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Edwards KA, Reed DE, Anderson D, Harding K, Turner AP, Soares B, Suri P, Williams RM. Opening the black box of psychological treatments for chronic pain: A clinical perspective for medical providers. PM R 2023; 15:999-1011. [PMID: 36633497 DOI: 10.1002/pmrj.12912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Karlyn A Edwards
- Department of Anesthesiology, Perioperative & Pain Medicine, Division of Pain Medicine, Stanford University, Stanford, California, USA
| | - David E Reed
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Administration Puget Sound Health Care, Seattle, Washington, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Derek Anderson
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Kaitlin Harding
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Aaron P Turner
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Bosco Soares
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Pradeep Suri
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Learning, Evidence, and Research (CLEAR) Center, University of Washington, Seattle, Washington, USA
| | - Rhonda M Williams
- Rehabilitation Care Services, Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
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Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors. J Gen Intern Med 2022; 37:2650-2660. [PMID: 34729698 PMCID: PMC8562932 DOI: 10.1007/s11606-021-07102-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Training future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees. OBJECTIVE Assess residents' training in SOP and treatment of OUD and identify training barriers. DESIGN Cross-sectional nationally representative survey was emailed in 2019. PARTICIPANTS Four hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs. MAIN MEASURES Program opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness. KEY RESULTS The response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was "very effective" in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68-5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01-3.22; P = 0.05). CONCLUSIONS In this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.
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Chen AMH, Gardner J, Wandling E, Wicker E, Grauer P, Sweeney MA. The impact of a provider motivational interviewing-based training on chronic pain management in a federally-qualified health center. Res Social Adm Pharm 2022; 18:3839-3845. [PMID: 35400614 DOI: 10.1016/j.sapharm.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 02/04/2022] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND While the issue of opioid misuse is very complex, pharmacists have a unique opportunity to participate in interprofessional, team-based care. Motivational interviewing (MI) has been shown to be effective in chronic disease management and could improve patient engagement and chronic pain outcomes. OBJECTIVES To determine the impact of an MI-based provider training on changes in chronic pain management prescribing and on provider and patient perceptions. METHODS Providers participated in a pharmacist-led, 4-session educational intervention covering the CDC opioid prescribing guidelines, pain management, clinical pearls, and MI. Providers were then asked to implement the training in patient appointments for chronic pain management and refer appropriate patients for follow-up on goals. In the follow-up, student pharmacists called patients twice monthly for three months using MI. To address the primary outcome, the number of opioid prescriptions, morphine daily equivalents, and naloxone prescriptions were recorded and compared from the electronic medical record for the year preceding and following the intervention. Patients and providers completed surveys to assess the impact of these interventions. RESULTS Providers (n = 11) reported increased confidence in MI from baseline to 12 months following the intervention but no change in satisfaction. Patients (n = 19) were able to set and accomplish 20 goals throughout the phone call intervention. Meanwhile, the number of opioid prescriptions significantly decreased from 569 to 368 prescriptions per year before and after the intervention, respectively. Morphine daily equivalents per prescription decreased from 26.8 to 26.4 for the year before versus the year following the intervention. CONCLUSIONS MI interventions for providers and patients may positively impact goal setting and opioid prescribing. However, MI alone may not successfully address provider satisfaction and patient physical functioning. Pain management is an area that may benefit from a multi-faceted, interprofessional approach.
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Affiliation(s)
- Aleda M H Chen
- Cedarville University School of Pharmacy, 251 N. Main St., Cedarville, OH, 45314, USA.
| | - Julia Gardner
- Cedarville University School of Pharmacy, 251 N. Main St., Cedarville, OH, 45314, USA.
| | - Elizabeth Wandling
- Cedarville University School of Pharmacy, 251 N. Main St., Cedarville, OH, 45314, USA.
| | - Emily Wicker
- Cedarville University School of Pharmacy, 251 N. Main St., Cedarville, OH, 45314, USA.
| | - Phyllis Grauer
- ChaRxis Consulting, 7661 Cook Rd., Plain City, OH, 43064, USA.
| | - Marc A Sweeney
- Cedarville University School of Pharmacy, 251 N. Main St., Cedarville, OH, 45314, USA.
