Pain Addiction Progress 2008-11

From Clinicaltools.com

Contents 1 Project Guide 2 Overview 3 Progress During November and first week of December 2008 3.1 Objective 1 3.2 Objective 2 3.3 Objective 3 3.4 Objective 4 3.5 Objective 5 3.6 Objective 6 3.7 Objective 7 4 Contact 5 Other Progress Reports

Project Guide

SBIR Phase I Contract #HHSN271200800012C

ADB Contract No. N43-DA-8-2213

Title: Web Based Training for Pain Management Providers

PI: T. Bradley Tanner, MD

Monthly Progress Report #5-6 of 6

Reporting Period: 11/1/08 – 12/8/08

Project Period: 6/9/08 – 12/8/08

Pain and Addiction Project Framework

Overview

This month we first focused on the final needs analysis evaluation, which was interviews of a group of the target audience, and then on the evaluation of the curriculum by the expert consultants. We developed action items based on results from each of these efforts and implemented many of them. We also wrote the Phase I final report as well as the Phase II proposal.

Progress During November and first week of December 2008

Objective 1

Determination of ASAM leader, expert consultants and expert advisory panel

Consultant Recruitment for Phase II. We asked consultants participating in the Phase I project to participate in the Phase II project. All 10 of the original 12 consultants who actively participated in the Phase I project agreed to continue consulting in Phase II; we gathered their biosketches and letters of support. We also recruited a new consultant, Win May, PhD, who has expertise in medical education, in particular, the use of standardized patients in education. The final list of 12 consultants who will participate in Phase II is included in Appendix A, along with a brief description of their expertise.

Objective 2

Evaluate current technologies and literature

Resources. We continued to expand our data base of over 100 annotated websites by adding screening and brief assessment tools. They are available at [1].

Technologies. We collected over 50 podcasts and powerpoint presentation complementary to those offered by our curriculum. These can be viewed at [2] and [3]

Objective 3

Develop needs analysis assessments

Interviews. We completed development of the interview needs analysis assessment, which consisted of 20 semi-structured questions. These interviews, conducted with the target audience, complete the needs analysis. Questions were primarily open-ended; many had follow-up questions for positive responses. The interview questions were based upon:

• Topics that could not be covered in a questionnaire format
• Results from earlier needs analysis surveys that needed to be clarified
• The curriculum outline

The questions were about clinician concerns and challenges in prescribing opioids and treating pain and addiction. We also asked about needs and preferences regarding continuing medical education (CME) courses on pain and addiction. The interview questions are included with the results in Appendix B.

Objective 4

Conduct needs analysis

Needs Analysis Survey List of Action Items. We developed and implemented a list of action items based on the results of the three final needs analysis surveys completed in October:

1. Target audience: clinicians who prescribe pain medications
2. Pain experts
3. Addiction experts

The action items primarily impacted planning for the design of the training program and thus will primarily be implemented during Phase II development. They include the following:

• Due to interest from the target audience, we will include a standardized patient (SP) component to the CME offerings on this website
• We will use chat as the modality for pain providers to communicate with the remote SP
• The SP interaction will last approximately 20 minutes
• We will develop resources as planned (due to strong interest in all of them). In addition to resources already planned, the resource center will include: guidelines and other related web pages and websites, podcasts, and slide presentations; screening and brief assessment tools, referral center linking to physician locaters, clinical forms, patient handouts, we will develop dosing algorithm flow charts, patient triage and treatment flow charts
• We combined chronic pain diagnoses together to form just one course with multiple cases from which to choose, covering the most common chronic pain conditions
• We will use the curriculum that we have outlined due to a favorable response to it, except as noted here and in the consultants section. We made minor changes in the curriculum in order to cover topics of interest that participants felt we had not emphasized enough, such as the importance of providing adequate pain relief for the patient

Interviews of Target Audience (Clinicians Who Prescribe Pain Medication). We conducted the final needs analysis evaluation, which consisted of interviews of six target audience members (clinicians who prescribe pain medication). Participants were interviewed by phone for approximately a half hour each using the semi-structured interview questions described in Objective 3. Participants included 5 internal medicine physicians and 1 family nurse practitioner.

