the arizona pain and addiction...this curriculum is intended to be used as the entire set of ten...
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1THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
THE ARIZONA PAIN AND ADDICTIONCURRICULUM
• TheUniversityofArizona–CollegeofMedicinePhoenix• TheUniversityofArizona–CollegeofMedicineTucson• MayoClinicSchoolofMedicine–ArizonaCampus• CreightonUniversitySchoolofMedicine–PhoenixRegionalCampus
• MidwesternUniversity–ArizonaCollegeofOsteopathicMedicine
• A.T.StillUniversitySchoolofOsteopathicMedicineinArizona
• A.T.StillUniversitySchoolofDentistry&OralHealthinArizona
• MidwesternUniversity–ArizonaSchoolofPodiatricMedicine
• NorthernArizonaUniversityPost-Master'sFamilyNursePractitionerCertificate
• NorthernArizonaUniversityDoctorofNursingPractice• GrandCanyonUniversityCollegeofNursingandHealthCareProfessions
• ArizonaStateUniversityCollegeofNursingandHealthInnovation
• UniversityofArizonaCollegeofNursing• UniversityofPhoenixCollegeofHealthProfessions• SouthwestCollegeofNaturopathicMedicineandHealthSciences
• A.T.StillUniversityPhysicianAssistantsDegreePrograminArizona
• MidwesternUniversityPhysicianAssistantProgram• NorthernArizonaUniversityPhysicianAssistantProgram
2THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
June25,2018
DearClinicalEducatorsofArizona:
IthasbeennearlyayearsincetherewasaStatewidePublicHealthEmergencydeclaredintheStateofArizonaduetotheopioidepidemic.WithmorethantwoArizonansdyingeverydayfromanopioidoverdose,multiplestakeholders,includingclinicaleducators,cametogethertochangetheparadigmofpainandaddictionmanagementhereinArizona.
WhiletheArizonaDepartmentofHealthServicesproposedastatewidecurriculumaspartofitsresponsetotheopioidepidemic,theArizonaCurriculumonPainandAddictionthatyourprogramshavejointlydevelopedhassurpassedallexpectations.Yourcollaborationacrossprogramtypes(MD,DO,NP,PA,DMD,ND,DPM)tolinkpainandaddiction,touseasocio-psycho-biologicalmodelandtostressdestigmatizationandclinicianintrospectionissomethingthathasnotbeenattemptedorseenbeforeinthenation.
We hope that your program is able to implement this curriculum into your educational structures as soon as possible.Thiscurriculumstrivestofundamentallychangethecultureofpainandaddiction–withnewdefinitions,newemphasesandthenewestevidencerepresentedinaforward-thinkingapproach.Itwilltakeyearstoseeadifferencefromtheseefforts,soweneedtostartnow.
AsparticipatinginthecreationandimplementationofthisArizonaCurriculum,youarepartofaboldmovetomakeagenerational,wide-sweepingchangetopainandaddictioneducation.Thankyouforyourinnovation,leadershipandcommitment.WeareproudtobeyourpartnersinArizona.
Sincerely,
CaraM.Christ,MD,MSDirectorArizonaDepartmentofHealthServices
3THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
INTRODUCTION
PURPOSETheArizona Curriculum on Pain and Addictionrepresentsalarge-scalecultureshiftintheeducationofthenextgenerationofprescribers.Whileitishopedthecurriculumwillbringaboutfocusedresultssuchasareductioninthenumberofopioid-relatedoverdoses,areductioninopioidsprescribed,andanincreaseinthenumberofprovidersabletotreatopioidusedisorder--thiscurriculummovesbeyondthesediscretegoalsto redefine pain and addiction as interlinked, complex, public health processes,requiringinterprofessionalcareandinvolvementofthecommunityandhealth-basedsystems.
BACKGROUNDOnJune5,2017,GovernorDougDuceydeclaredaStatewidePublicHealthEmergencyinArizonaduetotheOpioidEpidemic.RealtimedatafromtheArizonaDepartmentofHealthServicesOpioidOverdoseSurveillanceSystemrevealedoverone-hundredfatalandnonfataloverdosesbeingreportedeachweek.Therewereindicationsofunsafeandnon-evidence-basedpracticesofsomeprescribersandadistinctlackofstatewidecapacitytomanageopioidusedisorder.Inresponsetothesefindings,oneoftherecommendationsfromtheDepartmentwastocreateastatewidecurriculumforallprescribersonpainandaddiction(azhealth.gov/opioidactionplan).METHODSBeginninginJanuary2018,fourmeetingswereheldwithDeansandCurriculumRepresentativesfromalleighteenMD,DO,PA,NP,DMD,DPMandNDprogramsinArizona.Afterreviewingthesurveillancedataandcurrentprogramcurricula,thegroupusedbestpracticesfromotherschools,publishedtheoriesofpainandaddictioneducation,nationaltrendsfromtheNationalPainStrategyandNationalAcademiesofMedicine,andinputfromArizonapainandaddictionspecialiststocreatecurriculumdraftsthatweresystematicallyreviewedforrelevanceandscope.
