Mechanisms Surrounding Unsafe Opioid Prescribing in an SP Based Simulation Module
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1 Mechanisms Surrounding Unsafe Opioid Prescribing in an SP Based Simulation Module Department of Anesthesiology, Perioperative & Pain Medicine Jordan Newmark MD, Clinical Assistant Professor Marissa Heirich, Clinical Research Coordinator
2 Institute of Medicine Report 100 million American adults suffer from chronic pain Pain costs the US over $600 billion / year in treatment and lost productivity Across health care and society alike, there are major gaps in knowledge / education about pain IOM Report. Relieving Pain in America. 2011
3 Pain Education in North American Medical Schools Pain taught during other courses, and not in-of-itself Mean = hrs Mode = 4 hrs 16.3% of US medical schools offer a pain elective Opioid management underrepresented ACGME Program Requirements Residency Program Acute Pain Chronic Pain Family Medicine Yes No Internal Medicine No No Anesthesiology Yes Yes PM&R Yes Yes Neurology No Pain/Palliative Mgt Psychiatry No Dx Intractable Pain Emergency Medicine Procedural No Orthopedic Surgery No No Mezei L, Murinson BB. J Pain
4 CDC Data
5 Simulation Goals Reduce harm to patients and society from prescription opioids Know risk factors for opioid addiction Utilize opioid related diagnostic and management strategies Learner Demographics Pain Medicine Fellows Anesthesia and PM&R Residency N =18 Anesthesia Residents, Chronic Pain Rotation N =2
6 Simulation Methodology Orientation to simulation and SP Outpatient clinic encounter 40 minutes Outside records given from ED On-site REMS tools available Brief dictation written by learner Group debriefing with pain faculty Feedback/evaluations provided by SP and learner
7 Referral: From ED to pain clinic regarding chronic neck pain, frequent ED visits with hydromorphone refill requests HPI 39y F s/p MVA 2 years ago, now has axial chronic neck pain HM is the only medication that works, experiences cravings Prior PO morphine was not helpful No symptoms v/w radiculopathy, occulant malignancy, SCI Pt s PCP does not prescribe opioids Today she took her last HM tablet PMHx Bipolar Depression SP Clinical Story
8 SP Clinical Story Medications: HM 2-4mg tabs 2-6 per day prn Trileptal 600mg BID Physical Exam: VS WNL. B/L cervical paraspinal muscle trigger points Neuro exam WNL Social Hx: 1PPD tobacco use, occasional EtOH use. No illicit drugs Works at art museum. College degree in fine arts Conflicts with her boss for being sedated at work Once caught selling HM to a friend at work for their headaches FHx: Father alcoholic, whom sexually molested pt at age 12 Mother abused thyroid meds for weight loss Prior Diagnostics: MRI, 5 months prior non-specific age related changes REMS Elements: Opioid Risk Tool (ORT) High Risk PADT / 4As As per H&P UDS-POCT (+) opioids / HM only CURES Multiple, simultaneous, 1 o undisclosed providers
9 FDA Risk Evaluation & Mitigation Strategy (REMS) Opioid REMS Element Chronic Opioid Treatment Informed Consent Patient-Provider Agreement (PPA) Regular office visits Use of screening questionnaires / tools: Opioid Risk Tool (ORT) Pain Assessment & Documentation Tool / 4 A s Controlled Substances Utilization & Evaluation System (CURES) Urine Drug Screening-Point of Care Testing (UDS-POCT)
10 Management Approach I. Pt Data: opioid medication(s), dosing, and sources PDMP / CURES Urine Drug Screen Pill Count Opioid Risk Scale (ORT) Pain Assessment & Documentation Tool (PADT) & 4 A s Clinical Opioid Withdrawal Scale (COWS) Outside records and/or communication with OSH providers II. Arrive at a diagnosis (eg- tolerance, misuse, abuse, addiction) III. Decision on assuming opioid prescribing and associated care Informed consent Patient-provider agreement Dosing*, frequency of f/up, & refills (length of leash) Addiction Medicine consult Other resources (eg- complex care/social work consult)
11 Simulation Results Treatment Plan Opioid Use Discussed with SP Prescribed Opioid Opioid Rotation Opioid Wean Opioid Contract Limited Supply Addiction Consult Percent of Participants (%) No Discussion Tolerance / Dependence At Risk Opioid Addiction
12 Analysis Thomas Kilmann Conflict-Mode Instrument (TKI) Roter Interaction Analysis System (RIAS)
13 Thomas Kilmann Conflict Mode Instrument (TKI) Thomas Kilmann Conflict-Handling Modes vs. RIAS Global Affect Overall Score (OSSP) Dominance / Assertiveness Engagement / Responsiveness Collaborating Pearson Correlation.453*.455*.491* Avoiding Sig. (2- tailed) Pearson Correlation * -.541* Sig. (2- tailed) *Correlation is significant at the 0.05 level (2-tailed).
14 Roter Interaction Analysis System (RIAS) Analysis of interactions across medical and health care contexts, including: o Adult primary care o Emergency medicine o OB/GYN o Family planning o Surgical visits o Oncology o Pediatrics o Dentistry o Veterinary medicine o Genetics counseling o Telemedicine o Nursing o Mental health o Podiatry o Adolescent Medicine o Psychiatry Coding of multiple-speaker dyads (e.g., primary doctor-patient; primary doctor-3rd party; veterinarianclient; pediatrician-parent; pediatrician-child; medical assistant-patient; nurse-3rd party)
15 Roter Interaction Analysis System (RIAS) RIAS Coding Categories (selected of 40) Personal remarks, social conversation Shows concern or worry Reassures, encourages or show optimism Shows disapproval direct Back-channel responses Empathy statements Legitimizing statements Asks for reassurance Gives orientation, instructions Asks closed-ended questions medical condition Asks open-ended questions psychosocial Counsels - lifestyle Global Affect Ratings (selected of 10) Anger / Irritation Anxiety / Nervousness Dominance / Assertiveness Interest / Attentiveness Friendliness / Warmth Responsiveness / Engagement Sympathetic / Empathetic Hurried / Rushed
16 Analysis RIAS Global Affect Patient Provider Interaction (PPI) Overall Score (OSSP) Anger / Irritation -.542* -.447* Anxiety / Nervousness Interest / Attentiveness Warmth / Friendliness Sympathetic / Empathetic Engagement / Responsiveness -.543* -.637**.614**.583**.498*.502*.695**.623** * Respectfulness.738**.666** **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).
17 Discussion Our pilot findings suggest physicians global affect and conflict-handling have effects on both patientreported outcomes and decision making in a simulated opioid interaction. While sympathy played a role in building social rapport and higher patient satisfaction, it also influenced physicians prescribing decisions for a high risk patient. Physicians who were rated with higher sympathy scores (M=4.60, SD=.737) were more likely to prescribe opioids than those with lower scores (M=3.00, SD= 1.000); t(18) = 3.292, p=
18 Limitations Simulation RIAS Sympathy vs. Empathy Sample size
19 Future Directions Empathy Training is an Essential Learning Objective recognized by the American Association of Medical Colleges (AAMC) Future Simulations Utilization of Jefferson Scale of Physician Empathy Include wider range of disciplines (PCPs, other specialties)
20 Acknowledgements Many thanks to our simulation actors, participants, and the following Stanford Medicine affiliates: Division of Pain Medicine Systems Neuroscience and Pain Laboratory (SNAPL) Center for Immersive and Simulation-Based Learning (CISL)
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