The majority of primary care providers did not receive adequate training to detect, prevent, and manage patients at the interface of pain and addiction (CASA, 2005). But there are currently little data to guide training development so that it emphasizes the specific areas of greatest need. We surveyed a convenience sample of twenty-seven primary care providers (9 physicians, 9 residents, and 9 nurse practitioners) retrospectively about their training at the interface of treating pain and addiction. They were asked to rate their agreement that their clinical training adequately prepared them in 9 specific areas. The responses were very similar for each of the three groups. Sixty-four percent (64%) of participants disagreed (either strongly disagreed or disagreed) that they were adequately prepared to treat pain in patients in recovery. Sixty percent (60%) disagreed that they were prepared to treat pain in patients with current addictions. And 52% disagreed that they were adequately prepared to treat patients at risk for addiction. Perception of their training to assess pain in the context of addiction issues was more positive. Of the participants, 48% agreed or strongly agreed that they were adequately prepared to recognize addiction in a pain patient; still 28% disagreed. Similarly, 48% agreed or strongly agreed that they were adequately prepared to recognize patients at risk for addiction; but 36% disagreed. Primary care providers do not feel adequately prepared by their training in pain and addiction, especially in the areas of treatment. Training needs related to treatment increase as the risk of addiction increases. Educational curricula are needed to ensure that pain treatment providers have the skills necessary to assess and treat patients at the interface of pain and addiction. Reference: CASA. Under the counter: The diversion and abuse of controlled prescription drugs in the U.S., 2005.

Background: Using NIH/NIDA SBIR funds, we are developing a Web-based curriculum for medical students to improve competence and clinical skills performance on treating pain patients with opioids and minimizing risk of opioid misuse.

Objective: To obtain faculty feedback regarding the ability of the proposed curriculum to fill practice gaps and impact clinical skill through practice via chat-based, online standardized patient interviews.

Methods: Through consultants and the AMERSA member list, we recruited preclinical and clinical faculty who teach students about pain or addiction topics. Faculty completed an on-line survey, consisting of structured and open-ended questions about the preliminary curriculum, and a short follow-up phone interview.

Results: Nine faculty (n=9) from seven medical schools participated. They identified topics that are well covered or not fully covered in medical curricula. Faculty provided constructive feedback to improve learning objectives and align topics with curriculum gaps. Suggestions included: 1) simplifying material on patient monitoring and risk reduction, 2) stressing proper screening to assess risk of misuse or diversion before prescribing opioids, and 3) focusing on adequately treating pain while minimizing the risk of potential opioid misuse. Faculty reported that students were under-prepared in most of the topics proposed. Most faculty (89%) agreed or strongly agreed that each proposed course would strengthen clinical skills. A majority (67%) felt that a SP interview in each course would enhance mastery of clinical skills, and 78% agreed or strongly agreed that a chat-based standardized patient interview would be beneficial to student learning.

Conclusions: Faculty needs analysis affirmed that curriculum and performance gaps exist on adequately treating pain patients with opioids. Constructive feedback allowed us to revise our curriculum plan and more closely align each module with ACGME and medical student competencies. Our revised curriculum plan will be re-reviewed by faculty before module development. Preliminary findings lend support to future acceptance of our finalized program.

Assessing the Impact on Medical Students of an Online Curriculum on Opioid Dependence and Treatment

Mary P. Metcalf, PhD, MPH; T. Bradley Tanner, MD; Susan Wilhelm, PhD

Clinical Tools, Inc. 1506 E. Franklin St, #200, Chapel Hill, NC

Objectives: To develop and assess the impact of an online supplemental curriculum for medical students on various medical knowledge/competency, attitude, and performance measures.

Background: Treatment with buprenorphine is effective and can be conducted in a variety of settings by primary care providers. However, a number of biases exist towards treatment of opioid dependence in primary care. Medical school is an opportune time to addresses -and hopefully decrease – these biases with future physicians.