Assuch,anumberofforward-thinkingconceptswereestablisheduponwhichtobuildanewstatewidecurriculum:
• Thelinkbetweenpainandaddiction• Theuseofamacro-tomicro-perspectivetopainandaddiction(thesocio-psycho-biologicalapproach)• Thedestigmatizationofpainandaddiction• Theevidence-baseofpainandaddictioncare• Theinfluenceofthepharmaceuticalindustryonclinicians• Thefocusonclinicianandsystemintrospection,bothinpersonalbiasesandexcellenceofcare
INTENDED SCOPETherearetwelvetypesofcliniciansthatareauthorizedtoprescribeopioidsintheStateofArizona:DoctorsofMedicine(MD),DoctorsofOsteopathicMedicine(DO),DoctorsofPodiatricMedicine(DPM),DoctorsofMedicineinDentistry(DMD),RegisteredNursePractitioners(RNP),NaturopathicDoctors(ND),PhysicianAssistants(PA),DoctorsofOptometry,DoctorsofHomeopathy,andDoctorsofVeterinaryMedicine.Thiscurriculumisintendedforuseinthefollowinghealtheducationalprograms:
• Undergraduate:MD,DO,DPM,DMD,RNP,NDandPAprograms• Graduate:RNPprograms
STRUCTURE + INTENDED USEThestructureofthecurriculumisintuitivelyorganizedbyasetoftenCore Components,eachofwhichisexpandedanddetailedintospecificObjectivesandKeyReadings.Thesubsequentsectionslistimplementationstrategies(Toolbox)andassessmentmechanisms(Assessment).ThelastsectionisasamplemappingofthecurriculumtoEntrustableProfessionalActivities(Map),astandardizedcurriculumstructureformanyprograms.
ThiscurriculumisintendedtobeusedastheentiresetoftenCore Components,ratherthanchoosingindividualones(e.g.teachingonlyCore Components #1, #5, #8).ThetenCore Componentsarepertinenttoallprograms,butthedetailofwhichcanbeexpandedandcontracted,accordion-style,aspertinent.Thismaterialislikelytobebestintegratedacrosstheyearsoftraininginbothclassroomandclinicalsettings.
4THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
INTRODUCTION
IMPLEMENTATION + ASSESSMENTTheArizona Curriculumrepresentsaradicalchangetotheclassicalapproachtopainandaddictioneducation.Itwilltakeplanningandtimeforprogramstoimplementallcomponentsasintended.Inordertoassesstheeffectivenessofthisimplementationandeffectonlearners,astandardizedmetricwillbeadministeredannuallytoallprograms,withpre-andpost-trainingevaluationstobegiventoallstudentsattheendoftheirfirstandlastyearsoftraining.
TheArizonaDepartmentofHealthServiceswillprovidefurtherresourcesforprogramsthatincorporatethiscurriculum,includingaFaculty Guide,andaCurriculumSummitintheFallof2018.
NATIONAL REFERENCES• InstituteofMedicine.RelievingPaininAmerica:ABlueprintforTransformingPrevention,Care,Education,andResearch.(2011)
Washington,DC:NationalAcademiesPress.doi:https://doi.org/10.17226/13172• InteragencyPainResearchCoordinatingCommittee.National Pain Strategy: A Comprehensive Population Health-Level Strategy
for Pain.(2016).https://iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf
TABLE OF CONTENTS
• CurriculumVision• CoreComponents(#1-10)• Objectives(forCoreComponents#1-10)• ToolboxforOperationalization• Assessment+Follow-Up• MaptoEntrustableProfessionalActivities(EPA)
5THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
VISION + CORE COMPONENTS
CURRICULUM VISION
To redefine pain and addiction as multidimensional, interrelated public health issuesthatrequirethetransformationofcaretowardawhole-personinterprofessionalapproachwithacommunityandsystemsperspective.
