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Interprofessional Pain Educa3on

Harvard School of Dental Medicine and Brigham and Women’s

Center of Excellence in Pain Educa>on

Jeffry Shaefer, DDS, MS, MPH, Harvard School of Dental Medicine Antje Barreveld, MD, Brigham and Women’s Hospital, Department of Anesthesiology Paul Arnstein, PhD, RN, MassachuseHs General Hospital Michele MaHhews, PharmD, MassachuseHs College of Pharmacy and Health Sciences

Learning objec3ves

•  Recognize the concepts of the flipped classroom

•  Recognize the NIH program for teaching principles for pain management by crea3ng CoEPEs

•  Iden3fy how orofacial pain and pain management can best be taught via interprofessional educa3on

The flipped classroom •  The student reviews lecture material the night before class (PPT, handouts, publica3ons, case materials)

•  Class begins with a short pre-‐test •  The class is organized into small groups of 6-‐10 students

•  Each group sits at a discussion table and is asked to answer ques3ons about the case

•  Periodically the instructor will ask the groups to answer the ques3ons and will provide materials to support the discussion

What NIH Funding DOES at HSDM

Supports educa3on innova3on in 2015 • Teaches standards for opioid prescribing • Encourages self-‐directed learning • Allows “flipped-‐classroom” student interac3on • Creates inter-‐professional educa3on opportuni3es

Altarum Ins>tute/Palladian Partners REQUEST FOR PROPOSALS Jan 2012

!CoEPEs will develop pain management training resources for health care professionals to advance the assessment, diagnosis, and treatment of pain

NIH ICs Involved: ORWH OBSSR NIDA NIDCR NINDS

NIA NINR NICHD NIAMS NCCAM

NIH Pain Consor>um Centers of Excellence in Pain Educa>on

Harvard School of Dental Medicine and Brigham and Women’s CoEPE Thomas Jefferson School of Medicine Headache Collaborative CoEPE Southern Illinois University Edwardsville/St. Louis University CoEPE University of Pittsburgh CoEPE: Pain Challenges in Primary Care John D. Loeser CoEPE at the University of Washington University of Alabama at Birmingham CoEPE University of California, San Francisco, CoEPE University of Maryland Baltimore CoEPE The University of Pennsylvania CoEPE Rochester Area Collaborative CoEPE University of New Mexico CoEPE Johns Hopkins University CoEPE

A Pain champion collabora3ve Harvard School of Dental Medicine

Harvard Medical School Teaching Affiliates at

Brigham & Women’s Hospital and Massachuse^s General Hospital

Massachuse^s College of Pharmacy and Health Sciences

Regis College School of Nursing and Health Professions MGH School of Health Professions: Nursing

Massachuse^s School of Professional Psychology

HSDM and BWH Center of Excellence in Pain Education

Boston Pain champions

•  Principal Inves3gator: Dr. Jeffry Shaefer, DDS, MS, MPH, Assistant Professor of the Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine

•  Project Manager and Co-‐PI: Dr. Antje Barreveld, MD, Instructor of the Department of Anesthesiology, Periopera3ve and Pain Medicine and Fellow of Pain Management, Brigham and Women’s Hospital, Harvard Medical School Teaching Affiliate

•  Co-‐Inves3gator: Dr. Robert Jamison, PhD, Professor of the Department of Anesthesiology, Periopera3ve and Pain Medicine and the Department of Psychiatry, Pain Management Center, Brigham and Women’s Hospital, Harvard Medical School Teaching Affiliate

•  Co-‐Inves3gator: Dr. Ajay Wasan, MD, MSc, Assistant Professor of the Department of Anesthesiology, Periopera3ve and Pain Medicine and the Department of Psychiatry, Pain Management Center, Brigham and Women’s Hospital, Harvard Medical School Teaching Affiliate

•  Co-‐Inves3gator: Dr. David Keith, BDS, FDS, RCS, DMD, Professor of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine

