[The following notes were generated by Michele Haight, PhD.]

IAMSE Webinar Series, Winter 2020

Speakers: Suzanne Lady and Narda Robinson
Title: “Informing Pain Management Curriculum: A Multi-Disciplinary Discussion on Alternatives to Opioids”
Series: How is Health Science Education Tackling the Opioid Epidemic?

• “Pain as the 5^th Vital Sign” was an initiative launched in 1999 by the American Pain Society to bring awareness to practitioners and the public that patients experiencing pain were being under-treated. Each patient encounter required a pain rating assessment. As a result, pain became a huge clinical focus.
• During the 2000s, drug manufacturers funded publications and CME events for physicians to encourage the expanded use of opiates.
• In response to the opioid crisis, in 2007, he ACP and APS published guidelines for non- addictive, OTC pain medications as alternative treatment options for low back pain which included: analgesics, NSAIDs and secondarily, muscle relaxants.
• Recent studies do not necessarily support the efficacy of these suggested pain medications, especially in light of their side effects.
• Guideline recommended CAM treatments for pain include: Tai Chi, Yoga, Diet Modifications, Exercise, Mind/Body techniques, Acupuncture, Physical Therapy, Massage Dietary Supplements, Cognitive-based Therapy and Spinal Manipulation.
• Pain is influenced by a person’s biology, pain beliefs and attitudes and their social support system or lack thereof.
• Given the complexity of pain management, it is necessary to teach and approach pain management from a bio-psycho-social perspective.
• Spinal manipulation, one aspect of manual therapy, is a hands-on treatment which is often done by chiropractors, osteopaths, physical therapists, and medical doctors. It includes additional recommendations for exercises, making healthy lifestyle and dietary choices and engaging in stress reduction through mind/body medicine techniques.
• International and Interdisciplinary Guidelines on treating low back pain include the following:
• The following are recommendations for acute low back pain:
• The evidence demonstrates that manipulation enhances function while medications do not.

• Integrative medicine is a field that uses practices that traditionally have not been part of conventional medicine but are now being combined with conventional medicine as evidence for safety and effectiveness increases.
• In terms of pain management, we need to:

1. 1. bring together conventional and complementary medicine practitioners along with other disciplines that treat pain to create a team-based approach to pain management.
   2. include pain medicine as a mandatory part of the medical school curriculum.
   3. provide integrative medicine learning opportunities and experiences from day one in the curriculum.
   4. create interdisciplinary opportunities for multiple integrative medicine professionals to train together such as integrated clinical preceptorships and residencies.
   5. see patients as a whole and learn to palpate from year 1; if you do not touch patients, how do you know where they hurt and the quality of their pain?
   6. build a healthier workplace culture for overworked and overstressed practitioners

• Pain care is changing to multi-modal, evidence-informed options.
• Prescribing opioids is the path of least resistance for overworked practitioners.
• PRIMA (The Pain, Rehabilitation and Integrative Medicine Advantage) is a parallel training pathway for human and veterinary medicine. From the beginning of training acupuncture, biotherapy, manual therapy botanical medicine, phototherapy, movement therapy, etc. are taught alongside a more conventional curriculum. This gives broader meaning to the basic science topics and helps learners to incorporate CAM to facilitate healing without solely relying on medications and procedures. The 5 modalities of PRIMA practice are: medical acupuncture, medical massage, laser therapy, botanical medicine, and movement therapy.
• Challenges are to incorporating integrative therapies with conventional medicine include the following:

1. 1. lack of faculty support
   2. insufficient awareness of scientific support for integrative therapies
   3. prescribing habits of practitioners
   4. corporate influence over curricula
   5. reimbursement

• The solutions to the opioid crisis are not:

1. 1. more expensive tests
   2. more education solely about opioids
   3. drugs and procedures
   4. disengaged patients

• In current medical education, there is a lack of instruction in pain medicine, a lack of awareness of non-opioid options and insufficient scrutiny of corporate influence in physician training. There needs to be a longitudinal, 4-year, comprehensive integrative pain medicine curriculum for all physician trainees devoid of corporate influence.
• Sample Integrative curriculum:
  • Integrative Curriculum, Year 1 (14 hours) – acupuncture anatomy, neurophysiology, problem-based learning, experiential laboratory, Photomedicine physiology, clinical applications, experiential laboratory
  • Integrative Curriculum, Year 2 (14 hours) – Medical massage anatomy, physiology, techniques, experiential laboratory, Botanical medicine pharmacology, clinical practice, experiential laboratory
  • Integrative Curriculum, Year 3 (14 hours) – Integrative medical approaches to orthopedic and neurologic disease and injury, integrative rehabilitation and physical medicine, experiential laboratory
  • Integrative Curriculum, Year 4 (150-300 hours) – Hybrid online/onsite medical acupuncture comprehensive program
• Final Thoughts: We need to move away from opioid reliance by learning new ways to heal and be healed by various integrative therapies in order to help our patients take control of their lives and be well.

[The following notes were generated by Michele Haight, PhD.]

IAMSE Webinar Series, Winter 2020

Speakers: Sherry Jimenez and Jeremy Buchanan
Title: “Methods for Incorporating Opioid Education in Health Professions Curricula”
Series: How is Health Science Education Tackling the Opioid Epidemic?