CORE COMPONENTSUpongraduationfromahealthprofessionaleducationprograminArizona,astudentshoulddemonstratetheindependentabilityto:UPDATES TO THE GUIDELINESREDEFINE PAIN + ADDICTION
1 Define pain and addiction as multidimensional, public health problems.
2 Describe the environmental, healthcare systems and care model factors that have shaped the current opioid epidemic and approach to pain care.
3 Describe the interrelated nature of pain and opioid use disorder, including their neurobiology and the need for coordinated management.
4 Use a socio-psycho-biological model to evaluate persons with pain and opioid use disorder.
5 Use a socio-psycho-biological model to develop a whole-person care plan and prevention strategies for persons with pain and/or opioid use disorder.
6 Reverse the medicalization of chronic pain by empowering persons with self-management strategies, and include an awareness of chemical coping.
7 Use and model language that destigmatizes addiction, reflects a whole-person perspective, builds a therapeutic alliance and promotes behavior change.
APPLY AN EVIDENCE-BASED, WHOLE-PERSON APPROACH TO PAIN + ADDICTION
8 Employ an integrated, team-based approach to pain and/or addiction care.
9 Engage family and social support in the care of pain and/or addiction.
10 Critically evaluate systems and seek evidence-based solutions that deliver quality care and reduce pharmaceutical influence in the treatment of pain and opioid use disorder.
INTEGRATE CARE WITH A SYSTEMS PERSPECTIVE
6THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEThiscorecomponentsetsthetonefortherestofthecurriculumbyredefiningpainandaddictionasmultidimensional,integrated,population-healthbasedproblems.Thisdefinitionaimstotransformeducationawayfromthetraditionallysiloedandreductionistapproachtopainandaddiction.
OBJECTIVESA.MESSAGE:Painandaddictionaremultidimensionalissues.
A1Describetheestablishedandevolvingneurobiological,clinical,psychological,culturalandcognitivebasisofpainandaddiction.
A2Describethesocialdeterminantsofhealththataffectboththedevelopmentofchronicpainand/oropioidusedisorder.A3Describetheenvironmental,hostandcausativeagentsintheprogressionfromacutepaintochronicdisability.
B.MESSAGE:Painandaddictionarepublichealthproblems.B1Describetheimpactofchronicpainandopioidusedisorderonpopulationmorbidityandmortality.B2Describethelegallandscapeinthestateandnationformanagingpainandopioidusedisorder.
KEY READING• AmericanSocietyofAddictionMedicine.(2011,April12).PublicPolicyStatement:DefinitionofAddiction.RetrievedJune26,
2018,fromhttps://www.asam.org/resources/definition-of-addiction• CarrD.B.(2016)“PainIsaPublicHealthProblem”—WhatDoesThatMeanandWhyShouldWeCare?Pain Medicine,17(4),
626-627.doi:10.1093/pm/pnw045• Cohen,M.,Quintner,J.,&Rysewyk,S.V.(2018).ReconsideringtheInternationalAssociationfortheStudyofPaindefinitionof
pain.PAIN Reports,3(2).doi:10.1097/pr9.0000000000000634• InstituteofMedicineCommitteeonAdvancingPainResearch,Care,andEducation.Relieving Pain in America: A Blueprint
for Transforming Prevention, Care, Education, and Research.(2011)WashingtonD.C:NationalAcademiesPress;2,PainasaPublicHealthChallenge.Availablefrom:https://www.ncbi.nlm.nih.gov/books/NBK92516/
• InteragencyPainResearchCoordinatingCommittee.National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain.(2016).https://iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf
• Kolodny,A.,Courtwright,D.T.,Hwang,C.S.,Kreiner,P.,Eadie,J.L.,Clark,T.W.,&Alexander,G.C.(2015).ThePrescriptionOpioidandHeroinCrisis:APublicHealthApproachtoanEpidemicofAddiction.Annual Review of Public Health,36(1),559-574.doi:10.1146/annurev-publhealth-031914-122957
• SubstanceAbuseandMentalHealthServicesAdministration;OfficeoftheSurgeonGeneral.Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health.(2016)WashingtonD.C:USDepartmentofHealthandHumanServices;CHAPTER7,VISIONFORTHEFUTURE:APUBLICHEALTHAPPROACH.Availablefrom:https://www.ncbi.nlm.nih.gov/books/NBK424861/
1 Define pain and addiction as multidimensional, public health problems.
7THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEThiscorecomponentfocusesonthecomplexityoftheCDC-describedopioidepidemic.Thereareoverlappingfactorsthathaveshapedboththedevelopmentoftheepidemicandthecurrentclinicalapproachtopain.Morethanprovidingbackground,thiscentersonprevention,inordertoavoidasimilarepidemicinthefuture.