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Cuccolo NG, Crystal DT, Girard AO, Johnson AR, Ibrahim AMS, Sinkin JC, Lin SJ, Agag RL. Chaperone Use During Plastic Surgery Physical Examinations: Nationwide Provider Practices and Impact of Level of Training. Ann Plast Surg 2022; 88:366-371. [PMID: 35312646 DOI: 10.1097/sap.0000000000003182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical chaperones often play an important role during physical examinations, providing patient comfort and serving as medicolegal witness. The purpose of this study was to evaluate and compare practices regarding chaperone use by plastic surgery attendings and trainees. METHODS A voluntary survey was distributed to members of the American Council of Academic Plastic Surgeons. The survey included a standardized set of questions regarding physician demographics, nature of practice training, and current practices pertaining to chaperone use. Data were analyzed in a descriptive fashion. Ordinal logistic regression models were used to identify predictors of chaperone use. RESULTS We received 167 responses, of which 107 (64.1%) were attendings and 60 (35.9%) were trainees. In total, 78.3% of the respondents were male and 21.7% were female. Routine use of chaperones was reported at 58.6%. Compared with plastic surgery trainees, attending surgeons were 12.8 times more likely to use a chaperone during sensitive examinations (P < 0.001). In addition, male respondents were 6.43 times more likely than their female counterparts to involve a chaperone during sensitive examinations (P < 0.001). Forty-eight percent of the trainees acknowledged receiving education regarding chaperone use, and this cohort was 7 times more likely to use a chaperone when compared with trainees who had not received chaperone instruction (P < 0.001). CONCLUSIONS This study highlights the wide variability of chaperone use among plastic surgery attendings and trainees. Integration and standardization of chaperone education within plastic surgery training may be an effective technique to promote this practice and lead to improved patient-provider clinical experiences.
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Affiliation(s)
| | | | - Alisa O Girard
- From the Division of Plastic and Reconstructive Surgery, Robert Wood Johnson University Hospital, Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Ahmed M S Ibrahim
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeremy C Sinkin
- From the Division of Plastic and Reconstructive Surgery, Robert Wood Johnson University Hospital, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Richard L Agag
- From the Division of Plastic and Reconstructive Surgery, Robert Wood Johnson University Hospital, Robert Wood Johnson Medical School, New Brunswick, NJ
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Malik Z, Ahn J, Thompson K, Palma A. A Systematic Review of Pain Management Education in Graduate Medical Education. J Grad Med Educ 2022; 14:178-190. [PMID: 35463177 PMCID: PMC9017274 DOI: 10.4300/jgme-d-21-00672.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/03/2021] [Accepted: 01/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Despite the importance of pain management across specialties and the effect of poor management on patients, many physicians are uncomfortable managing pain. This may be related, in part, to deficits in graduate medical education (GME). OBJECTIVE We sought to evaluate the methodological rigor of and summarize findings from literature on GME interventions targeting acute and chronic non-cancer pain management. METHODS We conducted a systematic review by searching PubMed, MedEdPORTAL, and ERIC (Education Resources Information Center) to identify studies published before March 2019 that had a focus on non-cancer pain management, majority of GME learners, defined educational intervention, and reported outcome. Quality of design was assessed with the Medical Education Research Study Quality Instrument (MERSQI) and Newcastle-Ottawa Scale-Education (NOS-E). One author summarized educational foci and methods. RESULTS The original search yielded 6149 studies; 26 met inclusion criteria. Mean MERSQI score was 11.6 (SD 2.29) of a maximum 18; mean NOS-E score was 2.60 (SD 1.22) out of 6. Most studies employed a single group, pretest-posttest design (n=16, 64%). Outcomes varied: 6 (24%) evaluated reactions (Kirkpatrick level 1), 12 (48%) evaluated learner knowledge (level 2), 5 (20%) evaluated behavior (level 3), and 2 (8%) evaluated patient outcomes (level 4). Interventions commonly focused on chronic pain (n=18, 69%) and employed traditional lectures (n=16, 62%) and case-based learning (n=14, 54%). CONCLUSIONS Pain management education research in GME largely evaluated chronic pain management interventions by assessing learner reactions or knowledge at single sites.