Boston pain champions •  Co-‐Inves3gator: Dr. Michele Szabo, MD, Director of Medical Student Educa3on, Anesthesiology

Clerkship, Massachuse^s General Hospital •  Co-‐Inves3gator: Dr. Jennifer McSweeney, MD, Director of Medical Student Educa3on, Anesthesiology

Clerkship, Brigham and Women’s Hospital •  Co-‐Inves3gator: Dr. Nicole Holland, DDS, MS, Orofacial Pain Fellow, Harvard School of Dental Medicine •  Co-‐Inves3gator: Michele MaHhews, PharmD, Associate Professor of Pharmacy Prac3ce, Massachuse^s

College of Pharmacy and Health Sciences; Clinical Pharmacy Specialist, Pain Management Center, Brigham and Women’s Hospital

•  Co-‐Inves3gator: Dr. Penelope Glynn, PhD, RN, Dean of the School of Nursing, Science and Health Professions at Regis College

•  Co-‐Inves3gator: Dr Andrew Strassman,PhD Assocaite Professor of Anaesthesia, Anaesthesia and Cri3cal Care,Beth Israel Deaconess Medical Center

•  Co-‐Inves3gator: Julie Whelan Media Specialist, Countway Library of Medicine, Harvard Medical School, Boston

Pain Educa3on Guideline 1

•  Specific Aim : – To promote independent learning via uni-‐professional case-‐based modules on pa3ents with acute and chronic pain.

•  Hypothesis : – Cases tailored to the students’ clinical background in den3stry, medicine, pharmacy, or nursing

–  improve their knowledge, aZtudes toward trea>ng pain, and confidence in understanding and managing pa>ents with pain.


•  Specific Aim: – To conduct regular uni-‐professional small group sessions led by “pain champions”

•  Hypothesis: – Small group discussions provide a forum to help increase students’ confidence in understanding and trea3ng the mul3dimensional challenges of living with pain.


•  Specific Aim : – To conduct inter-‐professional workshops

•  Hypothesis : –  Inter-‐professional contacts promote teamwork and pa>ent-‐centered collabora>on in learning how to best work together to manage acute and chronic pain.

Our mission -‐ 1 •  Specific Aim 1:

–  To establish an inter-‐professional pain educa>on program and Center of Excellence in Pain Educa2on for dental, medical, nursing, and pharmacy students during their clinical rota3ons in Boston, MA

•  Hypothesis 1: – Although students par3cipate in some uni-‐professional (e.g. dental), pre-‐clinical lectures in pain management, the clinical training years are paramount to learning the prac3cal applica3on of inter-‐professional fundamentals in managing and understanding pain.

Our mission -‐ 2

•  Specific Aim 2: – To conduct pre-‐ and post-‐pain curriculum knowledge ques>onnaires and evalua>ons in all students.

•  Hypothesis 2: – The ques3onnaire results and evalua3ons will provide valuable data on the impact of this program

case -‐ 1

– 52 year old male with head and neck cancer and a history of substance abuse is admi^ed for repeat surgical resec3on.

– Learning objec3ves raised: •  substance abuse, prescrip>on abuse, diagnosis of dental pain, management of acute on chronic pain, treatment of xerostomia, pre-‐cancer treatment dental evalua>on and care, and end-‐of-‐life care.

case -‐ 2

– 39 year-‐old female with a temporomandibular disorder and fibromyalgia is referred for help with managing her pain.

– Learning objec3ves raised: •  disease pathophysiology, adjunct medica>ons, non-‐pharmacological approaches, alterna>ve therapies, gender differences in pain management, diagnosis and management of mas>catory and wide-‐spread muscle pain.

case -‐ 3

•  82 year-‐old male with herpes zoster with a 3-‐month history of chest wall pain is admi^ed for pain control and altered mental status.