OBJECTIVESA.MESSAGE:Multiplefactorsshapedthecurrentopioidepidemic.
A1Describetheenvironmental,healthcaresystems,industry,legal,andcaremodelfactorsthathaveshapedtheopioidepidemic.A2Describetheimpactasingleprovidercanhaveontheopioidepidemic.
B.MESSAGE:Multiplefactorsshapedthecurrentapproachtopain.B1Describetheoriginsof“painisthefifthvitalsign”andthecultural,industry,TheJointCommissionandothercaremodel
factorsthathaveshapedthetraditionalbiomedicalapproachtopain.
C.MESSAGE:Itwilltakeacomprehensiveapproachtoaddresstheopioidepidemic.C1Explainthemacro(e.g.,policy,systems,legal,societal)andmicrochanges(e.g.,clinicianprescribing,focusonpain
self-management)thatareneededtostemthisepidemic.C2Recognizethemacroandmicrobarrierstochangeforthisepidemic.C3Explainhowanepidemiclikethismightbepreventedinthefuture.
KEY READING• Ballantyne,J.C.(2017).OpioidsfortheTreatmentofChronicPain.Anesthesia & Analgesia,125(5),1769-1778.doi:10.1213/
ane.0000000000002500• Bonnie,R.J.,Ford,M.A.,&Phillips,J.(2017).Pain management and the opioid epidemic: Balancing societal and individual
benefits and risks of prescription opioid use.Washington,DC:TheNationalAcademiesPress.doi:10.17226/24781• Porter,J.,Jick,H.(1980).AddictionRareinPatientsTreatedwithNarcotics.New England Journal of Medicine,302(2),123-123.
doi:10.1056/nejm198001103020221• Quinones,S.(2015).Dreamland:The True Tale of America's Opiate Epidemic.NewYork:BloomsburyPress.
2 Describe the environmental, healthcare systems and care model factors that have shaped the U.S. opioid epidemic and approach to pain care.
8THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEKeytothecurriculum’svision,thiscorecomponentestablishesthelinkbetweenpainandaddiction.Painandaddictionarehighlycomorbidandshareneurobiologicmechanisms,clinicalmanifestations,andtreatmentapproaches.Separationoftheresearch,educationandclinicalmanagementoftheseconditionshasledtoanunnecessarilynarrowunderstandingandafragmentedapproachtocare.Integratingthesedomainsenhancestheclinician’sunderstanding,assessment,andtreatmentofpersonswithpainand/oraddiction.
OBJECTIVESA.MESSAGE:Painandopioidusedisorderareinterrelated.
A1Describetheneurobiologyofpainandaddiction,includingrewardandanti-reward.A2Describehowcoordinatedmanagementofpainandopioidusedisorderbenefitspatientsandtheiroutcomes.
B.MESSAGE:Substanceuserelatestopainandtheriskofdevelopingopioidusedisorder.B1Detailtherelationshipbetweensubstanceusedisorders,includingalcohol,tobaccoandotherdruguse,painandtherisk
ofdevelopingopioidusedisorder.B2Explaintherelationshipbetweenmentalillnessandtraumawithpainandsubstanceusedisorders.B3Explainthescreeninganddiagnosticcriteriaforsubstanceusedisorderwhentreatingsomeoneforacuteorchronicpain.
KEY READING• Blanco,C.,Wall,M.M.,Okuda,M.,Wang,S.,Iza,M.,&Olfson,M.(2016).PainasaPredictorofOpioidUseDisorderina
NationallyRepresentativeSample.American Journal of Psychiatry,173(12),1189-1195.doi:10.1176/appi.ajp.2016.15091179• Bonnie,R.J.,Ford,M.A.,&Phillips,J.(2017).Pain management and the opioid epidemic: Balancing societal and individual
benefits and risks of prescription opioid use.Washington,DC:TheNationalAcademiesPress.doi:10.17226/24781• Borsook,D.,Linnman,C.,Faria,V.,Strassman,A.,Becerra,L.,&Elman,I.(2016).Rewarddeficiencyandanti-rewardinpain
chronification.Neuroscience & Biobehavioral Reviews,68,282-297.doi:10.1016/j.neubiorev.2016.05.033• Elman,I.,&Borsook,D.(2016).CommonBrainMechanismsofChronicPainandAddiction.Neuron,89(1),11-36.doi:10.1016/j.
