MS Pain and Addiction

From Clinicaltools.com

Contents 1 Key Details 2 Need 3 Vision 4 Mission 5 Target Audience 6 Strengths 6.1 Medical Education Expertise 6.2 Remote Standardized Patient Expertise 6.3 SP can address different educational issues and better involve the student 6.4 Remote SP Technology has been tested and is available 7 Weaknesses/Constraints and Solutions 7.1 Scalability will be a Challenge 7.2 Limited Research to Guide Development 7.3 Topics of Pain and Addiction are Complicated 8 Opportunity 8.1 Pain and Addiction are Important Topics in Medicine 8.2 Medical school is a great time to introduce the topic of pain and addiction 8.3 Medical Schools Need to Focus on Efficiency 8.3.1 Medical schools need to expand their enrollment 8.3.2 On-line Learning is effective 8.3.3 The Internet is a useful tool for current medical students 8.4 Standardized Patients Are a Key to Improving Medical Education 8.4.1 Enthusiasm for live Standardized Patients is strong 8.4.2 A non face-to-face SP is well accepted 8.4.3 In some instances a remote SP may actually be preferable 9 Threats 10 Learning Types 11 Planned Educational Approach 11.1 deliberate practice 11.2 Problem-Based Learning 11.3 Team-Based Learning 12 A Complete Learning Environment 13 Goal 14 Objectives 15 Communication

Key Details

• Title: Medical Student Skills Training on Pain and Addiction Assessment
• Federal Funding: NIDA 1R44DA027245-01
• Federal Funding Program Officer: Yu Lin, PhD
• Federal Funding Grants Management Specialist: Diana Haikalis
• Principal Investigators: Mary P. Metcalf, PhD, MPH, CHEST; Bradley Tanner, MD
• Project Directors: Karen Rossie, PhD; Susan Wilhelm, PhD
• Research Assistants: Kimberly Workman, BA; Sara Virgil, BS; Lyla Hance, BA; Margaret Froneberger, BS
• Start: 09/01/09 End: 04/30/10
• Product: MedStudentLearning.com Website
• Project Links: Project Guide
• Curriculum Plan

Need

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 lack a comprehensive and efficient solution to meet their students' need.

Vision

Future physicians will assess patients with pain with a clear plan and approach to maximally treat the pain while placing the patient and public at minimum risk to the misuse potential of opioids.

Mission

To create a successful online skills training experience for medical students that provides the skills they need to properly assess patients in pain with an awareness of the risks of the addictive substances and the benefit of opioids to treat pain.

Target Audience

Primary: Medical Students (in years 1 to 4)

Secondary: Medical school course and clerkship directors and instructors who teach topics related to pain control and assessment. Curriculum review boards.

Strengths

Medical Education Expertise

• We have previous success with online medical education in the area of addiction (www.addictioncme.com)

• We have a currently funded Phase I NIDA contract to develop pain and addiction materials for pain treatment providers [e.g., post residency education]. (painandaddiction.clinicaltools.com)

Remote Standardized Patient Expertise

• We are experienced in the process of creating standardized patients that can be used to assess mastery of the topic, especially as it relates to real-time interviewing and decision making. (www.addictioncme.com/medicalstudents, www.geneticsolutions.com)

• We developed of a novel method for conducting remote standardized patient interviews. This innovative method combines common “chat” technology (such as Skype® or Google® Chat) with a trained Clinical Tools' staff member acting as a standardized patient. (Internal explanation of CTI SPs)

• We have expertise with process of delivering a remote SP experience with online chat. (www.addictioncme.com)

SP can address different educational issues and better involve the student

• In the first study of its kind, in 2006 it was shown that standardized patients used to teach pain education is effective (Chen et al. 2007).

• Five years ago the University of Arizona College of Medicine increased classroom-time spent on pain education from 3 to 7 hours in the first two years and now they're implementing a clinical rotation for 2009 that would teach students about pain in multiple disciplines (Rowley 2008).