•  Learning objec3ves raised: –  disease pathophysiology, neuropathic pain medica>ons, and pain management in elderly adults.

case -‐ 4

•  18 year-‐old female who recently moved to the area to start college with a history of depression and chronic pain from Juvenile Rheumatoid Arthri3s (RA) pain managed with high-‐dose opioid therapy presents to the emergency department with worsening pain.

•  Learning objec3ves raised: –  age differences in pain experience, the psychological impact of pain, safe and effec>ve opioid prescribing prac>ces, and strategies for opioid management in young adults, diagnosis and management of TMJ arthralgia symptoms

Interac3ve on-‐line case-‐based modules

•  HSDM learning objec3ves Acute pain management Recognizing the problem pa3ent (drug seeker, at risk pa3ent) Address acute pain for chronic pain pa3ent Pain management in the elderly and pediatric pa3ent

Pain Syndromes & Complica>ons

Cancer Pain Pain in End of Life Facial Pain Disorders TMJ / TMD / Dental

Fibromyalgia Syndrome Sickle Cell Chronic Pelvic Pain Chronic Abdominal Pain

Migraine Non-‐migraine HA Pediatric Pain Chronic Back Pain

Musculoskeletal Neuropathic Pain Syndrome

Pain in Noncommunica3ve

Pa3ents

Central Pain Syndromes

Pain in the Elderly Post-‐Opera3ve Opioid-‐induced Hyperalgesia

Abuse / Misuse / Diversion

CoEPE Case-based Scenarios

Mr. Gateway’s Hospital Course: The Emergency Department (ED) calls you and says: “We have a 52-‐year-‐old male smoker with a history of substance abuse with recurrent laryngeal cancer who presents with increased throat and neck pain, dysphagia (pain with swallowing), and dehydra3on.” You are part of the inter-‐professional team that will manage Mr. Gateway during his hospitaliza:on. You are asked to come evaluate the pa:ent who will be admi?ed to the surgical service and help advise on how to manage his pain.

Ques3ons you might consider for Mr. Gateway’s Dental Consult

•  How do you manage acute dental pain episodes in a pa3ent already on opioids to control chronic pain?

•  How do you dis3nguish tooth pain from reversible (requiring a normal filling) and irreversible (requiring endodon3c (root canal treatment)) pulpi3s?

•  How do you dis3nguish between a temporomandibular joint and/or a mas3catory muscle-‐based problem?

•  Describe the protocol for managing a pa3ent suffering from xerostomia.

•  Describe the priori3es for dental treatment planning for a pa3ent who is about to undergo radia3on for head and neck cancer.

Tooth pain differen3al

•  Caries •  Cracked Tooth •  Pulpal •  Periodontal •  Pericoroni3s •  Sinusi3s

Mrs. Farley’s chronic pain…

You are part of an inter-‐professional team composed of health care specialists from the following disciplines:

1)  Medicine 2)  Den3stry 3)  Pharmacy 4)  Nursing

Mrs. Chris3ne Farley has been suffering from temporomandibular joint (jaw) and myofascial (muscular) pain, and you are asked to be part of her inter-‐professional team to advise on how to best help manage her pain.

Learning Objec>ves

PART 1: 1) Describe temporomandibular disorder (TMD) pathophysiology, diagnosis, and management PART 2: 2) Describe fibromyalgia pathophysiology, diagnosis, and gender and psychological considera>ons PART 3: 3) Define pharmacologic treatment op>ons for TMD and fibromyalgia 4) Iden>fy non-‐pharmacologic and complementary and alterna>ve medicine (CAM) pain management strategies

