clinic: nine years of observation." Pediatrics 101.1 (1998): 37-42.
Nestel, Debra, and Tanya Tierney. "Role-play for medical students learning about communication: Guidelines for maximising benefits." BMC
Medical Education 7.1 (2007): 3.
Manzoor, Iram, Fatima Mukhtar, and Noreen Rahat Hashmi. "Medical students’ perspective about role-plays as a teaching strategy in community
medicine." J Coll Physicians Surg Pak 22.4 (2012): 222-5.