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Affiliation(s)
- Zayir Malik
- Zayir Malik, MD, is a Clinical Associate and Medical Education Fellow, Section of Emergency Medicine, Department of Medicine, University of Chicago
| | - James Ahn
- James Ahn, MD, MHPE, is an Associate Professor, Section of Emergency Medicine, Department of Medicine, University of Chicago
| | - Kathryn Thompson
- Kathryn Thompson, BS, is a Fourth-Year Medical Student, University of Chicago Pritzker School of Medicine
| | - Alejandro Palma
- Alejandro Palma, MD, is an Assistant Professor, Section of Emergency Medicine, Department of Medicine, University of Chicago
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Dieter AA, Willis-Gray M, Carey ET. Opioid Education in Obstetrics and Gynecology Training Programs. South Med J 2021; 114:4-7. [PMID: 33398352 DOI: 10.14423/smj.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Our primary objective was to assess the current state of pain and opioid education in obstetrics and gynecology (OBGYN) by performing a detailed review of the national educational curricula guiding OBGYN residency and fellowship training programs in the United States. METHODS From 2019 to 2020 we reviewed seven documents created to guide learning and structure educational training for OBGYN residency and fellowship programs in the United States: the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives Core Curriculum in Obstetrics and Gynecology, the 2016 Educational Objectives-Fellowship in Minimally Invasive Gynecologic Surgery, and the 2018 Guides to Learning in Complex Family Planning, Female Pelvic Medicine & Reconstructive Surgery, Gynecologic Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology and Infertility. Each document was reviewed by two authors to assess for items referring to pain or opioids. RESULTS The CREOG educational objectives, used to inform educational curricula for residency programs, were the most comprehensive, mentioning pain and/or opioid educational objectives the highest number of times and including the most categories. The CREOG document was followed by the Guides to Learning for Gynecologic Oncology and for Minimally Invasive Gynecologic Surgery. The Reproductive Endocrinology and Infertility Guide to Learning did not mention pain and/or opioids in the educational objectives. CONCLUSIONS Our study identifies an opportunity for consistent and appropriate opioid and pain management education in OBGYN training.
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Affiliation(s)
- Alexis A Dieter
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Marcella Willis-Gray
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin T Carey
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Joseph WJ, Cuccolo NG, Chow I, Moroni EA, Beers EH. Opioid-Prescribing Practices in Plastic Surgery: A Juxtaposition of Attendings and Trainees. Aesthetic Plast Surg 2020; 44:595-603. [PMID: 31907588 DOI: 10.1007/s00266-019-01588-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/10/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The rates of opioid abuse and overdose in America have risen in parallel with the rates of opioid prescribing by physicians. As such, we sought to examine the prescribing practices among plastic surgery attendings and trainees to determine the need for more thorough education. METHODS A survey was distributed to all ACGME-accredited plastic surgery residency programs and included questions regarding opioid-prescribing practices and self-rated ability pertaining to opioid management. Trends in prescribing practices based on prescriber position were analyzed using cumulative odds ordinal logistic regression with proportional odds and Chi-squared tests for ordinal and nominal variables, respectively. RESULTS We received 78 responses with a wide geographical representation from plastic surgery residency programs: 59% of respondents were male and 39.7% female, 29.5% were attendings, 26.9% senior residents, 29.5% junior residents, and 14.1% interns. Compared with attendings, interns prescribe fewer pills (p < 0.05) and were significantly more likely to prescribe oxycodone (p < 0.03). Junior residents were 4.49 times more likely (p = 0.012) and senior residents 3.65 times more likely (p = 0.029) to prescribe additional opioids to avoid phone calls and follow-up visits. Interns and senior residents were significantly less comfortable than attendings in managing patients requesting additional opioids (p < 0.02). CONCLUSIONS The results of this survey demonstrate that knowledge deficits do exist among trainees, and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of a thorough postoperative pain management education in residency may be a cogent strategy in mitigating the opioid crisis. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Walter J Joseph
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, PA, 15261, USA.
| | - Nicholas G Cuccolo
- Division of Plastic Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ian Chow
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, PA, 15261, USA
| | - Elizabeth A Moroni
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, PA, 15261, USA
| | - Emily H Beers
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, PA, 15261, USA
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Varley AL, Lappan S, Jackson J, Goodin BR, Cherrington AL, Copes H, Hendricks PS. Understanding Barriers and Facilitators to the Uptake of Best Practices for the Treatment of Co-Occurring Chronic Pain and Opioid Use Disorder. J Dual Diagn 2020; 16:239-249. [PMID: 31769729 PMCID: PMC10763074 DOI: 10.1080/15504263.2019.1675920] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Patients with a combination of chronic pain and opioid use disorder have unique needs and may present a challenge for clinicians and health care systems. The objective of the present study was to use qualitative methods to explore factors influencing the uptake of best practices for co-occurring chronic pain and opioid use disorder in order to inform a quantitative survey assessing primary care provider capacity to appropriately treat this dual diagnosis. Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), semi-structured qualitative interviews were conducted with 11 primary care providers (PCPs) to inform the development of a questionnaire. Interviews were audio-recorded and transcribed verbatim. Fifteen comments from an open-ended question on the questionnaire were added to the analyses as they described factors that were not elucidated in the interviews. Barriers and facilitators were identified and categorized using the CFIR codebook. Results: The most frequently described barriers were cost and inadequate access to appropriate treatments, external policies, and available resources (e.g., risk assessment tools). The most frequently described facilitators were the presence of a network or team, patient-specific needs, and the learning climate. Knowledge and beliefs were frequently described as both barriers and facilitators. Conclusions: While substantial funding has been allocated to initiatives aimed at increasing PCP capacity to treat this population, numerous barriers to adopting appropriate practices still exist. Future research should focus on developing and testing implementation strategies that leverage the facilitators and overcome the barriers illustrated here to improve the uptake of evidence-based recommendations for the treatment of co-occurring chronic pain and opioid use disorder.