• To address the statewide opioid crisis in Tennessee, in July 2018, as part of the Tennessee Department of Health, Tennessee Together effort, the Commission on Pain and Addiction Medicine Education developed 12 core competencies for use as a guide in developing opioid education curricula.
• Given the large number of health professions programs at LMU, the aims for interprofessional opioid education have been the following: integrate opioid education across the health professions’ curricula and connect the LMU students directly with the community to better learn challenges faced by patients, families, community service providers, etc.
• The DO, PA and NP health professions collaborated in the development of a day-long, Controlled Drug Misuse Symposium in 2018 which focused on best practices for substance use disorder prevention and non-prescription treatment options.
• Elements of this symposium included: pre/post survey questions, pre-reading materials and patient testimonials.
• Lessons learned from this symposium: the symposium was too long and there was not sufficient time for meaningful interactions.
• Two significant learner outcomes from this symposium were: increased knowledge about widespread controlled drug misuse and increased awareness of controlled drug misuse among themselves and others.
• A second interprofessional symposium was implemented in 2019 which focused on the Synthetic Opioid Surge.
• Aims for this symposium included: understanding the difference between synthetic opioid and opioids and describing different treatment models can contribute to positive health outcomes.
• This symposium incorporated the same format as the first symposium with an additional QR code for question submission. The symposium was shortened to half day and included a one hour 15 min. simulation with a patient who had overdosed. This simulation included actual community service providers (paramedics, police officers, etc.) and Standardized Patients. Although this simulation was a valuable learning experience for all, it was cumbersome in terms of time and compromised the speakers who presented afterwards.
• The 2020 symposium will be 4 hrs. long and focus on the relationship between adverse childhood events and opioid abuse. This event will occur in a much larger venue to better accommodate all interested parties and will be streamed to campuses in 4 other cities and 2 universities in the UK.
• To increase opioid awareness LMU, in collaboration with its other health professions schools, has created a short video which explores the interprofessional aspects of a vehicular collision scenario. The aims for this film are to promote team-based care and guide appropriate communication and interaction with other health care professionals.
• If you are interested in accessing this video or participating in the 2020 symposium (via streaming), please contact Dr. Jimenez or Mr. Buchanan at the following: Sherry.Jimenez@lmunet.edu, Jeremy.Buchanan@lmunet.edu
• Final thoughts: the process to develop and implement both the symposia and the video have been stellar examples of meaningful interprofessional collaboration. These types of collaborations can serve as models for how to move forward with developing and implementing interprofessional education.

[The following notes were generated by Michele Haight, PhD.]

IAMSE Webinar Series, Winter 2020

Speaker: Paul George
Title: “Integrating Opioid Use Disorder and Medication Based Treatment into Undergraduate Medical Education”
Series: How is Health Science Education Tackling the Opioid Epidemic?

• Rhode Island is the smallest state but one of the hardest hit by opioid overdose deaths.
• Life expectancy in the US has decreased in part due to the opioid overdose epidemic.
• Nationally, opioid prescription rates per population from 2000-2015 had a profound effect on the opioid overdose epidemic.
• Due to appropriate education, current physician opioid prescribing habits have changed and opioid prescription rates have tapered off. However, opioid prescription rates still remain a contributing factor to opioid overdose deaths.
• All medical school graduates need to be able to diagnose and treat opioid use disorder regardless of their specialty.
• The governor of Rhode Island mandated that all medical students be DATA (Drug Addiction and Treatment Act of 2000) waiver trained. Brown Alpert Medical School (AMS) enhanced its existing UME opioid use disorder curriculum to meet this requirement. This curriculum was reviewed and certified by the AAAP so that all Brown (AMS) graduates were certified DATA waiver trained in the state of Rhode Island. (There is now a federal pathway for US medical schools to obtain national certification for DATA waiver training.)

The Brown (AMS) Substance/Opioid Use Disorder thematic Curriculum across the UME Spectrum includes the following:

• Pre-Clerkship classroom curriculum: didactics on the science of pain, pharmacology of pain treatment, non-opioid and opioid pain treatments, non-pharmacologic treatment of pain
• Pre-Clerkship “Doctoring” curriculum: behavioral change and substance use counseling, SBIRT (Screening and Behavioral Intervention and Referral for
  Treatment), screening 5 patients for substance abuse disorder providing intervention and referral for treatment for positive screens, 1.5 hrs. interprofessional workshop (paper-based cases/team plan of care)
• 2 Week Clinical Skills Intercession Workshop (between years 2-3) pain management/opiates interprofessional 4 hr. workshop/patient panels/Standardized Patients
• Clerkship curriculum: documenting 5 substance use disorder patients (Internal Medicine/Family Medicine) providing interventions and referrals for treatment for positive screens, interactive workshops on pain and pain management (Internal Medicine, Family Medicine and Psychiatry), cases/sessions on chronic pain, evaluation and treatment of substance use disorders and substance misuse didactic session on MAT (medically assisted treatment)
• Proposed Year 4 curriculum mandatory 3hr. workshop with content on pain management and MAT-based cases

In partnership with the American Academy of Addiction Medicine, the Brown AMS curriculum also incorporates “outside” elements from the AAAM provider clinical support system.

• Recommendations for creating a Substance/Opioid Use Disorder curriculum: Make the curriculum integrated and longitudinal, make the curriculum interprofessional, partner with key stakeholders, use a variety of teaching modalities, link the curriculum across UME, GME and CME. (Private practice and community physicians are a high priority group for opioid
  education.)
• Final Thoughts: A waiver is not necessary for prescribing medications such as insulin or anti-hypertensives or oxycodone, etc., so what is the purpose of mandating a waiver for MAT for opioids? Perhaps it is time to rethink settings in which Methadone can be prescribed. LCME and ACGME need to include opioid education in their regulations.