Pain and Addiction Standardized Patient Example 1

From Clinicaltools.com

Contents

Project Overview
1. Case Overview
2. Case Focus
3. Checklist Items
Instructions to Participants (Students or Learners)
1. New Patient Questionnaire
2. Patient Vital Statistics
3. Patient Lab Results
Instructions to Standardized Patient Actors
1. Case Background
2. Prompts
3. Tips for Standardized Patient Actors
4. Sample Questions
5. Screening Instrument Questions and Answers
6. Standardized Patient Evaluation
Instructions to Evaluators
1. Evaluation Sheet

Project Overview

Overall Project Goal

To train health professional learners when and if it is appropriate to screen for drug abuse, specifically prescription opioids and other potentially addictive substances used to treat pain as well as other addictive substances the patient may use, and to evaluate the interpersonal interviewing techniques of learners.

Targeted Learners:

Clinicians who prescribe potentially addictive pain medications

Case Overview

This case focuses on the risk of opioid dependence in individuals with chronic pain. Learners will encounter a patient with chronic, consistent pain from an old injury who presents with minor flu symptoms. Learners will be tasked with screening a standardized patient, already on opioids, for opioid abuse, interpreting the screening results together with suggestive symptoms and determining if a brief assessment is needed. Conducting a brief assessment, elaborating on them if appropriate, and interpreting the symptoms of the standardized patient discerning pain symptoms from symptoms related to drug abuse or withdrawal. They will be tasked with deciding if the patient needs further assessment/treatment by a specialist according to the local resources available and the clinician's experience. The main learning objective of this case is to encourage learners to screen all patients for abnormal and/or possibly addictive addictive opioid use, to use further questions designed to determine the difference between proper and illicit use of pain medication, and to document screening and brief assessment results clearly. The standardized patient framework allows for a superior learning experience with this objective, as health professional learners are encouraged to use their interpersonal interviewing skills to arrive at an assessment that balances the pain relief needs of the standardized patient with the health care provider's responsibility to prevent possible dependence.

Case Focus

Interpreting signs of opioid dependence and screening results, investigative assessment technique, drug screening models, and mitigating current, chronic pain with safe usage of opioid pain relievers.

Major Purposes of Case

After meeting with the standardized patient (SP), the learner will:

Assess the patient's symptoms
Assess the patient's knowledge of the danger of opioid abuse
Develop a plan to treat the symptoms of the SP that accounts for the risk of opioid abuse

Case Specific Essential Knowledge, Skills and Behaviors to be Demonstrated:

Knowledge of opioid abuse risk behaviors
Usage of screening tools to determine patient's opioid dependence level
Sensitivity towards the patient's case
Pointed questioning that enables the learner to distinguish between pain management or drug abuse in the patient's case.

Primary Challenges Presented by the Patient's Behaviors

Long time pain medication use has blurred the difference between pain management and dependence
The patient is proud person who does not want to be on pain medication, but feels he must be to live a somewhat normal life
The patient has serious chronic pain that must be considered before continuing pain medication regiment or beginning a detoxification.

Expected Diagnosis and Problem List:

Significant risk for opioid dependence

Checklist Items

Risk Factor Assessment The learner:

Identified the major opioid dependence risk factors in the patient (long time opiate use, inability to function without medication, physical signs, etc)
Used at least two (2) substance abuse screening instruments in their assessment of the patient, including CAGE-AID, the Two-Item Conjoint Screening, the DAST-10, or others.
Ordered appropriate follow up tests and/or referrals

Patient Care The learner:

Presented a detailed assessment to the patient, that includes his/her opinion of the patient's state of health, the physician's concerns, and treatment options
Dealt with the patient in a sensitive, non-judgmental way about their possible drug dependence
Asked different types of questions in order establish a rapport with the patient and determine their level of drug use. This includes asking a mix of open-ended, assumptive, and targeted questions in a simple, matter-of-fact fashion while reassuring the patient that their answers are confidential

Instructions to Participants

New Patient Questionnaire

Presenting Situation: Chad Wright is complaining of chronic pain due to an old sports injury. He is visiting you to request Percocet to treat his knee injury.

Activities: You will encounter the patient as if you are an an examining room setting. You should assess them based on the patient's responses to your questions and the materials provided to you and provide a course for treatment following the encounter.

Patient Encounter: You are about to see Chad Wright. He is a 34 year old man who complains flu like symptoms. He also suffers from chronic pain in his knee due to a football injury he sustained while in college.

In the past 13 years since his injury, Chad has undergone surgery and extensive physical therapy to repair his knee. He has been prescribed various opioid pain medications with various effect.

He has come to you to get treatment for his flu symptoms and a new prescription for pain medication.