Methods: An online curriculum of 5 modules for medical students was created, focusing on basic skills of opioid abuse detection and treatment. A convenience sample of 24 volunteer medical students (n=24) at different institutions in years 2-4 completed a OSCE style interview of an SP via chat, completed the educational program, and then re-interviewed the SP. Measures assessed impact on medical knowledge, competency, attitude, and self-efficacy/intended behavior. Clinical skills were assessed using a Communication/Interpersonal Skills rating form and a Clinical Encounter Performance Checklist completed by the SP and an observer.

Results: Medical knowledge/competency increased from a pre-experience average of 68% to an post-test average of 83% ( p<0.05). Average self-efficacy scores increased (p<0.05) and Clinical Encounter Performance Checklist score increased for 84% of participants (p<0.05). Two-thirds of students improved Interpersonal Skills/Communication checklist scores, although the improvement was not statistically significant for this measure. Additional analysis are in process.

Conclusion: Medical student knowledge, competency, self-efficacy and performance were shown to be improved by the educational intervention. Attitude towards treatment of opioid dependence and interpersonal skills related to clinical encounters with possibly substance abusing patients did not show the improvement we had hoped. The intervention is being modified to address these issues more directly.

Purpose (217/250): Pain and addiction issues are common challenges for physicians. Comorbid substance abuse affects 20 - 40% of patients on opioid therapy for chronic pain. Non-medical use of opiates is common and an indicator of their abuse potential: an estimated 6.2 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health. Health professionals may be unaware that addiction is often uncommon among patients being treated for pain; and even when present, there are effective treatment options available.

At the completion of their training, medical students lack clinical skills in assessing pain and addiction potential which can lead to under treatment of pain, overuse of opioids in at-risk patients, diversion, exposure to addictive substances without proper monitoring, and worsening of prior addictive disease. Medical schools currently lack a comprehensive and efficient solution to meet their students' need.

Using funding from the National Institute on Drug Abuse, we developed an online curriculum for undergraduate medical students on the use of opioids to treat pain when substance abuse is a concern. The curriculum is designed to appeal to medical school course and clerkship directors and to instructors who teach topics related to pain control and assessment, and includes interactive online materials and 7 Standardized Patient cases.

Method(s) (166/250):The authors conducted a needs analysis with medical school faculty members (n=24), resident physicians (n=9), and current medical students (n=20) regarding the need for more instruction on assessment of pain and addiction, and to evaluate proposed topics. A mixed methods technique used online surveys with closed and open ended questions, and semi-structured interviews, yielding both qualitative and quantitative results. Results were used to assess need, measure interest, and determine the most relevant aspects of the curriculum plan for medical students.

A full curriculum was developed based on evidence-based guidelines for opiate prescribing published in February of 2009 by the American Pain Society (APS), the American Academy of Pain Medicine (AAPM), and the Oregon Evidence-based Practice Center at Oregon Health, and published literature found using PubMed searches. Content was aligned with AAMC and ACGME competencies. Seven instructional “Remote Live Standardized Patient (RLSP)” cases were created using an iterative expert review process. The SP s are “interviewed” by the medicals students using internet based “chat” (e.g. Google chat/similar).

Results (168/300): Faculty (n=15) all strongly agreed/agreed that there was a need (score 4.40 +/- 0.51 on a 5 point Likert scale). Additionally, resident physicians reported feeling insufficiently prepared by their medical school training to deal with issues of overlapping pain and substance abuse. A second, iterative round of need analysis with different medical school faculty (n=9) and current medical students (n=20) was used to assess the draft curriculum plan and RLSP cases. In particular, medical students had a positive response to the concept and were generally receptive to the use of chat-based Standardized Patients.

A curriculum outline including 9 one hour online modules and 7 SP cases has been developed. To allow medical school faculty to integrate either the entire program or the most relevant portions into their current programs, the curriculum is cross-referenced with the APS and AAPM guidelines, and AAMC competencies. The program includes evaluative components for both quantitative and qualitative feedback from students and supervising faculty.

