Use of Immersive Learning and Simulation Techniques to Teach and Research Opioid Prescribing Practices.

INTRODUCTION: Unsafe opioid prescribing practices to treat acute and chronic pain continue to contribute to the opioid overdose crisis in the United States, a growing public health emergency that harms patients and their communities. Poor opioid prescribing practices stem in part from a lack of education and skills training surrounding pain and opioid management. METHODS: As part of the Clinical Pain Medicine Fellowship at Stanford University, physicians were given the opportunity to participate in a pilot program to practice opioid management in a live, simulated interaction. Twenty-seven physician trainees participated in the simulation with a live, standardized patient actor. Before beginning the simulation, participants were given a detailed patient history that included the patient's risk for opioid abuse. They were also provided with relevant risk evaluation and mitigation (REM) tools. All simulation interactions were video-recorded and coded by two independent reviewers. A detailed coding scheme was developed before video analysis, and an inter-rater reliability score showed substantial agreement between reviewers. RESULTS: Contrary to expectations, many of the observed performances by trainees contained aspects of unsafe opioid prescribing, given the patient history. Many trainees did not discuss their patient's aberrant behaviors related to opioids or the patient's risk for opioid abuse. Marked disparities were also observed between the trainees' active patient interactions and their written progress notes. DISCUSSION: This simulation addresses a pressing need to further educate, train, and provide point-of-care tools for providers prescribing opioids. We present our experience and preliminary findings.

Qualitative Assessment of Clerkship Students' Perspectives of the Topics of Pain and Addiction in their Preclinical Curriculum.

OBJECTIVE: A majority of physicians feel poorly trained in the treatment of chronic pain and addiction. As such, it is critical that medical students receive appropriate education in both pain management and addiction. The purpose of this study was to assess the pre-clinical curriculum in pain medicine and addiction from the perspective of students after they had completed their pre-clinical training and to assess what they perceived as the strengths and weaknesses of their training. METHODS: The authors conducted focused interviews among clinical medical students who had completed at least 6 months of clerkships. The interviews targeted the students' retrospective opinions about the pre-clinical curriculum and their preparedness for clinical encounters with either pain or addiction-related issues during their rotations. Coders thematically analyzed the de-identified interview transcripts, with consensus reached through discussion and code modification. RESULTS: Themes that emerged through the focused interviews included: fragmented curricular structure (and insufficient time) for pain and addiction medicine, not enough specific treatment strategies for pain or addiction, especially for complex clinical scenarios, and lack of a trained work-force to provide guidance in the management of pain and addiction. CONCLUSION: This study demonstrated the feasibility of gathering student perspectives to inform changes to improve the pre-clinical curriculum in pain and addiction medicine. Students identified multiple areas for improvement at the pre-clerkship level, which have informed updates to the curriculum. More research is needed to determine if curricular changes based on student feedback lead to improved learning outcomes.

Weighing the Risks and Benefits of Chronic Opioid Therapy.

Evidence supports the use of opioids for treating acute pain. However, the evidence is limited for the use of chronic opioid therapy for chronic pain. Furthermore, the risks of chronic therapy are significant and may outweigh any potential benefits. When considering chronic opioid therapy, physicians should weigh the risks against any possible benefits throughout the therapy, including assessing for the risks of opioid misuse, opioid use disorder, and overdose. When initiating opioid therapy, physicians should consider buprenorphine for patients at risk of opioid misuse, opioid use disorder, and overdose. If and when opioid misuse is detected, opioids do not necessarily need to be discontinued, but misuse should be noted on the problem list and interventions should be performed to change the patient's behavior. If aberrant behavior continues, opioid use disorder should be diagnosed and treated accordingly. When patients are discontinuing opioid therapy, the dosage should be decreased slowly, especially in those who have intolerable withdrawal. It is not unreasonable for discontinuation of chronic opioid therapy to take many months. Benzodiazepines should not be coprescribed during chronic opioid therapy or when tapering, because some patients may develop cross-dependence. For patients at risk of overdose, naloxone should be offered to the patient and to others who may be in a position to witness and reverse opioid overdose.

Headache plus: trigeminal and autonomic features in a case of cervicogenic headache responsive to third occipital nerve radiofrequency ablation.

OBJECTIVE: To describe a case of cervicogenic headache with associated autonomic features and pain in a trigeminal distribution, all of which responded to third occipital nerve radiofrequency ablation. DESIGN: Single case report. SETTING: Massachusetts General Hospital Center for Pain Medicine. PATIENTS: A 38-year-old woman with history of migraines and motor vehicle accident. INTERVENTIONS: Right third occipital nerve diagnostic blocks and radiofrequency lesioning. OUTCOME MEASURES: Pain reduction; physical findings, including periorbital and mandibular facial swelling, tearing, conjunctival injection, and allodynia; and use of opioid and non-opioid pain medicines. RESULTS: The patient had complete relief of her pain and autonomic symptoms, and was able to stop all pain medications following a dedicated third occipital nerve lesioning. CONCLUSIONS: This case illustrates the diagnostic and therapeutic complexity of cervicogenic headache and the overlap with other headache types, including trigeminal autonomic cephalgias and migraine. It represents a unique proof of principle in that not only trigeminal nerve pain but also presumed neurogenic inflammation can be relieved by blockade of cervical nociceptive inputs. Further investigation into shared mechanisms of headache pathogenesis is warranted.