Vital Statistics:

Patient Name: Chad Wright

Height 70in Weight 200lbs Overweight No BP 139 sys 87dia

Temp 100.7 Pulse 97 Allergies? Penicillin Medications Percocet 10 mg/325 mg (2 tablets 3x a day) Calcium supplement 1000 mg/day Vitamin D 200 IU daily

Lab Results:

CTI Medical Group Laboratory Patient: Wright, Chad 1516 East Franklin Street, Suite 100 Med Rec# 73-583-90 Chapel Hill, NC 27514 Age: 34 years Phone: 919-960-8118

Date Drawn: 03-21-2008

Value Normal:

WBC 7,300(/µL3) 4,500-11,00(/µL3) Neutrophils 57 (%) 47-77(%) Band neutrophils 1.4 (%) 0-3(%) Lymphocytes 24 (%) 16-43(%) Monocytes 3 (%) 0.5-10 (%) Eosinophils 4.5 (%) 0.3-7 (%) Basophils 0.7 (%) 0.3-2(%) RBC 5.1 (x 106/µL) 4.6-6.2 (x 106/µL) HCT 42 (%) 37-47(%) Hgb 12.5 (g/dL) 12-16 (g/dL) MCV 82 (fL) 80-100 (fL) MCH 33 (pg) 28-32 (pg) MCHC 34 (g/dL) 32-36 (g/DL) RDW 11.9 (%) 11.7-14.2(%) Platelets 370,000(/mm3) 375,000(/mm3)

Blood cells appear normal in shape, size, and number.

ALT(SGPT) 68 (U/L)**H 0-48 (IU/L) AST(SGOT) 54 (U/L)**H 0-42 (U/L) Alkaline Phosphatase 78.4 (U/L) 20-125 (U/L) BUN 8 (mg/dL) 7-20 (mg/dL) Creatinine 1.1 (mg/dL) 7-1.4 (mg/dL) BUN/Creatinine 15.5 6-25 Albumin 4.5 (g/dL) 3.2-5.0 (g/dL)

Cholesterol 260 (mg/dL) 120-240 (mg/dL) LDL 135 (mg/dL) 62-130 mg/dL) HDL 89 (mg/dL) 35-135 (mg/dL) Triclycerides 150 (mg/dL) 0-200 (mg/dL)

TSH 3 (miU/L ) .5-6 (miU/L) T4 10 (ug/dL) 4-12 (ug/dL)

Instructions to Standardized Patient Actors

Case Background:

Your name is Chad Wright. You are 34 years old and married with 2 children. You work as an insurance adjuster.

While in college you played football in the position of offensive tight end. While attempting to receive a pass you were tackled and received an extensive knee injury in what was called a "catastrophic career ender."

The injury required four separate operations to restore mobility in the knee and then and agonizing 18 months of physical therapy to restore partial use. You still walk with a cane and experience significant periods of pain which requires medication if you are to have any productivity that day. Without your medication you are unable to work, socialize, or even concentrate for long periods of time.

Prompts:

1. I need medication for my pain. 2. I've tried other methods, but I cannot live a normal life without something to help me with this pain. 3. My knee hurts all the time. Can you write me a prescription for more medicine? 4. I need you to help me manage this, you don't know what being in pain all the time is like. Aren't you supposed to help me?

Tips for the Standardized Patient Actor:

Think of being in a chronic state of pain. The only relief you experience is the six to eight hours after you have consumed your medication. You feel as if you cannot live your life to the fullest if your knee is constantly bothering you. At this point in your life your medicine has become a necessity and even though you can see that it has become a crutch, the alternative is much worse. You are a proud person and you feel that having to constantly be evaluated to see if you need more meds is a demeaning waste of time.

Be Prepared to Answer Questions Such as: So why have you come to see me today?

I feel achy and slightly nauseous, my head hurts and I've got a bit of a fever. Usually, I wouldn't bother coming to the doctor about this, but it's been going on for about three days now, and I thought I should get checked out.

How often would you say you need you medicine?

Everyday, when I wake up there is sharp throbbing pain in my knee that gets worse if I do not take anything. I usually take meds three times a day: in the morning, after work, and then in the evening a few hours before bed.

Have you ever tried to use anything other than your meds to control the pain?

Not specifically, but I've definitely had a few extra drinks sometimes when I can feel it getting worse

Have you tried any more physical therapy, to get more mobility out of the knee?

I haven't done any more therapy, it's painful and doesn't really help much. I do walk as much as I can on my cane and try to be active with my kids.

How long have you been taking pain medication for this injury?

Since it happened pretty much. I was on more before and during the surgeries, and then the dosage came down some when I started physical therapy. It's been pretty steady since then, I've change medications about 3 or 4 times in the last ten years.

How much mobility do you have in the knee, does any movement make it hurt?

