UC Davis Train-the-Trainer Primary Care Pain Management Fellowship: Addressing the Pain Management Education Gap.

PROBLEM: Primary care providers are responsible for the majority of pain care and opioid prescribing, but they are often inadequately trained. Training current providers to address the crisis of excessive opioid prescribing and inadequate pain management is a substantial workforce problem that requires urgent action. This educational need is vast and requires a staged solution to amplify its effect. APPROACH: The University of California, Davis Train-the-Trainer (T3) Primary Care Pain Management Fellowship targets the most pressing topics related to pain management, including prescription drug abuse, responsible opioid prescribing, and substance abuse, as well as broad coverage of comprehensive pain management. It offers an innovative, scalable solution to address the education gap in pain management that, in part, fuels the opioid epidemic in the United States. The T3 Fellowship incorporates a competency-based curriculum and a hybrid educational model of in-person and distance-based learning and direct faculty-fellow mentoring to comprehensively train primary care providers in pain care and prepare them to train others. Since it was established in 2017, 2 cohorts (of 17 and 26 fellows) have completed the 10-month fellowship and a third cohort of 38 fellows started the program in September 2019. OUTCOMES: Pre- and postprogram surveys for the first 2 cohorts, and a 6-month postprogram survey for the first cohort, demonstrated fellows' improvement and sustained performance in pain competencies as well as increased recognition and understanding of pain and related topics. NEXT STEPS: If adopted by other institutions and expanded across the country, the T3 Fellowship holds potential for developing an ever-growing legion of trained professionals who will locally fill the need for effective pain management, including appropriate opioid prescribing. Advancing this model will require further economic and feasibility studies to assess costs, resources, and other variables, as well as a robust comprehensive outcomes program.

Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness: Inadvertent Oversight or Taboo?

As the United States experiences an epidemic of prescription drug abuse, and guidelines on safe practices in prescribing opioids in chronic pain have subsequently emerged from professional organizations and governmental agencies, limited guidance exists for prescribers of opioids to treat pain in patients with cancer or terminal illness. Patients with active cancer or terminal illness often have pain and are frequently prescribed opioids and other controlled substances. Current studies suggest that patients with cancer have similar rates of risk for misuse, abuse, and addiction as the general public. Moreover, palliative care and hospice programs appear poorly prepared for assessing or managing patients with aberrant behaviors or evidence of drug abuse. Further research and professional consensus are needed to help address the challenges associated with misuse, abuse, and addiction in patients with cancer and terminal illness.

Predictors of financial difficulties and work modifications among cancer survivors in the United States.

PURPOSE: The aim of this study is to examine predictors of cancer-related financial difficulties and work modifications in a national sample of cancer survivors. METHODS: Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, the prevalence of financial difficulties and work modifications was examined. Logistic regression and survey weights were used to model these outcomes as functions of sociodemographic and health covariates separately among survivors in active treatment and survivors under age 65 years. RESULTS: Among all survivors, 33.2% reported any financial concern, with 17.9% reporting financial difficulties such as debt or bankruptcy. Among working survivors, 44.0% made any work modification and 15.3% made long-term work modifications (e.g., delayed or early retirement). Among those in active treatment, predictors of financial difficulty included: race/ethnicity other than white, non-Hispanic [OR = 8.0; 95% CI 2.2-28.4]; income <200% of federal poverty level (FPL) [OR = 15.7; 95% CI 2.6-95.2] or between 200 and 400% of FPL [OR = 8.2; 95% CI 1.3-51.4]; residence in a non-metropolitan service area [OR = 6.4; 95% CI 1.6-25.0]; and good/fair/poor self-rated health [OR = 3.8; 95% CI 1.0-14.2]. Among survivors under age 65 years, predictors of long-term work modifications included good/fair/poor self-rated health [OR = 4.1; 95% CI 1.6-10.2], being married [OR = 2.2; 95% CI 1.0-4.7], uninsured [OR = 3.5; 95% CI 1.3-9.3], or publicly insured [OR = 9.0; 95% CI 3.3-24.4]. CONCLUSIONS: A substantial proportion of cancer survivors experience cancer-related financial difficulties and work modifications, particularly those who report race/ethnicity other than white, non-Hispanic, residence in non-metropolitan areas, worse health status, lower income, and public or no health insurance. IMPLICATIONS FOR CANCER SURVIVORS: Attention to the economic impact of cancer treatment is warranted across the survivorship trajectory, with particular attention to subgroups at higher risk.

Total economic cost and burden of dengue in Nicaragua: 1996-2010.

The burden of dengue in Nicaragua has been steadily rising during the last three decades; however, there have been few efforts to quantify the burden (measured in disability-adjusted life years [DALYs]) and cost to society. Using primary data from the Nicaraguan Ministry of Health (MINSA), the total cost and burden of dengue were calculated from 1996 to 2010. Total costs included both direct costs from medical expenditures and prevention activities and indirect costs from lost productivity. The annual disease burden ranged from 99 to 805 DALYs per million, with a majority associated with classic dengue fever. The total cost was estimated to be US$13.5 million/year (range: US$5.1-27.6 million). This analysis can help improve allocation of dengue control resources in Nicaragua and the region. As one of the most comprehensive analyses of its type to date in Nicaragua and Latin America, this study can serve as a model to determine the burden and cost of dengue.

Opioids, pain management and the law.

PURPOSE OF REVIEW: Approximately 100 million people suffer from chronic pain in the USA. Opioid medications are commonly prescribed to treat pain, but are becoming the most widely misused controlled substance nationally. Physicians who treat patients with chronic pain must be cognizant of the federal and state policies that govern the distribution of opioid medications as well as the current standards of medical practice for opioid prescribing. RECENT FINDINGS: The laws and policies regarding the standard medical practice for opioid prescribing are constantly subject to revision. The National Drug Control Policy announced its plan to fight prescription drug abuse in 2011 and unveiled the Risk Evaluation and Management Strategy initiative. Currently there is a Risk Evaluation and Management Strategy for Transmucosal Immediate-Release Fentanyl. Other resources, such as state-run prescription drug monitoring programs, are also available to many physicians. The level of participation in these programs by physicians and pharmacists varies by state, and funding for continuation of these programs is an ongoing issue. SUMMARY: The problems of undertreated pain and the epidemic of prescription drug abuse have coincided, creating a need for medical and social policy that protects society and access to appropriate care for those in pain. Federal and state laws are in evolution, and clinicians must remain aware of these changes as well as the issues behind them that will impact safe and appropriate care of patients in pain.