Transcript Christopher Shanahan, MD, MPH

Teaching
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
Facilitated Discussion
What challenges have you experienced, or do
you anticipate experiencing, in teaching
(colleagues, students, faculty, staff) opioid
prescribing for chronic pain?
Teaching
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
Faculty & Disclosures
Phoebe Cushman, MD
General Internal Medicine Fellow
Boston University
Christopher Shanahan, MD, MPH
Assistant Professor of Medicine
Boston University
Daniel Alford, MD, MPH
Associate Professor of Medicine
Boston University
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
Workshop Aim

To teach you how to instruct learners at your home
institution in opioid prescribing by applying concepts
from SCOPE of Pain: Safe and Competent Opioid
Prescribing Education

The aim is NOT to provide a comprehensive
understanding of managing opioids for chronic pain

Instead, we recommend that you complete the 3
modules of www.SCOPEofpain.org

Your learners will also benefit from completing the
modules prior to your teaching session
Workshop Objectives
In your role as a teacher, educator, trainer…

Recognize effective communication strategies for conversations
with patients who take opioids for chronic pain

Develop a risk-benefit framework in which to evaluate patients
who take opioids for chronic pain

Guide a peer learner through a patient conversation about opioids

Identify challenges and facilitators to teaching opioid prescribing
in your institution

Create an Action Plan for incorporating SCOPE of Pain into your
curriculum
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 opioid
prescribing
– Skills practice helps learners practice their communication
skills

Develop an Action Plan for your institution
What is ER/LA Opioids REMS?

Risk Evaluation and Mitigation Strategy: FDAmandated program including prescriber education,
patient education, package inserts, etc.

July 2012, FDA required a class-wide REMS from the
21 manufacturers of ER/LA Opioid Analgesics (REMS
Program Companies [RPC])
– FDA created essential content (Blueprint) for prescriber
education
– RPC to fund accredited CME providers
– SCOPE of Pain is an ER/LA Opioid REMS program
ER/LA Opioids REMS Goal
“to reduce serious adverse outcomes
(addiction, unintentional overdose, death)
resulting from inappropriate prescribing,
misuse, and abuse of ER/LA opioid
analgesics while maintaining patient access
to pain medications”
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
What Are the “Tools” in the Trainers’ Toolkit?
 Flexible
 All exercises can be completed a 45-minute grand
rounds 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
What Are the “Tools” in the Trainers’ Toolkit?
7 video vignettes
 2 video/power point presentations
 1 case discussion
 1 skill practice session (role play)

Case 1: Mr. Robinson (new patient)
62 year old male with chronic lower back, hip, and knee
pain 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 2
months 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
Case 1: Mr. Robinson
Substance use 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
Video: Mr. Robinson
Please note, video is available at SCOPEOFPAIN.ORG
Case 1: Mr. Robinson

How would you assess the patient’s level of
pain?
The PEG Scale
In the past week, how much:
Pain on average?
0
1
2
3
4
5
6
7
8
9
10
As bad as you
can imagine
No pain
Pain interfered with Enjoyment of life?
0
1
2
3
4
5
6
7
Does not
interfere
8
9
10
Completely
interferes
Pain interfered with General activity?
0
1
2
3
Does not
interfere
Krebs EE, et al. J Gen Intern Med. 2009;24(6):733-8.
4
5
6
7
8
9
10
Completely
interferes
Case 2: Mr. Russo (established patient at follow-up)
48 yo man with chronic posttraumatic right knee and
ankle pain s/p infected compound fractures from a
motorcycle accident 5 years ago. He always reports his
pain as 4-5 out of 10.
SH: Lives with girlfriend, no children. His cashier job in his friend’s
store allows him to sit most of the day. + past history of marijuana
use disorder > 10 years ago, denies other illicit drug use, no history
of tobacco or alcohol use disorder.
Current pain medications: Hydrocodone 5 mg/acetaminophen
500 mg 2 tabs po TID, Ibuprofen 800 mg po TID
Physical exam: Right knee and ankle are severely deformed with
very limited range of movement. He walks with a cane.
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 his
visit? Practice how you would frame the discussion.
Video: Mr. Russo
Please note, video is available at SCOPEOFPAIN.ORG
What is your role?
Not
Nicolaidis C. Pain Med. 2011;12(6):890-7.
Use a Health-Oriented, Risk/Benefit Framework
NOT…
• Is the patient good or bad?
• Does the patient deserve
opioids?
• Should this patient be
punished or rewarded?
• Should I trust the patient?
RATHER…
Do the benefits of opioid
treatment outweigh the
untoward effects and risks
for this patient (or society)?
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 the
untoward effects and risks for this patient (or society)?
•
“I am concerned that your cocaine use puts you at
increased risk for misusing the opioids.”
•
“I am concerned for your safety because taking higher
doses than I prescribe puts you at risk for an
unintentional overdose.”
•
“I am concerned that you are losing control of your
opioid use and that you have developed a new problem,
an addiction. I think the pills are causing more harm
than good.”
Small Groups
1) Skills Practice Session
• Guide a peer learner through a patient
conversation about opioids
2) Create an Action Plan
• Incorporating SCOPE of Pain into your
curriculum
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 materials
for the health professional and observer roles OR
 appears to be developing a confrontational relationship with the
patient 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 conversation
from their points of view
Health-Oriented, Risk/Benefit Framework
Do the benefits of opioid treatment outweigh the
untoward effects and risks for this patient (or society)?
•
“I am concerned that your cocaine use puts you at
increased risk for misusing the opioids.”
•
“I am concerned for your safety because taking higher
doses than I prescribe puts you at risk for an
unintentional overdose.”
•
“I am concerned that you are losing control of your
opioid use and that you have developed a new problem,
an addiction. I think the pills are causing more harm
than good.”
Create an Action Plan

Define
– 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?
Debrief
• What did you learn from using the toolkit?
• What worked and what did not?
• Questions?
THANK YOU!


Please fill out the paper evaluations
Please sign in (near door) if did have not already

Provide your email on both if we can follow up with you
regarding your opioid teaching

[email protected]
[email protected]
[email protected]


END OF
PRESENTATION
(AFTER THIS ARE EXTRA SLIDES ONLY)
32
How to Teach When Not the
Expert?
How to Teach When Not the Expert?

Not being the world’s leading authority on a topic
can make you more effective

Impress or Inspire?

BIGGEST authority or ACCESSIBLE authority?
How to Teach When Not the Expert?
1.
Review the material
2.
Don’t pretend to know everything
3.
Be a resource
4.
Teach what you know- and then learn more
5.
You know your audience and what they need to
know
How to Teach When Not the Expert?
Problems you might face:
1. Strong feelings…
– Be ready to make the distinction between FACT and FANCY
– Agree to disagree
– Make a note and do the research
2.
You don’t know the answer
– Say you don’t know the answer
– Say you aren’t sure, that sounds right but…
– Don’t be bulldozed by certainty in others
How to Teach When Not the Expert?
3.
Talk about why this is important to you: Context is
everything
4.
Don’t apologize
5.
Use your audience and their expertise to guide the
discussion (what do they want to know?)