• Students improve their learning outcomes when given a sense of autonomy during the learning process (Seibert et al. 2004), which is afforded to them during Standardized Patient scenarios.

Remote SP Technology has been tested and is available

• Students have the necessary skills, hardware and software to complete text, as well as audio/video remote Standardized Patient chat sessions as shown in our GeneticSolutions project as well as our Buprenorphine for Medical Students Education module. (www.geneticsolutions.com and www.addictioncme.com)

• On-line chat programs are widely accessible and free to the general public; there is no need for special interviewing facilities or software. (AIM, Yahoo, MSN, GoogleChat, etc.)

Weaknesses/Constraints and Solutions

Scalability will be a Challenge

• Using Remote SP for training requires person to person intervention. (Berg et al. 2007). Resolution: It may be possible to build a community of volunteers who can not typically participate as a local face-to-face SP due to work limitations or distance from a medical school. Alternatively it may be possible to have students learn the SP role, thus making the experience a team-based learning one. By rating other interviewers and seeing the experience from the patient's perspective, the student see the value in improving professionalism skills as well as gain empathy for the patient experiencing pain and/or addiction.

Limited Research to Guide Development

• There is limited research done into the efficacy of pain education through e-learning (Yanni et al. 2008). Resolution: Our experience with other topics has taught us that e-learning can be effective. Similarly there is little experience with remote Standardized Patients; however Standardized Patients are a common component of medical education and due to changes in the USMLE there will likely be more data forthcoming to guide development of a remote SP experience.

Topics of Pain and Addiction are Complicated

• The topic of pain and the topic of addiction are both subspecialites with very large knowledge bases and multiple best practice. Resolution: A talented and varied consultant pool will help, guide and assess the project. Also Clinical Tools has experience with both topics through other projects and a relationship with the American Society of Addiction Medicine.

• Pain due to cancer is different. Resolution: We will focus primarily on non-cancer pain – The typical cancer pain is treated by specialists and includes other issues that might best be learned in an integrative framework discussing cancer, hospice, pallative care, and etiology of cancer pain. Due to cancer survivorship, some cancer pain is chronic and some aspects of this curriculum focusing on addiction/diversion issues related to pain control would be appropriate.

• Focusing on the crossover of the addiction and pain could overwhelm the student. Resolution: It is important that the curriculum focus on the interaction and not on specific details regarding pain treatment or addiction treatment. In fact the complexity of the cases could be more engaging for students who are more used to a problem-based learning approach to medical education. As an example, the crossover allows one to ensure that the learner can recognize that drug seeking behavior by someone with persistent pain symptoms, may resemble addiction (so-called “pseudoaddiction,”) (Lusher et al. 2006). Similarly, completely stopping the addictive opioid or changing to a nonaddictive drug may not be possible for all patients and a harm reduction plan may be most appropriate (Passick et al. 2006).

• The evidence for how to treat pain when there is substance abuse has been called “weak” (Weaver & Schnoll 2002). Resolution: This is a common problem in medicine and makes the topic even more relevant since the proper approach must be individually customized to the patient. By giving students confidence in the topic, they can make decisions later based on a larger pool of data and expertise and be less influenced by local custom or pharmaceutical marketing. Also successful treatment modalities for chronic pain with comorbid substance use disorders have been described (Cheatle and Gallagher 2006, Weaver & Schnoll 2002a, b).

• You must avoid "feature creep" or the tendency to move outside the topic. For example, the ability to screen for mood and anxiety disorders is another key skill because these conditions are also frequently comorbid with chronic pain and substance abuse and further complicate treatment (Cheatle and Gallagher 2006). Resolution: This is a constant challenge. Input from members of the target audience and consultants can help ensure the curriculum stays on target.

• In the case of a chronic pain patient with a history of substance abuse, clear guidelines are important; such as use of a medication agreement/contract, patient goal setting, attention to medication amounts prescribed and monitoring with drug screens and pill counts (Weaver & Schnoll 2002).

