Empowering residents to address chronic pain and prescription opioid misuse in primary care A.L. Ruff, M.D. 1, D. P. Alford, M.D, M.P.H. 2, R. Butler 3, J.H. Isaacson, M.D University of Michigan Medical School, Ann Arbor, MI 2. Boston University School of Medicine, Boston Medical Center, Boston, MA 3. Cleveland Clinic Foundation, Cleveland, OH

Background Residents care for patients with chronic pain on long-term opioid therapy; many who exhibit signs of prescription opioid misuse. They often feel unprepared and lack confidence in caring for these patients. Resident practice management deficiencies have been seen in the areas of risk assessment and drug misuse monitoring. Colburn, J. L., D. R. Jasinski, and D. A. Rastegar. "Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic." Journal of opioid management 8.3 (2012): 153. Yanni, L. M., et al. "Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic." Journal of opioid management 4.4 (2007):

Objective Describe an educational intervention for Internal Medicine residents designed to: Improve confidence in safe opioid prescribing for chronic pain, Improve comfort communicating with patients with chronic pain, Lead to self-reported practice change managing patients taking chronic opioids, and Increase perceived support from preceptors for safe opioid prescribing

Methods The intervention included 2 educational sessions for Internal Medicine senior residents during an ambulatory block. Session one (3 hours) included: Lecture on opioid use disorders and chronic pain Skills practice session covering patient-centered communication skills Homework: Practice 1 newly-learned skill during at least 1 patient encounter throughout the subsequent week.

Session two (1.5 hours) occurred one week later and included: Debriefing of the patient encounters An overview of prescription opioid monitoring strategies, treatment and resources for opioid use disorders, and how to discontinue prescription opioids when appropriate. Methods continued

Curriculum

Pre and post assessments evaluating resident confidence and self- reported practices were performed prior to and following all residents completing the intervention including: Confidence in skills managing patients with chronic pain and opioid use disorders Utilizing appropriate safe opioid prescribing monitoring strategies including: Pill counts, urine drug screens, prescription drug monitoring programs Knowledge of available resources for patients with chronic pain and opioid addiction Perceived preceptor support for safe opioid prescribing practices Methods: Outcomes

Results 91 senior residents completed the intervention 44 (48%) and 43 (47%) residents completed the pre- and post- assessments respectively Utilizing a 4-point likert scale (1= strongly disagree, 2= disagree, 3=agree, 4=strongly agree), residents reported improved confidence in: Skills managing patients with chronic pain (2.4 vs 3.0, p <0.0001) Skills identifying which patients with chronic pain have developed an opioid use disorder (2.4 vs 3.0, p<0.0001) Understanding monitoring benefit vs harm in patients on chronic opioids (2.5 vs 3.0, p<0.0005) They noted improved ability to identify additional patient resources for those with chronic pain and opioid addiction.

They did not report a significant increase in: Use of safe opioid prescribing monitoring strategies Feelings of being supported in their decisions by precepting physicians. There was a non-significant trend toward improved resident reported comfort talking to patients with chronic pain about the need to discontinue opioids due to lack of benefit or too much harm. Results continued

Discussion Resident skills in the management of chronic pain and opioid use disorders can be taught with a brief, focused intervention increasing: Confidence in skills managing patients with chronic pain Confidence in determining which patients with chronic pain have developed a prescription opioid use disorder. Self-reported understanding of the risk/benefit framework surrounding the use of these medications. Confidence in their knowledge of patient resources for these disorders.