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Affiliation(s)
- Allyson L Varley
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sara Lappan
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Juliet Jackson
- Department of Social Work, University of Alabama, Tuscaloosa, Alabama, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrea L Cherrington
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Heith Copes
- Department of Criminal Justice, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter S Hendricks
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Roy P, Jackson AH, Baxter J, Brett B, Winter M, Hardesty I, Alford DP. Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices. PAIN MEDICINE 2019; 20:707-716. [PMID: 30649546 DOI: 10.1093/pm/pny292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing. DESIGN An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching. RESULTS The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching. CONCLUSIONS A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.
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Affiliation(s)
- Payel Roy
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Angela H Jackson
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Baxter
- Department of Family Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Belle Brett
- Brett Consulting Group, Somerville, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Ilana Hardesty
- The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel P Alford
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.,The Barry M. Manuel Office of Continuing Medical Education, Boston University School of Medicine, Boston, Massachusetts, USA
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Goodman-Meza D, Medina-Mora ME, Magis-Rodríguez C, Landovitz RJ, Shoptaw S, Werb D. Where Is the Opioid Use Epidemic in Mexico? A Cautionary Tale for Policymakers South of the US-Mexico Border. Am J Public Health 2019; 109:73-82. [PMID: 30495992 PMCID: PMC6301408 DOI: 10.2105/ajph.2018.304767] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2018] [Indexed: 12/31/2022]
Abstract
In North America, opioid use and its harms have increased in the United States and Canada over the past 2 decades. However, Mexico has yet to document patterns suggesting a higher level of opioid use or attendant harms.Historically, Mexico has been a country with low-level use of opioids, although heroin use has been documented. Low-level opioid use is likely attributable to structural, cultural, and individual factors. However, a range of dynamic factors may be converging to increase the use of opioids: legislative changes to opioid prescribing, national health insurance coverage of opioids, pressure from the pharmaceutical industry, changing demographics and disease burden, forced migration and its trauma, and an increase in the production and trafficking of heroin. In addition, harm-reduction services are scarce.Mexico may transition from a country of low opioid use to high opioid use but has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a widespread opioid use epidemic.
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Affiliation(s)
- David Goodman-Meza
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
| | - Maria Elena Medina-Mora
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
| | - Carlos Magis-Rodríguez
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
| | - Raphael J Landovitz
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
| | - Steve Shoptaw
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
| | - Dan Werb
- David Goodman-Meza and Raphael J. Landovitz are with Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles (UCLA). Raphael J. Landovitz is also with Center for Clinical AIDS Research and Education, Los Angeles. Maria Elena Medina-Mora is with Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, Mexico. Carlos Magis-Rodríguez is with National Center for the Prevention and Control of HIV and AIDS, Mexico City. Steve Shoptaw is with Department of Family Medicine, David Geffen School of Medicine at UCLA. Dan Werb is with Department of Medicine, University of California San Diego, La Jolla
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Olsen KR, Hall DJ, Mira JC, Underwood PW, Antony AB, Vasilopoulos T, Sarosi GA. Postoperative surgical trainee opioid prescribing practices (POST OPP): an institutional study. J Surg Res 2018; 229:58-65. [PMID: 29937017 DOI: 10.1016/j.jss.2018.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/02/2018] [Accepted: 03/13/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Increasing mortality from opioid overdoses has prompted increased focus on prescribing practices of physicians. Unfortunately, resident physicians rarely receive formal education in effective opioid prescribing practices or postoperative pain management. Data to inform surgical training programs regarding the utility and feasibility of formal training are lacking. METHODS Following Institutional Review Board approval, a single institution's resident physicians who had completed at least one surgical rotation were surveyed to assess knowledge of pain management and evaluate opioid prescribing practices. RESULTS Fifty-three respondents (68% males and 32% females) completed the survey. Most respondents denied receiving formal instruction in opioid pain medication prescribing practices during either medical school (62.3%) or residency (56.6%); however, nearly all respondents stated they were aware of the side effects of opioid pain medications, and a majority felt confident in their knowledge of opioid pharmacokinetics and pharmacodynamics. Of the respondents, 47% either "agreed" or "strongly agreed" that they prescribed more opioid medications than necessary to patients being discharged following a surgical procedure. Individual case scenario responses demonstrated variability in the number of morphine milligram equivalents prescribed across scenarios (P < 0.001). Male and nonsurgical specialty respondents reported prescribing significantly fewer overall morphine milligram equivalents in these scenarios. CONCLUSIONS This pilot study shows wide variability in opioid prescribing practices and attitudes toward pain management among surgical trainees, illustrating the potential utility of formal education in pain management and effective prescribing of these medications. A broader assessment of surgical trainees' knowledge and perception of opioid prescribing practices is warranted to facilitate the development of such a program.