• The definitions of opioid addiction and dependence do not work well for chronic pain patients because they emphasize tolerance and withdrawal (Robinson et al. 2001). Resolution: A consensus document was developed by several chronic pain professional organizations to provide separate definitions of tolerance, dependence, and addiction when opioids are used for chronic pain management (Savage et al. 2001). Providing a more complete understanding of the risks of controlled substances is actually a major benefit to all future physicians since as a result of inadequate definitions, addiction may be overestimated resulting in undertreatment of chronic pain (Savage 2002).

• The topic does not neatly fit into the standard medical school curriculum. Resolution: Medical education is clearly trending toward more interactive, cognitive, problem-based and team-based approaches. The trend should make the product more and more relevant and helpful for students.

Opportunity

Pain and Addiction are Important Topics in Medicine

• Pain is Common: One third to one half of adults in the U.S. suffer from chronic or recurrent pain (Elliott et al. 1999). Approximately a third of surveyed adults reporting chronic pain described it as being severe enough to require major life adjustments (Hart 2003). One third to one half of adults in the U.S. suffer from chronic or recurrent pain (Elliott et al. 1999). Approximately a third of surveyed adults reporting chronic pain described it as being severe enough to require major life adjustments (Hart 2003).

• Misuse of Opioids is Common: The high non-medical use of opiates is an indicator of their abuse potential: an estimated 4.4 million people over age 12 have used opiate pain medication in the past month, according to the 2004 National Survey on Drug Use and Health (SAMHSA 2004). Both the medical use and abuse of opioid analgesics has increased in the past decade (Joranson et al. 2000, Gilson et al. 2004). Both the medical use and abuse of opioid analgesics has increased in the past decade (Joranson et al. 2000, Gilson et al. 2004).

• Pain and Addiction Issues are Common Challenges for Physicians: Comorbid substance abuse affects 20 - 40% of patients on opioid therapy for chronic pain (Katz et al. 2003, Machikanti et al. 2001, Chabal et al. 1997). Use of opioids for chronic nonmalignant pain management is as high as 90% of patients in pain management centers (Manchikanti et al. 2004, Katz et al. 2003). Non-medical use of opiates is common and an indicator of their abuse potential: an estimated 4.4 million people over age 12 have used opiate pain medication in the past month, according to the 2004 National Survey on Drug Use and Health (SAMHSA 2004). Health professionals may be unaware that addiction is often uncommon among patients being treated for pain; and even in those cases there are effective treatment options available (O'Brien 2006).

• The Issues Related to Pain and Addiction are being Actively Investigated: A wide variety of research is available to guide the creation of the curriculum. As an example, a clear picture of the chronic nonmalignant pain patient at greatest risk for comorbid substance abuse is emerging. Identified risk factors include age, pain after motor vehicle accident, involvement of multiple regions, and past history of illicit drug use (Machikanti et al. 2006). A study of factors that would distinguish patients who use opioids inappropriately from those who do not found the following distinguishing factors: opioid overuse, other substance use, nonfunctional status, unclear etiology of pain, and exaggeration of pain (Atluri and Gururau 2004). Cases can also be developed with the knowledge that patients with a history of alcohol or cocaine abuse and alcohol or drug-related convictions are also at high risk for abusing prescription opioids (Ives et al. 2006). Finally, research has shown that disputes or arguments about analgesics are an indicator of potential addiction in the presence of pain symptoms (Lusher et al. 2006).

Medical school is a great time to introduce the topic of pain and addiction

Addiction attitudes develop early; it would thus be more effective to have an intervention specifically designed for the medical student. (Chen et al. 2007, Oneschuk et al. 1997). By focusing on the crossover of pain and addiction one can enhance interest in both topics, increase clinical relevance of medical school, address a topic that is typically not fully addressed, and impact a large public health problem. Students may already have biases regarding the types of patients who have difficulty with controlled substances; a focus on patients with pain may, in fact, be an effective way to teach students about the topic of misuse and addiction where attitudes are less likely to be solidified.

