daniel alford
TRANSCRIPT
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%)