neuron.2015.11.027• Nelson,S.,Simons,L.,&Logan,D.(2017).TheIncidenceofAdverseChildhoodExperiences(ACEs)andtheirAssociation
withPain-relatedandPsychosocialImpairmentinYouthwithChronicPain.The Clinical Journal of Pain,1.doi:10.1097/ajp.0000000000000549
• Rivat,C.,&Ballantyne,J.(2016).Thedarksideofopioidsinpainmanagement:basicscienceexplainsclinicalobservation.PAINReports,1(2).doi:10.1097/pr9.0000000000000570
• SubstanceAbuseandMentalHealthServicesAdministration.Tip 54: Managing chronic pain in adults with or in recovery from substance use disorders: Quick guide for clinicians.(2013).Rockville,MD:U.S.Dept.ofHealthandHumanServices,CenterforSubstanceAbuseTreatment.
• U.S.DepartmentofHealth&HumanServices.(2016,November).SurgeonGeneral'sReportonAlcohol,Drugs,andHealth.CHAPTER2.TheNeurobiologyofSubstanceUse,Misuse,andAddiction.Retrievedfromhttps://addiction.surgeongeneral.gov/sites/default/files/chapter-2-neurobiology.pdf
3 Describe the interrelated nature of pain and opioid use disorder, including their neurobiology and the need for coordinated management.
9THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEThiscurriculumflipsthetraditionalbiopsychosocialmodeltoinsteadfocusonsocial,psychological,andphysicalfunctioning.Thisemphasisontheinterpersonalandintersubjectivedomainsofpainandopioidusedisorderreflectsthemostrecentbasicscienceandclinicalevidencethatsocial,emotional,andcognitiveaspectsofpainarecentraltochronificationandtheassociateddysfunctionanddisability–andnotasecondaryissueoradistraction.Ratherthanbeginningwithareductionistapproachthatfocusesoncellularandmolecularmechanismsandthenprogressestosocialandpsychologicalphenomenaasmerelytheresultofthemicroscopicprocesses,person-orientedoutcomesaretheprimaryfocusatearlystagesofthiscurriculum.
OBJECTIVESA.MESSAGE:Clinicalunderstandingofpainandaddictionencompassessocial,psychologicalandbiologicaldimensions.
A1Describethesocio-psycho-biologicalmodelofpain,anddetailthecomponentsofeach.A2Describethesocio-psycho-biologicalmodelofopioidusedisorder,anddetailthecomponentsofeach.
B.MESSAGE:Evaluationofpainandopioidusedisorderrequiresawhole-personapproach.B1Performawhole-personassessmentofapersonwithacutepain.B2Performawhole-personassessmentofapersonwithchronicpain.B3Describepatient-centeredandclinician-centeredpartsofthepaininterview.B4Discussredflagsnotedduringahistoryandphysical,andtheassociatedwork-upwhenpresent.B5Discusstheindicationsforimagingforcommonpaincomplaints.B6Evaluateapersonwithopioidusedisorder,usingawhole-personassessmentandvalidatedtools.B7DemonstrateuseofScreening,BriefIntervention,andReferraltoTreatment(SBIRT)forpersonswithaddiction.B8Explainthediagnosisofpainand/oropioidusedisorderusingpatient-centeredlanguage,recognizingtheimpactofpatient
expectationscanhaveontreatmentoutcomes.
KEY READING• Carr,D.B.,&Bradshaw,Y.S.(2014).TimetoFlipthePainCurriculum?Anesthesiology,120(1),12-14.doi:10.1097/
aln.0000000000000054• Darnall,B.,Sturgeon,J.,Kao,M.,Hah,J.,&Mackey,S.(2014).FromCatastrophizingtoRecovery:Apilotstudyofasingle-
sessiontreatmentforpaincatastrophizing.Journal of Pain Research,219-226.doi:10.2147/jpr.s62329• Gatchel,R.J.,Peng,Y.B.,Peters,M.L.,Fuchs,P.N.,&Turk,D.C.(2007).Thebiopsychosocialapproachtochronicpain:
Scientificadvancesandfuturedirections.Psychological Bulletin,133(4),581-624.doi:10.1037/0033-2909.133.4.581• U.S.DepartmentofVeteransAffairs.(2016,September).OpioidUseDisorder:AVAClinician’sGuidetoIdentificationand
ManagementofOpioidUseDisorder(2016)(Rep.).Retrievedhttps://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Opioid_Use_Disorder_Educational_Guide.pdf