Medical Schools Need to Focus on Efficiency

Medical schools need to expand their enrollment

• Medical school class sizes continue to increase to meet the increased need for physicians in the U.S, but school resources remain the same (AAMC 2008). The Association of American Medical Colleges recommends an overall increase of 15-30% of medical students (Center for Workforce Studies 2006). An IT solution can help meet these needs without further burdening medical school faculty. In fact, in a survey by the AAMC, "IT-based self-directed/independent learning tools" along with patient simulations were potential solutions for more than half the respondents (Center for Workforce Studies 2006).

On-line Learning is effective

• On-line learning is a successful supplement to face-to-face instruction (see De Leng et al. 2006, Kerfoot et al. 2006, and Mostaghimi et al. 2006 for examples). Wiecha et al. (2006) directly compared an on-line course in diabetes management with a conventional curriculum and found that pre/post test improvements were significantly higher for on-line students. Peterson et al. (2006) describe a Web-based curriculum designed for first-year medical students that significantly improved knowledge and intended behavior on smoking cessation assistance to patients. Relan (2005) described how case-based learning can be effective via the Internet. Our experience with genetics education for medical students shows a willingness to utilize a curriculum that has been developed outside the institution as long as it is unbiased and developed with experts in the field. (see Preliminary Work).

The Internet is a useful tool for current medical students

Peterson et al. (2004) acknowledge the role that technology now plays in medical school curricula; current medical school students are of the digital age and students are quick to embrace electronic resources when studying. Seibert et al. (2004) again noted that students learn better when taught through real-world scenarios, such as Standardized Patients, because they are more engaged and in turn their learning outcomes improve.

Standardized Patients Are a Key to Improving Medical Education

Enthusiasm for live Standardized Patients is strong

• Schools must also integrate Standardized Patient training within their curriculum as it is now a required element in the USMLE Step 2 CS (http://www.usmle.org/Examinations/step2/step2cs.html).

• The demands on the traditional face-to-face standardized patient programs in most medical schools will be challenged in the coming years as medical school enrollment grows. (AAMC 2008)

• Medical students are generally excited about the use of a computer-generated patient program and find it a valuable learning experience (Stevens et al. 2006). However, the use of computer generated patients is uncommon due to the high costs to develop and maintain the necessary software (Huang 2007).

• While computer-generated patients provide the advantage of on-line convenience, they are more limited than "real" standardized patients in their ability to effectively teach necessary communication skills, such as empathy. One reason cited for this limitation is the contrived nature of computer-generated patients (Deladisma et al. 2007).

A non face-to-face SP is well accepted

• Students in our GeneticSolutions project expressed gave positive feedback about the realism of a chat-based remote SP experience and commented on the

ease of the interview after they got started. (Tanner TB, Metcalf MP, Buchanan A, Prince-Elcan C, Wright J. Medical Student Training in Genetics via Web- based Curriculum. Poster presented at the Innovations in Medical Education Conference. March 7, 2008. Pasadena, CA.)

• In surveys done by Clinical Tools, current medical students, and faculty, have expressed interest in possibly using an alternative SP interview. (See Preliminary Work)

• USMLE is using a Telephone Patient Encounter (e.g., remote) SP experience. (http://www.usmle.org/Examinations/step2/cs/content/description.html)

In some instances a remote SP may actually be preferable

• Some members of the public can participate in a remote SP experience but not in a typical face-to-face interaction. (Maybe the Wiki page for SPs?

• Remote access to Sps can be more efficient in terms of carbon footprint and costs related to travel (Maybe the Wiki page for SPs?

• Some topics may be better taught without the “face” which can give the learner a false impression based on existing biases (Maybe the Wiki page for SPs?)

