Pauline Anderson

March 23, 2017

ORLANDO — As the country continues to face an epidemic of opioid misuse, medical schools should consider using simulation and immersive learning to teach students about the safe management of these drugs, researchers say.

"One reason we have this opioid epidemic is the lack of education surrounding opioids," Jordan L. Newmark, MD, pain medicine associate program director, and clinical assistant professor, Division of Pain Medicine, Stanford University, California, told Medscape Medical News.

"I'm a very strong advocate for the use of simulation," he said. "It's a powerful technique that should be considered when we're trying to teach about opioids."

Dr Newmark presented data on their center's use of this strategy here at the American Academy of Pain Medicine (AAPM) 2017 Annual Meeting.

Simulation uses professional or amateur actors who play out various patient-doctor scenarios. It's a teaching technique often used in other fields, including surgical anesthesiology.

"It's still pretty limited in the area of pain, although it's catching on," said Dr Newmark.  "I want to see this grow in the pain world as it's grown in the anesthesiology world.

"Some people use simulation for rare events that may never occur in a trainee's career," he said. "My personal opinion — and there are those who may disagree — is that that's not the most efficient way of using simulation."

For this analysis, the Stanford researchers looked at the performance of 5 anesthesia residents and 18 pain fellows who faced a "standardized patient" asking for a refill of hydromorphone. The patient fit criteria for opioid addiction or moderate opioid use disorder.

All simulation sessions were filmed, archived digitally, and reviewed in a retrospective fashion. Researchers provided a group debriefing and individual feedback.

The idea is for students to learn to appropriately diagnose an opiate-related issue and come up with a plan that's safe and effective, said Dr Newmark.

Simulation offers several benefits over a real-life experience. "What's unique about simulation is that we can video-capture the experience and do an analysis of their performance afterwards and give them feedback," said Dr Newmark.

"The other beauty of simulation is that every single patient is the same, so I can effectively compare trainees against each other and make inferences about how one person is doing versus the other."

Dr Newmark called the experience "immersive learning."

"In this particular simulation, trainees are immersed in an experience where the patient has risks for addiction and they're asking for a refill because they have no tablets left."

The research found that most participants (72.7%) used prescription drug monitoring programs and more than half (59.1%) used urine drug screens as an assessment tool.

Fewer considered the 4As (a series of four opioid risk-benefit questions developed by a pain psychologist, looking at analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors), the opioid risk tool, or pill counts.

Missed Concerns

About 13.6% of fellows/residents had "few opioid related concerns."

"Some of the participants missed the opioid-related concerns for this patient," commented Dr Newmark.

"I'm doing retrospective research to see why some participants perform better than others and then how to build educational interventions around that so everyone does better."

Most participants were nonspecific about a diagnosis. As for treatment strategies, the majority provided a refill along with weaning.

Dr Newmark said he would like to see "more accuracy" in diagnosis and safe treatment plans.

Anonymous surveys yielded favorable remarks from participants with regard to "realism" and "relevance to future practice."

The downside to using simulation in medical schools is the cost (which includes hiring actors) and the time needed to invest in the initiative, said Dr Newmark.

It's unclear whether this kind of simulation teaching tool affects clinical practice. "That's very hard to assess as it takes a lot of data mining and logistics," said Dr Newmark. "To a certain degree, we don't know if it's truly changing patient outcomes, but that goes for all simulations, not just for pain."

The study "is a very valuable demonstration" of how using immersion training and a simulated patient encounter helped students learn how to employ recommended risk assessment techniques, commented Steven Stanos, DO, a pain medicine physical medicine and rehabilitation specialist in Seattle, Washington.

Such assessment techniques are needed to more effectively monitor patients for abuse and addiction, he told Medscape Medical News.

"Greater resources and time need to be integrated into medical school and residency training curricula around acute and chronic pain assessment and management."

The study received no outside funding.

American Academy of Pain Medicine (AAPM) 2017 Annual Meeting. Poster 159. Presented March 17, 2017.

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