Pain and Addiction Framework

From Clinicaltools.com

Title: Web Based Training (in Addiction Medicine) for Pain Management Providers
Funding: NIDA Contract No. #HHSN271200900003C
ADB Contract No. N44-DA-8-2213
Funding Project Officer: Quandra Scudder
Principal Investigator: T. Bradley Tanner
Project Director: Karen Rossie
Project Period: 4/1/09 – 3/31/11
Product: PainandAddictionTreatment.com
Pain Addiction Progress Reports

Need

The majority of providers in the pain practice community did not receive adequate training to detect, prevent, and manage patients at the interface of pain and addiction (CASA, 2005). Without this training, many providers do not follow evidence-based and clinical consensus recommendations for preventing, recognizing, and managing substance misuse and addiction in pain patients, even though recommendations are not difficult to understand, resources exist, and the risk of mistreatment is obvious and deleterious for the physician as well as patient. Based on the results of their 2005 physician survey, CASA made the following recommendation: "Associations of health care training institutions and medical training programs should require education and training in prescribing and administering controlled drugs; identifying diversion; identifying, diagnosing and treating substance misuse and addiction; and identifying, diagnosing and treating psychiatric disorders and pain in ways that minimize the risk of abuse and addiction" (CASA 2005).

Reference: CASA: The National Center on Addiction and Substance Abuse at Columbia University (CASA). Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. July 2005. Available at: http://www.casacolumbia.org/absolutenm/articlefiles/380-Under%20the%20Counter%20-%20Diversion.pdf. Accessed July 11, 2008.

Vision

A health care system where interaction with a physician carries minimal risk of developing addiction and hope and confidence that addiction problems will be discovered and treated prompty and efficiently.

Mission

To create an online environment that enables pain management providers to better manage co-morbid substance misuse and addiction or risk for addiction in patients suffering from pain.

Target Audience

Clinicians who treat pain and have not had sufficient education in addiction medicine, including
1. primary care physicians,
2. resident physicians,
3. nurse practitioners.
Specialists who treat pain are also included in the target audience.

Overall Constraints

There is minimal evidence available, so evidence-based medicine (EBM) is not enough to drive the content. Some case studies, epidemiological data and strong clinical consensus will need to be included.
Some care is dictated by guidelines which vary from state to state and which may not be based on science or in agreement with other guidelines
Multiple guidelines exist from different organizations with varying overlap.
Learning must qualify for CME credit including the need to impact clinical outcomes.
The solution must fit within the vision of the CTI Learning Management System.
There are multiple CME experiences funded by pharma which are available at low or no cost to the physician.

Learner Constraints

Health professional learners do not usually browse the web looking for web sites that will help them alter their practice.
Pain management providers tend to focus on the diagnosis and treatment of pain, not on the risks of opioids or how to use them specifically for a patient where addiction is an issue.
Knowledge Base can vary considerably between learners. Learner audience includes non-physician providers such as Physician Assistants and Nurse Practitioners.
Learning Time Block: Some learners prefer to learn in smaller or larger blocks of time or during hours where it might be difficult to provide a live learning experience.
Learning Time: Retaining physicians once they have been engaged is difficult since they are busy and have multiple demands on their time.
Learning styles vary between learners.
Resistance: Health professionals have established matrices of knowledge, an attempt to alter a matrix will cause resistance.
Fear: Learners want to retain patients and may feel that the approach will harm rapport.

Strengths

Understanding of the issues is low as is compliance with standards. Co-morbid pain and addiction is an area of medicine for which primary care providers are not well-prepared. There is room to teach
The downside of not knowing or practicing incorrectly are multiple; thus there are many incentives, including legal ramifications as well as regulatory requirements.
Strong consensus clinical opinion has been defined by organized medicine that can drive the content where EBM is not available.
A novel content management system (CMS) environment that fits the task can be used.

Goal

Primary care and specialist professionals who treat patients with pain problems enhance their skills and receive support for managing addiction, and share experience via a state-of-the-art online environment that will include the novel use of a simulated, Standardized Patient educational experience. Proven approaches for translating research into practice will be adapted to the Internet.
Design an online environment for pain management providers that provides a unique combination of skills training, a resource catalog and collaboration related to the topic of pain and addiction. Pain managers can go to the website to collaborate, answer point of care questions and receive CME credit on a just-in-time basis or via standard educational curricula. The clinician who treats pain will, as a result of this project, be able to reduce the risk of misuse of prescribed substances and recognize and assure adequate treatment of substance misuse and addiction in chronic pain patients. They will also be able to provide adequate pain management in patients with substance use disorders without further contributing to their substance problem.
To provide practicing and future physicians with the skills to 1) avoid addiction in the process of pain treatment, 2) identify existing and ongoing addiction, and 3) treat addiction in their office based practice.

Project Objectives

Build a suite of skills training courses with supportive content that offers real world challenges in the form of brief cases, more complicated case and standardized patients
Build a catalog of quality resources and a e-commerce high quality search engine that gives users a quick and simple way to find the resources they need using any Internet-capable tool, including cell phones with small screens
Establish tools so learners can communicate with other learners and provide feedback to others who seek to enhance their practice

Curriculum

Nine Pain and Addiction Courses are planned - 7 "core" courses and 2 clinical application courses. All courses will focus on clinical skill-building and will feature case studies and/or a standardized patient experience.

Overall Curriculum Objectives

Upon completion of the training, the learner will be able to:

Screen pain patients for addiction and assess them for addiction risk
Triage patients to the appropriate level of care to stratify risk.
Initiate pain treatment with opioids while simultaneously avoiding addiction complications for the patient.
Monitor patients during ongoing pain treatment for substance use problems
Coordinate care for pain patients with specialists in pain and addiction
Utilize appropriate treatment structure and/or referral if a pain patient develops substance use problems.
Practice sound clinical/office protocols to avoid diversion.
Demonstrate clinical skills knowledge through given case scenarios to common pain conditions.
Demonstrate clinical skills knowledge through given case scenarios related to stage of addiction, that is, active addiction, in treatment, or in recovery.