I can bend the joint to about 35 degrees, 45 if its warmed up a little. All movement hurts though.

How long have you been on the Percocet?

I've been on that for about 4 years. But it doesn't seem to be working as well as it used to. I think I need more.

How long has it been since you had any?

It's been about three days.

How are you feeling?

Well, my knee is really killing me. I also feel a little nauseous and achy. It's almost like I've got the flu, I get mild sweats and go back and forth between being really hot and really cold.

Have you ever tried to stop taking your meds?

A couple of times, like I'd just tell myself to try and stop for awhile, you know, get used to it. But it always ends up with me not being able to do anything normal and feeling like crap all the time, not to mention not being able to sleep. So I've never made it more than a week.

Answers to Screening Instrument Questions

As the standardized patient you will be asked a series of diagnostic questions by the learner in order to assess your level of drug use. Below are questions from four common screening instruments, followed by the answers you should give. In some cases you will need to improvise answers as the learner may use other screening instruments or ask unexpected questions. The answers below should be used as a guide to field these unexpected questions.

CAGE-AID Have you felt that you ought to Cut down on your drinking or drug use? Chad's response: I have thought about cutting down my pain medication many times, but I don't know how I can do that and still function. I would love to not be tied to the pills, but they seem to be the only thing that can make my knee pain bearable. Have people Annoyed you by criticizing your drinking or drug use? Chad response: While I wouldn't say that she has criticized my pain medication intake, my wife would definitely like to see me taking fewer pills in order to be ok. She sees how much pain I'm in when I'm not taking them, so she understands why I'm on them, but I know she would feel better if I didn't have to rely on them so much. Have you felt bad or Guilty about your drinking or drug use? Chad response: I have had bouts of guilt about having to rely on the Percocet to maintain my daily schedule, but I don't feel like I had a choice about getting into this cycle. At this point, it's about trying to keep as normal of a life as I can, and without the meds I can't do that. It's that simple. Have you ever had a drink or used drugs first thing in the morning (Eye Opener) to steady your nerves, to get rid of a hangover or to get the day started? Chad response: No. Not since back in college, "hair of the dog" you know...

Drug Abuse Screening (DAST-10)

Drug Use Questionnaire

The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is "Yes" or "No". Then circle the appropriate response beside the question. In the following statements "drug abuse" refers to: 1.the use of prescribed or over-the-counter drugs in excess of the directions, and 2.any non medical use of drugs. The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right. These Questions Refer to the Past 12 Months 1.Have you used drugs other than those required for medical reasons? - No 2.Do you abuse more than one drug at a time? - No 3.Are you unable to stop using drugs when you want to? - Yes 4.Have you ever had blackouts or flashbacks as a result of drug use? - No 5.Do you ever feel bad or guilty about your drug use? - Yes 6.Does your spouse (or parents) ever complain about your involvement with drugs? - Yes 7.Have you neglected your family because of your use of drugs? - No 8.Have you engaged in illegal activities in order to obtain drugs? - No 9.Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? - No 10.Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)? - No

Addiction Behaviors Checklist

Note to standardized patient actors*

The Addiction Behaviors Checklist is completed by the physician as they assess the patient. The questions are presented here with answers that the physician should record after speaking with the standardized patient. You should craft your answers to the physician's questions so that the physician's most likely answer would be what is presented below.

Instructions: Code only for patients prescribed opioid or sedative analgesics on behaviors exhibited "since last visit" and "within the current visit" (NA = not assessed)

Addiction behaviors - since last visit 1.Patient has used illicit drugs or evidences problem drinking - Yes 2.Patient has hoarded meds - No 3.Patient has used more narcotic than prescribed - Yes 4.Patient ran out of meds early - Yes 5.Patient has increased use of narcotics - Yes 6.Patient used analgesics PRN when prescription is for time contingent use -No 7.Patient received narcotics from more than one provider - No 8.Patient bought meds on the street - No

Addiction behaviors - within current visit 1.Patient appears sedated or confused (e.g., slurred speech, unresponsive) - No 2.Patient expresses worried about addiction - Yes 3.Patient expressed a strong preference for a specific type of analgesic or a specific route of administration - Yes 4.Patient expresses concern about future availability of narcotic - No 5.Patient reports worsened relationships with family - No 6.Patient misrepresented analgesic prescription or use - No 7.Patient indicated she or he "needs" or "must have" analgesic meds - Yes 8.Discussion of analgesic meds was the predominant issue of visit 9.Patient exhibited lack of interest in rehab or self-management - No 10.Patient reports minimal/inadequate relief from narcotic analgesic - Yes 11.Patient indicated difficulty with using medication agreement - No

Other 1.Significant others express concern over patient's use of analgesics - Yes

Check list

Documented screening properly