4 Use a socio-psycho-biological model to evaluate persons with pain and/or opioid use disorder.
10THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEEvidence-basedtreatmentofchronicpainfocusesonawhole-personapproachthatemphasizesactivetreatmentsandself-managementstrategieswhileavoidingunnecessaryexposuretoopioids.Evidence-basedtreatmentofopioidusedisordercentersonmedication-assistedtreatment,whileagainemployingawhole-personapproachtocare.Thiscorecomponentisthemostinvolvedinthiscurriculum,andstressesthemultimodalnatureoftreatmentcareplansandthenecessarypreventionandriskmitigationstrategiesbeforeandduringtreatment.
OBJECTIVESA.MESSAGE:Treatmentforpainandopioidusedisorderrequiresasocio-psycho-biologicalapproach.
A1Describeamultimodaltreatmentplanforapersonwithacutepain.A2Describeawhole-persontreatmentplanforapersonwithchronicpain.A3Discusstheevidencefortheuseofopioidsforacuteandchronicpain.A4Discusstheuseofnon-pharmacologicandnon-opioidpharmacotherapyforacuteandchronicpain.A5Understandthelegalrequirementsforprescribingopioidsforapatientwithacuteandchronicpain.A6Describeamultimodaltreatmentplanforapersonwithopioidusedisorder.A7Describetheprocessofcoordinatingcareandarrangingforahigherlevelofcareforapersonwithopioidusedisorder.A8Addressthemanagementofacutepaininspecialpopulations,includingpersonsinthepre-andpost-operativeperiods,
perinatalperiods,theelderly,thepediatricpopulationandthosewithsubstanceusecomorbidities.A9Explaintherationaleformultifacetedtreatmenttopersonwithpainandopioidusedisorder.
B.MESSAGE:Specificattentionmustbegiventopreventionandriskmitigationstrategiesaspartofatreatmentplanforacutepain,chronicpainand/oropioidusedisorder.B1Demonstrateabilitytoimplementriskmitigationstrategiestopreventadverseoutcomesfromthetreatmentofpain.B2Recognizetheclinicalpresentationofsubstancewithdrawalandknowclinicalandcommunityresourcestoaddressit.B3Discusstheriskfactorsforpainchronificationandpain-relateddisability,anddesignpreventionstrategies.B4Demonstrateabilitytomanagechallengingpatientsandpeople-pleasingbehaviorofproviders.
C.MESSAGE:Treatmentplansforpersonsonlong-termopioidtherapymustincludeanexitstrategy,whichtransitionspersonsfromlong-termopioidtherapytoadifferenttreatmentstrategy,tominimizeopioid-relatedadverseevents.C1Contrastcomplexpersistentopioiddependencewithsimpledependenceandopioidusedisorder.C2Describethreeapproachestoanopioidexitstrategy.C3Discusstheimportanceofrecognizingandaddressingsubstanceusedisorders,mentalhealthcomorbiditiesandmedical
comorbiditieswhenmanagingapersonwithchronicpainonlong-termopioidtherapy.
KEY READING• Dowell,D.,Haegerich,T.M.,&Chou,R.(2016).CDCGuidelineforPrescribingOpioidsforChronicPain—UnitedStates,2016.
JAMA,315(15),1624.doi:10.1001/jama.2016.1464• Krebs,E.E.,Gravely,A.,Nugent,S.,Jensen,A.C.,Deronne,B.,Goldsmith,E.S.,...Noorbaloochi,S.(2018).Effectof
OpioidvsNonopioidMedicationsonPain-RelatedFunctioninPatientsWithChronicBackPainorHiporKneeOsteoarthritisPain.JAMA,319(9),872.doi:10.1001/jama.2018.0899
• Schuckit,M.A.(2016).TreatmentofOpioid-UseDisorders.New England Journal of Medicine,375(4),357-368.doi:10.1056/nejmra1604339
• SubstanceAbuseandMentalHealthServicesAdministration.Tip54:Managingchronicpaininadultswithorinrecoveryfromsubstanceusedisorders:Quickguideforclinicians.(2013).Rockville,MD:U.S.Dept.ofHealthandHumanServices,CenterforSubstanceAbuseTreatment.
