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

1. Safe Prescribing and
Use of Opioids
April 10-12, 2012
Walt Disney World Swan Resort

2. 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.

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. Training Physicians
in 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. 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. Training
Residents
and
Faculty

7. Residents and Faculty
Educational Goals
Support
from
Na#onal
Ins#tute
on
Drug
Abuse
(N02
DA40252)
Center
of
Excellence
for
Physician
Informa#on

8. 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

9. 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

10. 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

11. Station Tasks example

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. 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. Faculty Training - Evaluation of OSCE
N=19
Definitely
YES
In 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. 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
1=Not at all confident;
5=Very confident
5-pt scale (reliability 0.73)
*p=.003

16. Practice
*
In the outpatient setting, with chronic pain
patients, 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. Practice
Non-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. Confidence to Teach

19. Confidence to Teach
*
* p=.001

20. 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)

21. Statewide
Physician
Training

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. 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. 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. 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. www.opioidprescribing.com

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

29. Module 4: The Interview

30. Module 4: “Roundtable” Discussion

31. 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

32. 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%)