A summative evaluation with medical students will begin in 2010-2011.

Conclusion (93/100):: An evidence based curriculum has been created that includes necessary clinical skills competencies, medical knowledge, and the most up to date practice guidelines. The curriculum matches needs identified by faculty. Future research will asses if the curriculum improves the training and self-efficacy of medical students/future physicians. Although difficult to measure, it is hoped that better trained medical students will deal more effectively with the complicated issues that arise in treating pain, especially in terms of demonstrating appropriate awareness of the risks to the patient in terms of existing or potential substance use problems.

Purpose (209/250): The majority of providers in the pain practice community have not fully incorporated evidence-based and clinical consensus recommendations for preventing, recognizing, and managing substance misuse and addiction in pain patients. This problem exists despite the fact that the recommendations are not difficult to understand, resources exist, and the risk of mistreatment is obvious [and deleterious for the physician as well as patient]. The majority of these providers did not receive adequate training to detect, prevent, and manage patients at the interface of pain and addiction. More specifically, the problems include: 1) Existing training programs give little attention to the problem of substance misuse and addiction in pain patients, 2) Addiction potential is not seen as a comprehensive understanding of the varying risk in addiction potential, severity, type, history, impact, or duration, 3) Existing training typically focuses on knowledge acquisition rather than skills training, and, 4) Pain treatment providers have little time thus they need quick and simple access to high quality addiction resources when managing pain patients.

To address these problems we have created an online environment that enables pain management providers to better manage co-morbid substance misuse and addiction or risk for addiction in patients suffering from pain, using contract funding from the National Institute on Drug Abuse.

Method(s) (160/250): During 2008 we assembled a panel of 12 pain and addiction expert consultants, including physicians, nurses, researchers, and a psychologist. An extensive needs analysis was conducted with primary care providers and with pain and addiction experts (N=56); they provided feedback about the target audience's educational needs and online learning preferences and the proposed education plan.

Usability tests with two different groups of pain management providers (physicians, and nurse-practitioners) were conducted during 2009. The primary focus was to assess the interface of the online "chat-based" standardized patient (SP) interview experience using mixed methods including "think aloud", qualitative surveys and open ended interview questions. Additionally, participants were asked to provide feedback on a "self-assessment" tool which will be included in the training program.

Iterative rounds of review from experts were employed to assess the educational content of the continuing education modules, SP cases, and the informational Guides. Resources were added to an online database based on expert recommendation, Google(R), and PubMed searches.

Results (217/300): We have designed an online environment for pain management providers that provides a unique combination of skills training/continuing education, resources, and collaboration related to the topic of pain and addiction. Pain managers can use the website to collaborate, answer point of care questions, and/or receive CME credit on a just-in-time basis or via standard educational curricula. To provide skills training for primary care and specialist professionals who treat patients with pain problems we created a novel SP educational experience available via Internet chat with a live SP performing the role of a patient with issues relevant to both pain and addiction.

A functional online resource has been created that responds to the usability recommendations and needs analysis work. Six online educational courses and 2 SP cases have been reviewed by experts and will be available for continuing medical education credit in Fall 2010. Over 200 resources are available, each with a short annotation, and the ability for the user to provide an additional critique.

Future work will assess if as a result of this project, the clinician will be able to: 1) reduce the risk of misuse of prescribed substances, 2) recognize and assure adequate treatment of substance misuse and addiction in chronic pain patients, and 3) provide adequate pain management in patients with substance use disorders.

Conclusion (62/100): The project has successfully built a suite of skills training courses with supportive content that offers real world challenges in the form of brief cases, more complicated cases and SPs. The curriculum includes a catalog of quality resources and a high quality search engine that gives users a quick and simple way to find the resources they need using any Internet-capable tool.