5 Use a socio-psycho-biological model to develop a whole-person care plan and prevention strategies for persons with pain and/or opioid use disorder.
11THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEThemedicalizationofpaindescribestheprocessoverthepastcenturywherebytheunderstandingandmanagementofpainhasbeenremovedfromthelaypublicandco-optedbythemedicalprofession.Thishastransformedtheclinicianandthemedicalsystemintotheprimary,activemanagerofpainwiththeimplicitunderstandingthatthepersonexperiencingpaintakesapassiverole.Additionallythestructuralpathologyparadigmmostcommonlypracticederroneouslyfocusesresourcestowardidentifyingandcuringanatomicabnormalitieslongafteracutepainhastransitionedtoachronicconditionrequiringactivelifestylemanagementapproaches.Demedicalizationofchronicpainaimstoreestablishtheself-efficacyofthepersonwithpainbyrecognizinghimorherasplayingtheactiveroleatthecenterofacareteam.Self-managementstrategiesformthefoundationforimprovingfunctionandqualityoflifeforpersonswithchronicpain.
OBJECTIVESA.MESSAGE:Inordertoreversethemedicalizationofchronicpain,theroleofactivemanagementofpainmustbetransferred
fromthemedicalsystemtothepersonwithchronicpain.A1Describethemedicalizationofchronicpain,recognizingtheroleofthebiomedicalmodelinpromotingpassivetreatmentsfor
chronicpainandhowthismodelisperpetuatedbyindustry,financialincentives,specialtytraining,andgovernmentaldecisions.A2Describehowthedemedicalizationofchronicpainenhancespatientoutcomes.A3Describeseveralself-managementstrategiesforchronicpainandtheevidencebehindthem.A4Counselpersonswithpainonself-managementstrategies.
B.MESSAGE:Patientstrategiestoavoidunpleasantphysicalsensationsandemotionaldistressinclude“chemicalcoping”thatcanleadtopooroutcomes.B1Describetheagonistandwithdrawaleffectsofopioidsandothercontrolledsubstancesonmultiplesystemsincludingsocial
bonding,affectivedimensionofpain,anxiety,moodandsleep.B2Definechemicalcoping,itsprevalenceindifferentpopulations,riskfactors,clinicalpresentationandhowitdiffers
fromaddiction.B3Describeatherapeuticapproachtochemicalcoping,includingaddressingtheunderlyingsufferingcausingthebehavior.
KEY READING• Pelletier,R.,Higgins,J.,&Bourbonnais,D.(2015).Isneuroplasticityinthecentralnervoussystemthemissinglinktoour
understandingofchronicmusculoskeletaldisorders?BMCMusculoskeletalDisorders,16(1).doi:10.1186/s12891-015-0480-y• SubstanceAbuseandMentalHealthServicesAdministration.Tip54:Managingchronicpaininadultswithorinrecoveryfrom
substanceusedisorders:Quickguideforclinicians.(2013).Rockville,MD:U.S.Dept.ofHealthandHumanServices,CenterforSubstanceAbuseTreatment.
6 Reverse the medicalization of chronic pain by empowering persons with self-management strategies, and include an awareness of chemical coping.
12THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEChronicpain,substanceuseandaddictionareoftenassociatedwithnegativeperceptionsthatarefurtheredbystigmatizinglanguage.Theuseofnonjudgmental,person-firstlanguagewithpatientsandcolleaguesisnecessaryforculturaltransformationandtoreducethenegativeimpactofstigmaonthecommunity.Person-firstlanguageshouldbepairedwithlanguagethatreflectsawhole-personperspectiveandevidence-basedapproachestomentalhealthconditions,addictionandchronicpain,whilemovingawayfromthestructuralpathologyparadigmofchronicpain.
OBJECTIVESA.MESSAGE:Stigmanegativelyaffectsthetreatmentandoutcomesofpersonswithchronicpainand/oraddiction.
A1Describetheimpactofstigmaonlegal,policy,researchandcareservicesforpersonswithpainand/oraddiction.A2Contrastthescience-basednatureofaddictionandchronicpainwithcommonlyheldperceptions.A3Modelrespectfulandnonjudgmentalcommunicationwithpersonswithpainandaddiction.A4Useactivereflectiontouncoverpersonalbiasestopersonswithchronicpainand/oraddiction.