• A remote SP can play the role of different ages, genders, or races or ethnicities. (ASPE website? Or maybe the Wiki page for SPs)

Threats

Commercial Competition: We could find no examples of Web-based pain and addiction training specifically for medical students. There are many CME sites that provide training opportunities, but these opportunities are for practicing physicians or other health professionals. Furthermore, much of the training that exists for current health care professionals is not entirely Web-based – components must be downloaded or physical attendance at a meeting is required. Additionally, pharmaceutical influence comes into play in some of the available learning opportunities, creating a bias within the education. In other cases, the determination of learning isn't readily available so that the user does not receive feedback for in-course questions, nor are they tested on the amount of knowledge they gained through the course itself.

Computer-based (e.g. virtual) standardized patients can potentially be delivered more efficiently. Some skills can be taught via a computer driven user/response system. Although they typically have high up front costs, if successful a virtual SP can be delivered at minimal expense and complexity. A computer generated system is going to be more successful in an area of medicine where there are absolute correct answers and where the process has clearly correct and incorrect paths. For the topic of pain and addiction, such clarity and simplicity does not exist. Medical students are generally excited about the use of a computer-generated patient program and find it a valuable learning experience (Stevens et al. 2006). However, the use of computer generated patients is uncommon due to the high costs to develop and maintain the necessary software (Huang 2007). While computer-generated patients provide the advantage of on-line convenience, they are more limited than "real" standardized patients in their ability to effectively teach necessary communication skills, such as empathy. One reason cited for this limitation is the contrived nature of computer-generated patients (Deladisma et al. 2007).

Medical schools can obtain educational materials from other educational institutions, AAMC and from national organizations, like the Pain Society. We have not found a comprehensive educational curriculum from these sources on the topic of pain and addiction.

Comparison of Currently Available Online Pain Education vs Clinical Tools' Product

Product	PainEDU	COPE: Collaborative Opioid Prescribing Education	Medscape	Pain.com	Clinical Tools' Product
Sponsor	Endo Pharmaceuticals	University of Washington	Medscape	Dannemiller Memorial Educational Foundation and SynerMed Communications	Clinical Tools, Inc
Targeted solely towards medical students					X
Multiple cases offered	X	X	X	X	X
Free of pharmaceutical bias		X	X	X	X
Gives question feedback	X		X		X
Has a pre/post test in the course			X	X	X
Progression monitor available	X	X		X	X
Estimated time of completion available		X		X	X
Author information available	X		X	X	X
Author financial disclosures available		X	X	X	X

Learning Types

Education and Skills Training: Theoretical Basis of Educational Approach

The educational approach will be based on three basic learning principles:

1.Adult learning: Medical students are experienced learners due to the extensive training they receive in college and in medical school. The adult learning principles defined by Knowles (1998) offer a framework for the proposed modules based on problem-solving techniques. Our modules will utilize case scenarios, and users will be given opportunities to choose courses of action based on presented material.

2.Social learning: This project also incorporates the concept of teaching through modeling or social learning (Bandura 1977). Bandura’s theory is applicable to adult learning as it focuses on both the learner and the environment. The guidance provided by the case-based scenarios and standardized patient(s) offers a (virtual) model that demonstrates a reasonable approach to working with patients. We believe such an interaction is more likely to contribute to more effective skill building.

3.Cognitive theory: Cognitive theory as it applies to learning is also relevant to our teaching method. A cognitive approach emphasizes the need to understand individual differences. For this project, the concepts of memory and experience are most relevant. We will help the learner elaborate on new and existing knowledge to create a meaningful learning experience (see Flannery 1993).

Planned Educational Approach

deliberate practice

Emil P mentioned the following: Although it may be a bit late, one of the current "hot concepts" in medical education is "deliberate practice" – the repetitive practice of a skill where feedback is immediate and specific. Performance is repeated until 100% "mastery" is reached. Long-term retention is strengthened. K. Anders Ericsson is the primary name for deliberate practice. He has a review in 2005 or 2006 Academic Medicine supplement (RIME issue) (actually it was 2004). Another author is Diane Wayne from Northwestern who used deliberate practice to train residents to mastery on the ACLS protocol with very good results. I think her article came out in Chest in January of 2008. (both articles saved on Q drive)

