daniel alford

Safe Prescribing and Use of Opioids

April 10-12, 2012 Walt Disney World Swan Resort

Accepted Learning Objectives: 1. Analyze current professional education programs on safe use of opioids and new programs under development. 2. Explain a potentially transformative on-line educational tool for health professionals that enable them to train by interacting with “virtual patients.” 3. Describe a Massachusetts program for training physicians on safe opioid prescribing, and the curriculum developed to teach residents and faculty.

Disclosure Statement

•  Dr. Daniel P. Alford and Sarah Ball have  disclosed no relevant, real or apparent personal or professional financial relationships.

•  Benjamin Lok has disclosed that he has a relationship with Shadow Health, Inc.

April 11, 2012

Daniel P. Alford, MD, MPH, FACP, FASAM Associate Professor of Medicine

Boston University School of Medicine Boston Medical Center

Training Physicians in the Safe and Effective

Use of Opioids

Agenda   Training internal medicine residents and

faculty  National Institute on Drug Abuse (NIDA) sponsored

teaching residents and faculty using Objective Structured Clinical Exams (OSCE)

  Statewide physician training  Massachusetts Board of Registration in Medicine

sponsored ½ day conferences and on-line training

Training Residents

and Faculty

Residents and Faculty Educational Goals

Support  from  Na#onal  Ins#tute  on  Drug  Abuse  (N02  DA40252)  Center  of  Excellence  for  Physician  Informa#on  

Two-Part Education Program

Didactic (1-hour PowerPoint lecture)   Assess pain, function and opioid misuse risk

  Monitor for opioid benefits and risks

  Identify and manage opioid misuse

  Identify exit strategies for lack of benefit and/or increased risk

OSCE (Objective Structured Clinical Exams)   Performance-based assessments of clinical skills using four 20-minute

stations using standardized patients (SP) and immediate faculty observer feedback

OSCE Stations

Station 1: Assess opioid misuse risk and discuss monitoring plan before starting opioids

Station 2: Assess cause of aberrant opioid taking behavior and discuss modified treatment plan

Station 3: Discuss opioid taper due to lack of benefit and apparent risk/harm

Station 4: Perform a brief intervention for concurrent substance abuse in patient benefiting from opioids for chronic pain

OSCE Description

Time (20 min) Activity

2 Read station case & specific tasks (3 per case)

10 SP interview

1 Learner self-assess “What was the most challenging part of the interview?”

1 SP assess learner “How did the interaction feel to you?”

5 Faculty observer gives feedback to learner

1 Move to next station

Station Tasks example

Resident Training Characteristics N=39

  31% reported no previous training in the use of opioids for managing chronic pain

  74% reported that their prior training was not enough

  23% reported starting patients on long-term opioids in the past three months

Resident Training Conclusions

  At 8 month follow up:   Increased confidence in ability to communicate effectively

with patients with chronic pain on long-term opioids

  Increased self-reported safe and effective opioid prescribing practices

  OSCEs are time consuming   Can only train a small number of residents at one time

  Training faculty who precept residents using a “train the trainers” model may be more efficient way to train more residents

Faculty Training - Evaluation of OSCE N=19

In general the OSCE…

Definitely YES

% (n)

Taught me something new 100 (19)

Was a valuable learning tool 100 (19)

Provided me with valuable feedback 95 (18)

Evaluated my skills fairly 95 (18)

Provided a good cross-section of opioid prescribing issues 95 (18)

Stimulated me to learn more about opioid prescribing 84 (16)

Helped me identify my strengths and weakness 84 (16)

Resembled real life clinical encounters 84 (16)

Confidence

In the outpatient setting, how confident are you…

Identifying risk factors for prescription opioid misuse

Discussing risks & benefits of long-term opioid therapy

Distinguishing inappropriate “drug seeking” from appropriate “pain relief seeking” behaviors

Discussing results of abnormal urine drug tests

Discussing aberrant medication taking behaviors

Knowing when long-term opioid therapy is beneficial

Stopping opioid therapy due to lack of benefit or increased risk

*

*p=.003

1=Not at all confident; 5=Very confident 5-pt scale (reliability 0.73)

Practice

In the outpatient setting, with chronic pain patients, how often do you… …assess pain using a numerical rating score?