Despite these improvements, residents did not self-report an increase in their use of opioid monitoring strategies. Possible reasons why rates may not have increased include: Only residents underwent training Unreliable patient continuity in resident clinic Limited survey design Lum, Paula J., et al. "Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings." JAIDS Journal of Acquired Immune Deficiency Syndromes 56 (2011): S91-S97. Wenghofer, Elizabeth Francis, et al. "Survey of Ontario primary care physicians’ experiences with opioid prescribing." Canadian Family Physician 57.3 (2011): Dobscha, Steven K., et al. "Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates." Pain Medicine9.5 (2008): Chaudhry, Sarah R., et al. "Primary Resident Physician: Improving Continuity of Care." Journal of Graduate Medical Education 7.2 (2015): Neher, Jon O., Gary Kelsberg, and Drew Oliveira. "Improving continuity by increasing clinic frequency in a residency setting." FAMILY MEDICINE-KANSAS CITY (2001): Garfunkel, Lynn C., et al. "Resident and family continuity in pediatric continuity clinic: nine years of observation." Pediatrics (1998): Discussion continued

Lack of improvement in resident comfort discussing the need to discontinue opioids with their patients may be the result of Skill difficulty Limited time allotted in this short intervention In the future, more time will need to be devoted to allowing learners to practice their skills in this area and the addition of a second role play may be beneficial. Discussion continued Nestel, Debra, and Tanya Tierney. "Role-play for medical students learning about communication: Guidelines for maximising benefits." BMC Medical Education 7.1 (2007): 3. Manzoor, Iram, Fatima Mukhtar, and Noreen Rahat Hashmi. "Medical students’ perspective about role-plays as a teaching strategy in community medicine." J Coll Physicians Surg Pak 22.4 (2012):

It was our hypothesis that educating residents would “trickle up” to preceptors, resulting in residents feeling increasingly supported by their preceptors in utilizing newly learned decision making skills. No change was noted following the teaching intervention. More focus will need to be placed on including preceptors in this type of educational intervention. Discussion continued

Limitations Response rate was below 50% (48% and 47% respectively). It is unknown if residents who did not complete the survey had a similar experience to those that did. All data was self-reported and may differ from actual skills and practices. Social desirability bias may have led residents to over- report “good” behavior.

Limitations continued Study did not evaluate how improvement in resident confidence affects patient care and patient experience and further study will be needed in this area. Study also did not evaluate preceptor opinions and impressions regarding the resident’s changed approach.

Conclusion A brief, focused educational intervention can improve residents’ confidence in safe opioid prescribing for chronic pain but did not lead to self-reported practice change managing patients taking chronic opioids. Residents did not perceive increased support in their decision making by precepting physicians despite the intervention. How this change in confidence affects patient care requires further study. This model can be adapted to trainees in many areas.

References Colburn, J. L., D. R. Jasinski, and D. A. Rastegar. "Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic." Journal of opioid management 8.3 (2012): 153. Yanni, L. M., et al. "Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic." Journal of opioid management 4.4 (2007): Lum, Paula J., et al. "Opioid-prescribing practices and provider confidence recognizing opioid analgesic abuse in HIV primary care settings." JAIDS Journal of Acquired Immune Deficiency Syndromes 56 (2011): S91-S97. Wenghofer, Elizabeth Francis, et al. "Survey of Ontario primary care physicians’ experiences with opioid prescribing." Canadian Family Physician 57.3 (2011): Dobscha, Steven K., et al. "Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates." Pain Medicine9.5 (2008): Chaudhry, Sarah R., et al. "Primary Resident Physician: Improving Continuity of Care." Journal of Graduate Medical Education 7.2 (2015): Neher, Jon O., Gary Kelsberg, and Drew Oliveira. "Improving continuity by increasing clinic frequency in a residency setting." FAMILY MEDICINE- KANSAS CITY (2001): Garfunkel, Lynn C., et al. "Resident and family continuity in pediatric continuity clinic: nine years of observation." Pediatrics (1998): Nestel, Debra, and Tanya Tierney. "Role-play for medical students learning about communication: Guidelines for maximising benefits." BMC Medical Education 7.1 (2007): 3. Manzoor, Iram, Fatima Mukhtar, and Noreen Rahat Hashmi. "Medical students’ perspective about role-plays as a teaching strategy in community medicine." J Coll Physicians Surg Pak 22.4 (2012):