Problem-Based Learning

The problem-based learning approach (PBL) has steadily gained acceptance as a good teaching tool in medical schools. Problem-based learning involves presenting case-based studies as the fundamental learning tool in the curriculum. Anderson and Glew (2002) note that a problem-based learning approach to medical education improves basic problem-solving skills, enhances the understanding and retention of key concepts, and improves performance in clerkships. In an interactive learning environment, students can have more control over their learning as compared to predetermined path formats such as videotapes, audiotapes, workbooks, and lectures. A learner can work his or her way through a clinical case, making choices and obtaining feedback. The clinical scenario is interactive, challenging, engaging, and representative of a real world condition. Our lessons maximize potential benefit (according to social learning theory) by mirroring the real world experience and are a potent teaching tool.

Team-Based Learning

The team-based learning approach (TBL) was first developed by Dr. Larry K. Michaelsen (TBL Collaborative 2005) within business education, but is applicable to many learning situations such as medical school. Team-based learning involves an instructor presenting a situation to a group of individuals, broken up into small groups, and within the team they work on coming up with a solution. This increases the ability to take gained knowledge and apply it to real-world situations, as well as developing strength in team-building. Through team-based learning, students foster discovery and and create a supportive environment where communication and education can develop (Seibert et al. 2004). The learning experience is not contained to just the classroom as students have to prepare on their own prior to class, then go through a process of readiness and assurance within the classroom setting before applying the course concepts to the problem at hand (TBL Collaborative 2005).

A Complete Learning Environment

We will create a unique learning environment that represents more than just a random collection of modules. Our goal is to provide the resources that medical students will need in future clinical training and beyond. The resource area that will be created will provide a place to view and obtain patient education materials, find direction to other relevant Internet sites, and access indexed information based on the module's material. The content will be updated as necessary and will be available whenever the learner has access to the Internet. We will provide an opportunity for the learner to join a community of similar students via discussion capability (bulletin boards). All these aspects combine to create a holistic, module-based approach. The generation that is now entering medical schools, Millenials, value their connection to others through social and team-oriented connections. They have the ability to read visually, respond quickly, learn better through discovery, and can shift their attention rapidly through multi-tasking (Oblinger and Oblinger 2005). It is a situation of immediacy rather than slow progression towards understanding. It is more likely they will seek out information online than in the classroom. Millennial students learn best with free-form courses that assess what learning is needed and gives them the opportunity to learn what they do not already know (May 2008). Additionally, students improve their learning outcomes when given a sense of autonomy during the learning process (Seibert et al. 2004), which is afforded to them during Standardized Patient scenarios. Because of this type of learning behavior, the online Standardized Patient experience is ready-made for this generation as it is a team-based experience which utilizes discovery as a means of learning.

Goal

• Phase I Goal: Create an educational module for medical students which incorporates a standardized patient for teaching purposes that focuses on the topic of pain and addiction can be created, meet usability standards, and be rated as useful by a team of consultants and the target audience. Create a curriculum outline for 5 to 7 similar modules covering the range of what medical students need to learn in this subject area.
• Phase II Goal: Develop the curriculum outlined in Phase I on the topic of pain and addiction that incorporates standardized patients for teaching purposes. Test usability with the target audience. Conduct a summative evaluation that shows significant improvements in pre/post knowledge, attitude, intended behavior and clinical skills (as measured by pre/post standardized patient assessments and documentation review) when compared to wait-list controls.

Objectives

Communication

Clinical Tools Frameworks

• Practicing Physicians
  • Pain and Addiction
  • SBIRT
  • Tobacco and AHEC
  • Buprenorphine Practice Advisor
• Medical Students
  • Alcohol
  • Buprenorphine
  • MS Pain and Addiction
  • ELSI of Genetics (ELSI = Ethical, Legal and Social Implications)

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Consumers

• Dementia Care Central

Intermediaries

• EndingSuicide
• Brain Train

Health Researchers

• HealthProposal