….assess overall function?

*p<.05

*

1=Never/Rarely; 5=Always 5-pt scale (reliability 0.69)

Practice

Baseline 3-m f/u

Frequency of…. using controlled substance agreement 4.59 4.76

conducting urine drug testing 4.12 4.18

conducting pill counts 1.91 1.71

1=Never/rarely, 5=Always

Non-significant changes in…

Confidence to Teach

Confidence to Teach

* p=.001

*

Teaching

When precepting a resident caring for a patient with chronic pain on long-term opioids, how often do you teach them about… identifying risk factors for opioid misuse

assessing the risks of long-term opioid therapy

assessing the benefits of long-term opioid therapy

monitoring for prescription opioid misuse of drugs

assessing the etiology for aberrant opioid taking behavior

assessing when to stop opioid therapy due to lack of benefit or increased risk

1=Never/Rarely; 5=Always 5-pt scale (reliability 0.86)

Statewide Physician Training

Statewide Physician Training

  November 2009 Executive Director, MA Board of Registration in Medicine (BORIM) approached BU CME office regarding increasing number of complaints regarding opioid prescribing and need to train physician in safe and effective opioid prescribing

Statewide Physician Training

  June 2010 first live ½ day training (5 CME credits)

  6/2010 – 3/2012 completed 7 trainings with 8th scheduled for 6/2012

  Funding SAMHSA or Pharma and modest registration fee ~$75

  Marketed by BORIM “Dear Colleague” email

  February 2011 www.opioidprescribing.com was launched (4 CME credits)

  Funding SAMHSA and MA BORIM with NO registration fee

  Concurrently…

  August 2010 MA enacted a law mandating physician education to be implemented by BORIM

  February 2012 BORIM requires 3 hours of opioid prescribing CME

Live ½ Day Trainings

  Didactics

  Scope of the problem

  Opioid efficacy, safety

  Prescription monitoring program

  Assessment & monitoring tools

  Communicating w/ patients, risk- benefit framework

  Exit strategies, addiction treatment

  Case discussion/video demonstrations

  Panel discussion (Board of Registration, Department of Public Health, DEA, State Police, AG office)

Live ½ Day Training Stats 6/2010-3/2012

  1,275 clinicians have attended 7 MA trainings   92% physicians

  51% Primary Care (IM/FM)

  13% psych

  35% other

  8% NP/PA, RN, or Other

  Each training reached capacity w/in 48 hrs of publicity with waiting lists >100 per training

  March 2012 training sponsored by VT BORIM

  Talks underway with NH and RI

www.opioidprescribing.com  

On-line Training   Module 1: Opioid efficacy & safety, assessment & monitoring tools

  Module 2: Communicating with patients & psychiatric co-morbidities

  Module 3: Case study

  Module 4: Three video vignettes   Starting opioids, discussing monitoring   Assessing aberrant opioid taking behavior, increasing monitoring   Addressing lack of benefit and excessive risk, discontinuing opioid

Module 4: The Interview

Module 4: “Roundtable” Discussion

On-line Training Stats 2/2011-3/2012

  8109 users   65% MD/DO   17% Dentists   12% NP/PA   2% RN   4% other

  14% of users from out-of-state

Overall Training Stats Live & On-line: 6/2010-3/2012

  Average participant rating 4.42 out of 5

  53% participants made a commitment to change practice with most common answers:

  Use pill counts, urine drug tests (27%)   Better documentation (12%)   Use patient agreements, informed consents (12%)   Use prescription monitoring program (5%)   Change in educating or communicating w/ pts (3%)