The AAFP's recent 2018 Residency Education Symposium, held here March 23-27, included sessions common to both the Program Directors Workshop and the Residency Program Solutions (RPS) conference, as well as separate programming for each of these two meeting components.
Tim Munzing, M.D., leads a session at the AAFP's recent Residency Program Solutions conference on the importance of opioid training. He says physicians must be super cautious and document painstakingly when writing opioid prescriptions.
One particular RPS session titled "Teaching Residents Appropriate Opioid Prescribing" focused on an issue that many family physicians struggle with daily in their efforts to treat patients who suffer from chronic pain or who have become dependent on pain medication.
Tim Munzing, M.D., residency program director at the Kaiser Permanente Family Medicine Residency in Anaheim, Calif., led a three-person panel that tag-teamed the topic of educating residents about the issues involved. His co-panelists were assistant program director Kara Cummins, M.D., of Long Beach, Calif., and Scott Murray, M.D., of San Juan Capistrano, Calif.
Munzing's background as a medical expert reviewer for the Medical Board of California, the DEA, the FBI and multiple other law enforcement agencies more than qualifies him to speak about opioids; he's reviewed nearly 150 cases involving the drugs in the past 14 years.
- The AAFP's recent Residency Program Solutions conference, part of the 2018 Residency Education Symposium, featured a session on providing opioid training in residency programs.
- The session's three-physician panel was led by FP Tim Munzing, M.D., a residency program director who also serves as a medical expert reviewer for the Medical Board of California, the DEA, the FBI and other law enforcement agencies.
- Panelists examined the roots of the opioid crisis and provided insight into what residents need to know, including recognizing predictors of patient misuse, identifying red flags and educating patients who are starting an opioid regimen.
"We've had a number of cases that resulted in double-digit deaths," said Munzing.
For the one-hour RPS presentation, the panel examined the roots of the opioid crisis and the current standard of care.
"What are the things that are vitally important when we're seeing patients, and what can we teach our residents to help them when they are considering prescribing opioids or other controlled substances?" Munzing asked.
Opioid Crisis Background
Munzing pointed out that physicians who trained many years ago, himself included, once practiced under a very different set of prescribing rules.
"We were told to get the pain score down to zero, that people wouldn't get addicted, to just up the dosage," said Munzing. Now physicians know that was wrong, he added.
Munzing flashed slides of a U.S. map in in which states were color-coded by the number of opioid prescriptions issued per 100 people and graphs showing the upward trend of U.S. deaths from 2002 to 2015.
He said current statistics show that some 91 people die each day from opioid drug overdose, including deaths from illicit opioids; of those, about 50 die every day from prescription opioid pain reliever overdose.
"If a 747 crashed every week, and every person (on it) died every week, how many weeks would it take for them to say the 747 can't fly? Probably week number two," said Munzing.
Predicting Patient Misuse
There are predictors that indicate which patients are prone to misuse prescription opioids, and when Munzing polled his audience, 60 percent of attendees knew that the list does not include gender, race, literacy level, disability or socioeconomic status.
Munzing then shared a list of characteristics that do predict which individuals are more likely to get into trouble with opioids. That list included a patient/family history of drug or alcohol abuse, previous drug-related criminal conviction, and psychiatric disorders.
"That's why it's vitally important when you're doing a history of someone for whom you're considering prescribing a controlled substance that you ask about mental health history and drug and alcohol history," said Munzing. Ask about past and current issues, he added.
He went over the universal precautions for opioid prescribing, which are
- evaluate the need;
- assess the risk;
- select the specific opioid treatment;
- discuss with the patient, get a written agreement and informed consent;
- monitor the patient closely; and
- document thoroughly.
Munzing urged physicians to always look for nonpharmacologic alternatives and adjunctive treatments first and then nonopioid alternatives.
If opioids are chosen as a treatment, "start low and go slow with very limited prescription numbers," said Munzing. Lastly, trust, but verify as best you can, what your patient is telling you.
