Safe Prescribing and  Use of Opioids        April 10-12, 2012 Walt Disney World Swan Resort
Accepted Learning Objectives:1. Analyze current professional educationprograms on safe use of opioids and newprograms unde...
Disclosure Statement•  Dr. Daniel P. Alford and Sarah Ball have     disclosed no relevant, real or apparent   personal or ...
Training Physiciansin the Safe and Effective     Use of Opioids                April 11, 2012   Daniel P. Alford, MD, MPH,...
Agenda  Training internal medicine residents and   faculty      National Institute on Drug Abuse (NIDA) sponsored       ...
TrainingResidents   and Faculty
Residents and Faculty                             Educational GoalsSupport	  from	  Na#onal	  Ins#tute	  on	  Drug	  Abuse...
Two-Part Education ProgramDidactic (1-hour PowerPoint lecture)     Assess pain, function and opioid misuse risk     Moni...
OSCE StationsStation 1:   Assess opioid misuse risk and discuss monitoring plan             before starting opioidsStation...
OSCE DescriptionTime(20 min)                           Activity   2       Read station case & specific tasks (3 per case) ...
Station Tasks example
Resident Training              Characteristics N=39  31% reported no previous training in the use of   opioids for managi...
Resident Training Conclusions  At 8 month follow up:       Increased confidence in ability to communicate effectively   ...
Faculty Training - Evaluation of OSCE                                    N=19                                             ...
Confidence                                                                                                  *In the outpat...
Practice                                                                   *In the outpatient setting, with chronic painpa...
PracticeNon-significant changes in…                                             Baseline 3-m f/u Frequency of….     using ...
Confidence to Teach
Confidence to Teach               *                      * p=.001
TeachingWhen precepting a resident caring for a patientwith chronic pain on long-term opioids, howoften do you teach them ...
StatewidePhysician Training
Statewide Physician Training  November 2009 Executive Director, MA Board of Registration  in Medicine (BORIM) approached ...
Statewide Physician Training  June 2010 first live ½ day training (5 CME credits)      6/2010 – 3/2012 completed 7 train...
Live ½ Day Trainings  Didactics     Scope of the problem     Opioid efficacy, safety     Prescription monitoring progr...
Live ½ Day Training Stats                       6/2010-3/2012  1,275 clinicians have attended 7 MA trainings     92% phy...
www.opioidprescribing.com	  
On-line Training  Module 1: Opioid efficacy & safety, assessment & monitoring tools  Module 2: Communicating with patien...
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 ...
Overall Training Stats             Live & On-line: 6/2010-3/2012  Average participant rating 4.42 out of 5  53% particip...
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Daniel Alford

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Safe Prescribing and Use of Opioids
National Rx Drug Abuse Summit 4-11-12

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Daniel Alford

  1. 1. Safe Prescribing and Use of Opioids April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. Accepted Learning Objectives:1. Analyze current professional educationprograms on safe use of opioids and newprograms under development.2. Explain a potentially transformative on-lineeducational tool for health professionals thatenable them to train by interacting with “virtualpatients.”3. Describe a Massachusetts program for trainingphysicians on safe opioid prescribing, and thecurriculum developed to teach residentsand faculty.
  3. 3. 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.
  4. 4. Training Physiciansin the Safe and Effective Use of Opioids April 11, 2012 Daniel P. Alford, MD, MPH, FACP, FASAM Associate Professor of Medicine Boston University School of Medicine Boston Medical Center
  5. 5. 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
  6. 6. TrainingResidents and Faculty
  7. 7. Residents and Faculty Educational GoalsSupport  from  Na#onal  Ins#tute  on  Drug  Abuse  (N02  DA40252)  Center  of  Excellence  for  Physician  Informa#on  
  8. 8. Two-Part Education ProgramDidactic (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 riskOSCE (Objective Structured Clinical Exams)   Performance-based assessments of clinical skills using four 20-minute stations using standardized patients (SP) and immediate faculty observer feedback
  9. 9. OSCE StationsStation 1: Assess opioid misuse risk and discuss monitoring plan before starting opioidsStation 2: Assess cause of aberrant opioid taking behavior and discuss modified treatment planStation 3: Discuss opioid taper due to lack of benefit and apparent risk/harmStation 4: Perform a brief intervention for concurrent substance abuse in patient benefiting from opioids for chronic pain
  10. 10. OSCE DescriptionTime(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
  11. 11. Station Tasks example
  12. 12. 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
  13. 13. 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
  14. 14. Faculty Training - Evaluation of OSCE N=19 Definitely YESIn general the OSCE… % (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)
  15. 15. Confidence *In the outpatient setting, how confident are you…Identifying risk factors for prescription opioid misuseDiscussing risks & benefits of long-term opioid therapyDistinguishing inappropriate “drug seeking” from appropriate “pain reliefseeking” behaviorsDiscussing results of abnormal urine drug testsDiscussing aberrant medication taking behaviorsKnowing when long-term opioid therapy is beneficialStopping opioid therapy due to lack of benefit or increased risk 1=Not at all confident; 5=Very confident 5-pt scale (reliability 0.73) *p=.003
  16. 16. Practice *In the outpatient setting, with chronic painpatients, how often do you……assess pain using a numerical rating score?….assess overall function? 1=Never/Rarely; 5=Always 5-pt scale (reliability 0.69) *p<.05
  17. 17. PracticeNon-significant changes in… 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
  18. 18. Confidence to Teach
  19. 19. Confidence to Teach * * p=.001
  20. 20. TeachingWhen precepting a resident caring for a patientwith chronic pain on long-term opioids, howoften do you teach them about…identifying risk factors for opioid misuseassessing the risks of long-term opioid therapyassessing the benefits of long-term opioid therapymonitoring for prescription opioid misuse of drugsassessing the etiology for aberrant opioid taking behaviorassessing when to stop opioid therapy due to lack of benefit orincreased risk 1=Never/Rarely; 5=Always 5-pt scale (reliability 0.86)
  21. 21. StatewidePhysician Training
  22. 22. 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
  23. 23. 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
  24. 24. 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)
  25. 25. 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
  26. 26. www.opioidprescribing.com  
  27. 27. 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
  28. 28. Module 4: The Interview
  29. 29. Module 4: “Roundtable” Discussion
  30. 30. 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
  31. 31. 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%)

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