Use of video laryngoscopy and camera phones to communicate progression of laryngeal edema in assessing for extubation: a case series.

Video laryngoscopy has demonstrated utility in airway management. For the present case series, we report the use of video laryngoscopy to evaluate the airway of critically ill, mechanically ventilated patients, as a means to reduce the risk of immediate postextubation stridor by assessing the degree of laryngeal edema. We also describe the use of cellular phone cameras to document and communicate airway edema in using video laryngoscopy for the patients' medical records. We found video laryngoscopy to be an effective method of assessing airway edema, and cellular phone cameras were useful for recording and documenting video laryngoscopy images for patients' medical records.

Curriculum and cases for pain medicine crisis resource management education.

Medical crises that may occur in the setting of a pain medicine service are rare events that require skillful action and teamwork to ensure safe patient outcome. A simulated environment is an ideal venue for both acquisition and reinforcement of this knowledge and skill set. Here, we present an educational curriculum in pain medicine crisis resource management for both pain medicine fellows and attending physicians as well as the results of a successful pilot program.

Correlating virtual reality and box trainer tasks in the assessment of laparoscopic surgical skills.

OBJECTIVE: The purpose of this study was to examine the correlation in the assessment of laparoscopic surgical skills in medical students with the use of a virtual reality laparoscopic trainer and a low-fidelity video box trainer with comparative tasks. STUDY DESIGN: Third-year medical students were asked to perform 3 basic skills set modules on LapSim (Surgical Science, Gothenburg, Sweden): coordination, grasping and lifting, and handling the intestines. Each task was set at the easiest level, and each student was allowed a maximum of 10 attempts to complete each task. Similar-appearing tasks were chosen for comparison with the use of a standard video box trainer: pegboard, cup drop and rope pass, respectively. Laparoscopic skills were evaluated with the use of both trainers during 1 session. Pearson's correlation coefficients were used to compare paired data on each student using statistical software. RESULTS: Forty-seven of 65 medical students were assigned to clinical clerkships on-campus at Temple University School of Medicine participated in the study. All 47 students participated in the video box trainer tasks; 34 students completed both the video box trainer and LapSim skills set. Observations that were obtained on the LapSim virtual reality system and video box trainer simulator demonstrated several correlations. The time to completion for the LapSim coordination task and the pegboard task were correlated (r = 0.507; P = .006), as were the grasping and lifting task completion time on LapSim and the comparative box trainer cup drop task completion time (r = 0.404; P = .022). When accounting for errors, the LapSim coordination task tissue damage score was correlated with the sum of all box trainer errors (r = 0.353; P = .040); the average grasping and lifting tissue damage was correlated with the total number of errors during all box trainer tasks (r = 0.374; P = .035). CONCLUSION: Overall, in evaluating laparoscopic skills, the LapSim and video box trainer were correlated positively with one another. The scoring of laparoscopic skills by both systems appears to be equivalent for the measurement of time to task completion and number of errors.

Radiocontrast media allergic reactions and interventional pain practice--a review.

BACKGROUND: Millions of interventional pain procedures are performed each year in the United States. Interventional pain physicians commonly administer radiocontrast media (RCM) under fluoroscopy for these procedures. However, RCM can cause various types of hypersensitivity or allergic type reactions, in an acute or delayed fashion. Furthermore, some patients report a prior history of hypersensitivity reactions to RCM when presenting to the interventional pain clinic. Both scenarios present challenges to the interventional pain physician. OBJECTIVE: To describe the various types of hypersensitivity reactions to RCM, as well as strategies to prevent and manage these reactions, within the context of interventional pain practice. METHOD: A review of the literature from 1975 through 2011 regarding allergic type reactions to RCM, as well as iodine, and shellfish allergy, was undertaken in an effort to review and develop recommendations on managing these patients presenting to the interventional pain clinic. Keywords used in the literature search were: radiocontrast media, contrast allergy, contrast reaction, iodine allergy, shellfish allergy, and fluoroscopy. The included articles were concerned with the basic or clinical science of contrast allergy, including the physiology, epidemiology, diagnosis, and management of such reactions. Meta-analysis, review articles, and case reports addressing contrast media reactions were also included. Articles which discussed contrast media reactions in a peripheral fashion were excluded. RESULTS: In reviewing the literature, it is apparent that the mechanisms and pathophysiology of RCM hypersensitivity reactions are still being characterized, which should soon lead to improved screenings, as well as prevention and treatment strategies. Many common themes are described throughout the literature regarding patient risk factors, testing, prevention,diagnosis, and treatment of RCM allergic-type reactions. LIMITATIONS: The current review did not perform a meta-analysis of the available data, as most of the available articles were trials that were randomly controlled. Therefore, the conclusions of the present article are general, and qualitative in nature. CONCLUSION: Although the mechanisms of various RCM allergic-type reactions are not entirely understood, the interventional pain physician should have a basic understanding of patient risk factors, prevention, diagnosis, and treatment of these reactions. The current review allowed for prevention and treatment strategies for managing patients with RCM hypersensitivity reactions.