Munzing described a scenario where a patient receives an opioid prescription for an injury and takes that prescription for eight straight days. One year later, 13.5 percent of all patients who fit that description will be on an opioid.
"That is super scary. There is nothing I do as a family doctor that is potentially more dangerous to a patient as writing a script for an opiate," said Munzing.
During his portion of the session, co-presenter Murray covered, among other topics, how to establish realistic patient goals before starting opioid treatment.
"Sit down with the patient and say, 'Our goal is to help you function better,'" Murray said. "If we could change from 'pain meds' to 'function meds,' that would be a lot nicer nomenclature."
Murray said he advises patients to take the lowest dose possible of an opioid medication, and he is very clear about the "why."
He tells patients, "I want you to be able to go out and exercise, move and increase your function." Murray also stressed the importance of monitoring patients who take prescription opioids to keep them safe.
Panel speaker Kara Cummins, M.D., left foreground, engages with FPs Michael Paronish, M.D., of Boardman, Ohio, and Francesca Adriano, M.D., of San Diego, at the session's close. Panelist Scott Murray, M.D., second from left, has colleagues waiting in line with questions.
"Tools that work the best are state-sponsored opioid prescription drug monitoring programs (PDMPs) and urine drug screens," he said. He noted that he educates patients about that process and tells them, "I'm looking for the medicine I'm prescribing to be there (in the urine screen) and nothing else."
Murray encouraged those in the audience to look at their residency curriculum to see what they are offering in terms of emerging options on pain management and to consider their residents' confidence levels in utilizing pain management tools.
Readers can access the slide presentation from the session,(23 page PDF) which provides additional important details, such as dosing specifics, a morphine-equivalent dosing chart, dangerous drug combinations, 2016 CDC guidelines for controlled substances and more.
Identifying Red Flags
For her portion of the presentation, Cummins identified the red flags to look for on state PDMP websites. "We recommend to our residents that they check the PDMP at least twice a year, if not three to six times a year," she said.
Potential red flags include
- early refills;
- medications greater than 100 mg/day;
- multiple concurrent prescribers;
- multiple pharmacies;
- drug combinations such as an opioid, a benzodiazepine and carisoprodol;
- escalating dosing by the prescriber; and
- escalating prescriptions by the patient.
Cummins also reviewed additional warning signs and said her internal alarm goes off when she sees that a patient is driving a long way for an office visit. I ask myself, "Why is this patient driving two hours when there's a doctor down the street?"
Ditto when multiple family members are on the same opiate medication, especially when it's a husband and wife.
Cummins also looks for evidence of drug overdose episodes, and she relies on reports from family members, as well as ER reports of drug overdose. She also becomes suspicious when patients are anxious to buy, sell or give medications to family members -- and when they express grave concern for an aunt or cousin who needs the medicine.These kinds of behaviors should encourage a physician to dig a little deeper, said Cummins.
Resident Teaching Opportunities
Cummins spoke about the importance of equipping residents with the tools they need to understand appropriate opioid prescribing. "We need to make this part of the DNA of our teaching programs," she said.
She noted that during the past year, her program has developed a pain management curriculum that combines several didactic lectures, specific modules the residents have to complete, chart reviews and small-group discussions about difficult patients.
Why the effort? "Because when residents first graduate, these are the doctors that patients think are the most vulnerable. If we equip our residents to be able to take care of these difficult, difficult patients, hopefully we'll help decrease this problem in the future," she said.
Munzing reiterated -- multiple times -- the importance of documentation. "Most of the cases I review would never come to me if they were well documented," he said. And remember that simply staying off law enforcement's radar doesn't mean mean you are practicing good medicine, he cautioned.
"We used to think that having people on high-dose opiates for chronic pain was the right thing to do. But this is 2018, and this is really about patient safety," said Munzing.
As educators, he stressed, "We need to transmit this information to our residents because they are our future. And it's easier to change (the habits of) people who are developing their practices than to change people who've been out in practice for a long time."
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