Introduction: The need for better skills training related to addiction risk associated with pain treatment is understood (CASA, 2005;; Merrill, 2002; Lin, 2007). But data to guide such development so that it emphasizes the greatest need is limited. Materials and Methods: We interviewed six primary care providers about their concerns and challenges in prescribing opioids and treating pain and addiction as well as their needs and preferences regarding continuing medical education (CME) courses on pain and addiction.

Results: The PCPS greatest concern when prescribing opioids to patients was the potential for addiction. Their greatest challenges were: 1) diversion, 2) co-occurring psychiatric disorder, and 3) inability of non-opioid treatments to relieve pain. Some participants felt that additional training would help address these challenges. For treating pain in already-addicted patients, they requested information on: 1) discerning drug-seeking behavior due to addiction vs. under-treated pain, 2) identifying relapse into addiction, 3) urine drug testing, 4) informed consent and treatment agreements, 5) how to take an addiction history, and 6) referral resources and clinical tools to help clinicians identify, interview, and manage addicted patients. Participants expressed the most interest in back pain, fibromyalgia, neuropathy, and osteoarthritis. Their greatest interest for practical skills training was in screening for addiction or interviewing pain patients.

Conclusions: PCPs identify a need for education on the risk of addiction in patients with pain. Meeting that need will require a comprehensive resource addressing multiple skills deficits and tools to help the provider find appropriate resources.

This research is funded by NIDA/NIH contract #HHSN271200800012C

References
1. CASA. Under the counter: The diversion and abuse of controlled prescription drugs in the U.S. The National Center on Addiction and Substance Abuse at Columbia University. 2005.
2. Lin JJ, Alfandre D, Moore C. Physician attitudes toward opioid prescribing for patients with persistent noncancer pain. Clinical Journal of Pain. 2007;23(9):799-803.
3. Merrill JO, Rhodes LA, Deyo RA, Marlatt A, Bradley KA. Mutual mistrust in the medical care of drug users. Journal of General Internal Medicine. 2002;17:327-333.

Introduction: With funding from a grant from NIH/NIAAA (#1R44AA016724-01A1), we created an online medical student curriculum on alcohol abuse. To assess mastery of clinical concepts, we developed a novel method of conducting remote live standardized patient interviews using Google chat, where a trained staff member is the SP. In advance of a summative evaluation in Spring 2010, we conducted a pilot test to assess utility of the case and gather student feedback.

Project Description/Methods: We developed a standardized patient case, Cynthia Stewart, who presents with insomnia and is diagnosed with alcohol abuse. Five third year students interviewed Cynthia during a 45 minute Google chat. Students completed the online courses, then performed a second SP interview. Clinical skill competency was measured using a 13 item done/not done checklist completed by both the SP and an independent reviewer. Interpersonal skills were evaluated by the SP using a 9-item checklist and a 5 point Likert scale. Student self-assessment, assessment of the SP by the student, and patient notes were also collected.

Outcomes: Clinical skill competency rose modestly from pre-test (64%) to post-test (77%). Interpersonal skills rose modestly from pre-test (2.65) to post-test (3.22). Student self-assessment of interpersonal skills were much higher (4.03 pre and 4.11 post) than those assessed by the SP. Students had a favorable view of the SP performance (3.90 post experience). All students correctly identified alcohol abuse on the patient notes.

Students were asked usability questions about the standardized patient experience. Eighty percent (4/5) agreed or strongly agreed that the interviewing process was a valuable learning experience, that the SP interviews were consistent pre/post experience, and that the patient case was typical of a real patient. All students (n=5) agreed or strongly agreed that the SP interview via Google chat was an interesting way to practice clinical skills. Students provided open-ended feedback on ways to increase the difficulty of the SP case.

Conclusions: Students were able to improve clinical skills through a chat-based SP interview. The data allows the development team to refine the patient case and conduct a more thorough evaluation with a larger n.