2 Assessing Mrs. Farley’s Pain –

a review on ques>ons to ask a pa>ent with pain

When assessing a pa3ent’s pain, it is important to ask certain ques3ons to get a full understanding of the pa3ent’s pain history. There are different methods you can use to remember the important ques3ons to ask. One op3on is the pneumonic “OPQRST.” O – Onset: When did the pain start? What was happening at that 3me? P – Pallia>ve and Provoca>ve factors: What makes the pain be^er? Worse? (Include specific ac3vi3es, posi3ons, or treatments.) Q – Quality: Describe the pain. Is it burning, sharp, shoo3ng, aching, throbbing, etc.? R – Region and Radia>on: Where is the pain? Does it spread to other areas? S – Severity: How bad is the pain? (There are several scales to use; these will be discussed in the following slide.) T – Timing: When does the pain occur? Has it changed since onset? If so, how? Reference: Powell RA, Downing J, Ddungu H, Mwangi-‐Powell FN. Pain Management and Assessment. In: Andrea Kopf NBP, editor. Guide to Pain Management in Low-‐Resource Semngs. Sea^le: IASP: Interna3onal Associa3on for the Study of Pain; 2010. p. 67-‐79 h^p://www.iasp-‐pain.org/AM/Template.cfm?Sec3on=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=11669.

TMD Treatment

What is standard TMD therapy?

What medica3ons are effec3ve for

TMD?

What is the goal of TMD

treatment?

When are occlusal

treatments indicated?

When is physical therapy

(PT) and behavioral therapy (BT) indicated?

What success can one expect from TMD treatment?

What medica>ons are effec>ve for TMD?

These will be discussed in detail later in the module. Some examples include: Non-‐steroidal an3-‐inflammatory drugs (NSAIDs) or other analgesics for acute pain episodes; muscle relaxants for acute muscle pain; sleep medica3ons can help control night-‐3me parafunc3on; a 10-‐day regimen of an3-‐inflammatory medica3on or a Medrol (steroid) dose pack for TMJ arthralgia

Tchivileva IE, Lim PF, Smith SB, Slade GD, Diatchenko L, McLean SA, Maixner W. Effect of catechol-O-methyltransferase polymorphism on response to propranolol therapy in chronic musculoskeletal pain: a randomized, double-blind, placebo-controlled, crossover pilot study. Pharmacogenet Genomics. 2010 Apr;20(4):239-48. doi: 10.1097/FPC.0b013e328337f9ab. PubMed PMID: 20216107; PubMed Central PMCID: PMC2876724. Mujakperuo HR, Watson M, Morrison R, Macfarlane TV. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD004715. doi: 10.1002/14651858.CD004715.pub2. Review. PubMed PMID: 20927737. Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J Orofac Pain. 2002 Winter;16(1):64-70. PubMed PMID: 11889661. Annaswamy TM, De Luigi AJ, O'Neill BJ, Keole N, Berbrayer D. Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions. PM R. 2011 Oct;3(10):940-61. doi: 10.1016/j.pmrj.2011.06.013. Review. PubMed PMID: 22024326.

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Yanni LM, et al. Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education. J Grad Med Educ. 2010; 2(2):260-‐8.

Why Should We Care About Interprofessional Education in Pain ?

Our mission -‐ 2

•  Specific Aim : – To conduct pre-‐ and post-‐pain curriculum knowledge ques>onnaires and evalua>ons in all students.

•  Hypothesis : – The ques3onnaire results and evalua3ons will provide valuable data on the impact of this program

1. Rate your perceived level of proficiency with regard to achieving each of the following objectives, both before this case and after it, on the following scale: 1 2 3 4 5 Not at all Proficient Somewhat Proficient Moderately Proficient Very Proficient Extremely Proficient

Objec3ve

Level of Proficiency Before Case

(1-‐5 Scale)

Level of Proficiency Aper Case

(1-‐5 Scale)

1a. Conduct an assessment of an older adult in pain using a holis3c approach.

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1.b. Discuss the appropriate use of opioids for pain management in older adults.

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1.c. U3lize an opioid risk tool in a clinical semng. 1

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1.d. Consider disease and age-‐related changes in pain management of older adults.

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1.e. Develop a teaching plan for an older adult taking opioids for pain.