Analysis of Data From Interviews of Target Audience (Clinicians Who Prescribe Pain Medication). The main results were as follows:

• Greatest concern when prescribing opioids to patients: potential for addiction.
• Greatest challenges in addressing addiction-issues when treating pain:

1. Diversion/diversion potential
2. Co-occurring psychiatric disorder
3. Inability of non-opioid treatments to relieve pain

• Some participants mentioned that additional training on addiction medicine and pharmacology would help address these challenges.
• Regarding treating pain among already-addicted patients, participants wanted more information about discerning drug-seeking behavior due to addiction vs. drug-seeking behavior due to undertreated pain
• Identifying patients who have relapsed into addiction was a concern mentioned by all participants
• Participants also requested more information about the following:

1. Urine drug testing
2. How to do informed consent and treatment agreements
3. How to take an addiction history

• Need for referral resources and clinical tools to help clinicians identify, interview, and manage addicted patients.
• Pain-causing conditions that should be covered in a CME curriculum about pain and addiction (highest rated):

1. Back pain
2. Fibromyalgia
3. Neuropathy
4. Osteoarthritis

• Participants agreed that conditions that are treated similarly (with opioids) should be grouped together and discussed in the same CME course
• They were interested in CME courses on how to manage both acute and ongoing chronic pain.
• Participants also commented about the use of a standardized patient (SP) as a CME experience. Topics of greatest interest included screening for addiction or interviewing a pain patient.

Overall, participants thought that the planned CME website about pain and addiction was a worthwhile endeavor that meets the needs of the target audience. One participant commented, “This is a sensitive and important area. Doctors will be interested.”

The full results are provided below in Appendix C.

Results from this needs analysis informed the questions asked of the consultants in their curriculum survey, therefore, we developed a single set of action items based on the results of this survey and the consultant feedback. See Action Items under Objective 6.

Objective 5

Determine the content and design (“framework”) of the proposed educational training modules

• Curriculum. We further refined the curriculum Pain and Addiction Courses in response to the results of the latest needs analysis and feedback from the consultants (described below). The curriculum changes are described in Objective 6 below and the final curriculum is described in Appendix D.

Objective 6

Evaluate curriculum plans with advisory panel and revise as needed

We sent the draft curriculum outline to the expert consultants/advisory panel and asked their feedback via an online survey using Survey Monkey followed with a phone interview.

Curriculum Survey. We developed a survey consisting primarily of open-ended questions on the curriculum that will be used to have the project's expert consultants conduct their review. We sent the draft of the curriculum to our 11 consultants asking them to take the survey. Seven experts completed the full survey and an eighth consultant sent open-ended commentary after the survey was closed. Highlights of the results from the survey include:

• Five out of six consultants stated that the overall curriculum is appropriate.
• Seven out of seven consultants mentioned areas where the curriculum was incomplete, including pain treatment for patients on buprenorphine or methadone, assessment tools, Federal Regulations for prescribing a controlled substance, urine drug testing, fear of regulatory scrutiny, behavioral health comorbidities, cancer pain, diversion and cancer patients, proper use of opioid analgesics, and vulnerability to addiction, including genetic and environmental factors.
• Four out of seven participants stated that the curriculum was either accurate, or accurate with one exception. Reasons for inaccuracy included a need for more detail, and a concern with overall focus on limiting opioid use in Courses 5-8.
• One consultant did not feel that the individual pain diagnoses should be covered.
• Three consultants felt that fibromyalgia should be included.
• Five participants felt that CAGE-AID, Opioid Risk Tool, Pain Assessment and Documentation Tool, and SOAPP are important screening instruments to feature on the website.
• At least six of seven participants selected “Pain patient who is in recovery,” “Pain patient also in addiction treatment,” “Detection (pain and addiction issues),” and “Pain patient who has untreated addiction” as the proposed topics which would best lend themselves to a standardized patient experience as part of the website's CME program.