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Affiliation(s)
- Kevin R Olsen
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.
| | - David J Hall
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Juan C Mira
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Patrick W Underwood
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ajay B Antony
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; Department of Orthopedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
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Alford DP, Carney BL, Jackson AH, Brett B, Bridden C, Winter M, Samet JH. Promoting addiction medicine teaching through functional mentoring by co-training generalist chief residents with faculty mentors. Subst Abus 2018; 39:377-383. [PMID: 29452056 DOI: 10.1080/08897077.2018.1439799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so. METHODS This 5-year (2008-2012) controlled educational study assessed whether internal medicine and family medicine chief residents' (CRs) addiction medicine teaching increased by co-training with faculty mentors at a Chief Resident Immersion Training (CRIT) program in addiction medicine. All CRIT CR attendees identified a residency program faculty mentor to support addiction medicine teaching after CRIT through functional mentoring with a focus on developing and implementing an Addiction Medicine Teaching Project ("Teaching Project"). Approximately half of the CRs attended CRIT with their mentor (co-trained) and half without their mentor (solo-trained). Addiction medicine teaching outcomes were compared between groups using 6- and 11-month questionnaires and 4 bimonthly teaching logs. Of co-trained CRs, mentor characteristics that positively influenced addiction medicine teaching outcomes were identified. RESULTS One hundred CRs from 74 residency programs attended CRIT from 2008 to 2012; 47 co-trained with their mentors and 53 solo-trained without their mentors. At 6-month follow-up, the co-trained CRs were more likely to meet at least monthly with their mentor (22.7% vs. 9.6%, P < .01) and more likely to identify their mentor as a facilitator for Teaching Project implementation (82.2% vs. 38.5%, P < .01). At 11-month follow-up, a higher percentage of co-trained CRs had completed their Teaching Project (34.0% vs. 15.1%, P < .05). Both CR groups had similarly large increases in other addiction medicine teaching outcomes. Mentors with more experience, including years of teaching, was associated with better CR Teaching Project outcomes. CONCLUSIONS Co-training generalist chief residents with a faculty mentor appeared to facilitate functional mentoring-driven Teaching Project implementation but did not further increase already high levels of other addiction medicine teaching. Faculty mentors with more years of teaching experience were more effective in facilitating Teaching Project implementation.
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Affiliation(s)
- Daniel P Alford
- a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA.,b Section of General Internal Medicine, Boston University School of Medicine , Boston , Massachusetts , USA
| | - Brittany L Carney
- a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA
| | - Angela H Jackson
- a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA.,b Section of General Internal Medicine, Boston University School of Medicine , Boston , Massachusetts , USA
| | - Belle Brett
- c Brett Consulting Group , Somerville , Massachusetts , USA
| | - Carly Bridden
- a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA
| | - Michael Winter
- d Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health , Boston , Massachusetts , USA
| | - Jeffrey H Samet
- a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA.,b Section of General Internal Medicine, Boston University School of Medicine , Boston , Massachusetts , USA.,e Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
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Changing Prescribing Behavior in the United States: Moving Upstream in Opioid Prescription Education. Clin Pharmacol Ther 2018; 103:982-989. [DOI: 10.1002/cpt.1015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/08/2017] [Accepted: 01/04/2018] [Indexed: 11/07/2022]
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