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1.f. Discuss roles of the interprofessional team in pain management of older adults.

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Student must complete this before going on to the next slide.

Rate your responses on the following scale: 1 2 3 4 5 Strongly Disagree Somewhat Disagree Moderately Agree Somewhat Agree Strongly Agree

2. This case met the stated objec3ves. 1

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3. This case delivered balanced and objec3ve evidence-‐based content.

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Rate your responses on the following scale: 1 2 3 4 5 Not Effec3ve Somewhat Effec3ve Moderately Effec3ve Very Effec3ve Extremely Effec3ve 4. To what extent was the organiza3on of this case effec3ve?

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5. To what extent is this teaching format an effec3ve way for you to learn this material?

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My Courses assessment

•  4. For pa>ents with neuropathic pain, opioid therapy should only be considered:

•  A@er a failed trial of an2depressant or an2convulsant adjuvant analgesics

•  Aper a trial of non-‐opioids like acetaminophen or NSAIDs failed to help

•  Aier both of the above •  Aper neither of the above

Tramadol (Ultram):

1.  Should only be used in cancer pa3ents 2.  Has mu receptor effects depending on dose 3.  Can be administered both orally and transdermally 4.  Can be used safely in pa3ents with recent history of opioid misuse 5.  2 & 4

•  2. What is the most common diagnosis for Temporomandibular Disorders?

•  TMJ arthralgia •  Refrac3ve disc displacement •  Disk displacement with reduc2on (reciprocal disc)

•  Myofascial pain •  Muscle spasm

•  Ins>tu>onal Level Challenges •  Top administra3ve leadership support needed

•  The Lack of Ins>tu>onal Collaborators •  Lack of willing/available schools for interprofessional partnerships

•  Prac>cal Issues •  Scheduling to bring students together across the professions

•  Faculty Development Issues •  Faculty need training to become effec3ve interprofessional educators

•  Content & process of learning different from other content

Barriers to Interprofessional Educa>on

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Page 34.

e. anesthesia, seda3on and pain control

•  DOMAIN V: DELIVERY OF CARE: The prac3ce of general den3stry requires an understanding of the manner in which care is delivered in a compassionate, efficient and effec3ve manner. The general den3st must be able to provide emergency and comprehensive care for all popula3ons in the community u3lizing current technologies in pain control and anxiety management.

•  19. Control of Pain and Anxiety -‐ The general den3st must be able to employ techniques to manage orofacial discomfort and psychological distress.

e. anesthesia, seda3on and pain control

•  DOMAIN V: DELIVERY OF CARE: The prac3ce of general den3stry requires an understanding of the manner in which care is delivered in a compassionate, efficient and effec3ve manner. The general den3st must be able to provide emergency and comprehensive care for all popula3ons in the community u3lizing current technologies in pain control and anxiety management.

•  19. Control of Pain and Anxiety -‐ The general den3st must be able to employ techniques to manage Orofacial Pain discomfort and psychological distress.

Orofacial Pain •  TMJ func3on: normal from abnormal •  TMJ joint disorders: Disc displacement, OA •  Mas3catory muscle disorders: myosi3s, spasm, myofascial pain

•  Headache Disorders: TTHA, Migraine, Cluster •  Neuropathic pain: neuralgia, atypical odontalgia •  Dis3nguish nocicep3ve pain from neuropathic pain

•  Understand what they can manage and which pa3ents should be referred

Dissemina3on and Impact for Pain educa3on

Inter-‐professional unity : • promote confident collabora>on between all pa>ent care providers Evidence-‐based pain curriculum dissemina>on : • use to establish universal standards for pain management educa>on in each discipline Liaisons with administra>on and curriculum commiHees to ensure implementa>on : •  na>onal ini>a>ve directly influences educa>on locally Collabora>on with “Pain Champions” at other ins>tu>ons : • unified approach to pain educa>on guarantees improved pa>ent care and safety

Ques>ons?

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