The complete survey questions and a summary of the thematic analysis of the responses are found in Appendix E.

Consultant Phone Follow-up. Using a modified Delphi approach, we developed several open-ended questions to clarify and expand on the first round of feedback and to get feedback on our planned response to that feedback. Five of the seven experts who completed surveys participated in the phone follow-up. Others did not participate due to their time constraints. Highlights of that interview include:

• Two out of five consultants felt that headache is complex and should stand alone.
• Two out of five consultants felt that specific conditions should be grouped by noiceptive and neuropathic pain.
• Five out of five consultants were OK with using categories of acute vs. chronic breakdowns.
• Five out of five consultants stronlgy prefer the term “opioids,” saying that it is now understood that the term includes opiates.
• When asked what other clinical tools we could include on the website besides screening risk/assessment tools, three out of five consultants recommended basic opioid prescribing guidelines. Two recommended Compton's treatment misuse tracking tool, two recommended Gourlay and Heit's universal precautions for treating pain, one mentioned Passik's 10 principles, and one mentioned differential diagnosis.
• The two consultants who were asked if there is a better way to “sell” the course on diversion to PCPs in our needs analysis who are not very interested in it expressed surprise that the PCPs were not interested in diversion and recommended focusing on legal requirements.
• One consultant stated that the most need for more training about pain and addiction lies in primary care. Another said that every speciality and health care provider dealing with pain should be reached. Another mentioned including oncologists, orthopedists, surgeons, and to a lesser extent, neurologists, and even addiction specialists. Only one consultant felt that most specialists do not need more training on pain and addiction.

The complete interview questions and results are included in Appendix F.

Action Items and Their Implementation. Based on the final needs analysis and the consultant feedback we revised the courses. The primary change was that we combined the courses based on chronic pain diagnosis into one course with multiple cases and we restored the courses we had outlined on the stage of addiction or recovery. The courses will be:

Core Courses:

1. Assessing Substance Use Disorders at Initial Evaluation of Pain Patients
2. Minimizing Risk of Substance Use Disorders When Prescribing Controlled Substances to Pain Patients
3. Managing Substance Misuse and Addiction in Ongoing Treatment of Chronic Pain Patients
4. Protecting Your Medical Practice from Diversion Problems

Clinical Application Courses:

1. Clinical Cases: Treating Common Pain Conditions While Minimizing Risk of Misuse and Addiction
2. Clinical Cases: Treating Pain at Various Stages of Addiction

• We also revised course objectives and expanded the list of skills to be taught based on consultant feedback, adding greater emphasis to topics they felt were not emphasized well enough including: role of psychosocial factors in pain and addiction, importance of adequate treatment of pain, drug urinalysis, importance of use of alternative medications to opioids, both medications and other treatments. (See Appendix D for the full curriculum outline)
• We selected the main clinical assessment tools to be taught and offered on the website: CAGE and CAGE-AID, Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients in Pain (SOAPP), Pain Assessment and Documentation Tool (PADT), and Brief Pain Inventory.
• We plan to emphasize basic opioid prescribing guidelines and feature them prominently on the website
• We plan to focus on laying a solid foundation using clinical guidelines for which there is strongest evidence and consensus and avoid making recommendations for particular treatments where there is no strong consensus

The complete list of action items derived from consultant feedback is included as Appendix G.

Objective 7

Create Phase II project plan, including delivery, methodology, system architecture, and contents of training program (outline complete design of product and content areas)

• During the first week of December we developed the final Phase I report and developed the Phase II proposal.

Contact

Please feel free to contact me if you have any questions or concerns. I can be reached at (919) 960-8118 or tanner at clinicaltools dot com.

T. Bradley Tanner, MD (President, Clinical Tools, Inc.)

Other Progress Reports