B.MESSAGE:Languagemustbetailoredtoattendtothepatient’suniquesocio-psycho-biologicalfactors.B1Describetheeffectivenessofmotivationalinterviewingforsubstanceusedisordersandchronicpain.B2Demonstratetechniquesofmotivationalinterviewingtechniquestosupportbehaviorchange.B3Assessanindividual’sreadinessforchangeandtailortreatmentapproachestothepatient’sstageofchange.
C.MESSAGE:Atherapeuticalliancewithpersonswithpainand/oraddictionenhancestreatmentoutcomes.C1Describetheimportanceofthetherapeuticallianceinworkingwithpersonswithpainand/oraddiction.C2Modelthedevelopmentofatherapeuticalliancebydemonstratingempathyaswellasreachingagreementonfunctional
goalsandapproachestoreachthesegoals.C3Demonstratevalidation,partnering,andboundarysettinginsituationswithahighdegreeofnegativeaffect.
KEY READING• AmericanPsychiatricAssociation.(n.d.).APALearningCenterAddiction,Stigma,andDiscrimination:ImplicationsforTreatment
andRecovery(ArchivedWebinar).RetrievedMarch27,2018,fromhttps://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=1303
• Goldberg,D.S.(2017).Pain,objectivityandhistory:Understandingpainstigma.Medical Humanities,43(4),238-243.doi:10.1136/medhum-2016-011133
• SAMHSANationalRegistryofEvidence-basedProgramsandPractices.(2017).MotivationalInterviewingforBehavioralHealthConditions.RetrievedMarch27,2018.
• Szalavitz,M.(2017,June11).WhyWeShouldSaySomeoneIsA'PersonWithAnAddiction,'NotAnAddict.RetrievedMarch27,2018,fromhttps://www.npr.org/sections/health-shots/2017/06/11/531931490/change-from-addict-to-person-with-an-addiction-is-long-overdue
7 Use and model language that destigmatizes addiction, reflects a whole-person perspective, builds a therapeutic alliance and promotes behavior change.
13THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEIntegrated,team-basedcareisthefuturedirectionofmedicalcare,andthereisgoodevidencethatanintegrated,team-basedapproachtopainleadstothebestoutcomes.Thesilosofcarethatcharacterizeconventionalmedicalapproachescreateobstaclestosuccessfulcarecoordination.
OBJECTIVESA.MESSAGE:Team-basedapproachtopainandaddictioncareiseffective.
A1Describethecomponentsandcharacteristicsofaneffectiveteamtoassistinthecareofsomeonewithpainand/oraddiction.
B.MESSAGE:Interdisciplinary,integratedcarehasaroleinthecareofallpatients.B1Describetheprocessofcreatinganinterdisciplinarycareteamintheoutpatientsetting.
KEY READING• Gallagher,R.,Verma,S.(2004).BiopsychosocialPainMedicine:IntegratingPsychiatricandBehavioralTherapiesintoMedical
Treatment.Seminars in Neurosurgery,15(01),31-46.doi:10.1055/s-2004-830012• Kamper,S.J.,Apeldoorn,A.T.,Chiarotto,A.,Smeets,R.J.,Ostelo,R.W.,Guzman,J.,&Tulder,M.W.(2014).Multidisciplinary
biopsychosocialrehabilitationforchroniclowbackpain.Cochrane Database of Systematic Reviews.doi:10.1002/14651858.cd000963.pub3
• SAMHSA-HRSACenterforIntegratedHealthSolutions.(2014,March).EssentialElementsofEffectiveIntegratedPrimaryCareandBehavioralHealthTeams.RetrievedMarch27,2018,fromhttps://www.integration.samhsa.gov/workforce/team-members/Essential_Elements_of_an_Integrated_Team.pdf
• SubstanceAbuseandMentalHealthServicesAdministration;OfficeoftheSurgeonGeneral.Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health.(2016)WashingtonD.C:USDepartmentofHealthandHumanServices;CHAPTER6HEALTHCARESYSTEMSANDSUBSTANCEUSEDISORDERS.Availablefrom:https://www.ncbi.nlm.nih.gov/books/NBK424848/
• Watkins,K.E.,Ober,A.J.,Lamp,K.,Lind,M.,Setodji,C.,Osilla,K.C.,...Pincus,H.A.(2017).CollaborativeCareforOpioidandAlcoholUseDisordersinPrimaryCare.JAMAInternalMedicine,177(10),1480.doi:10.1001/jamainternmed.2017.3947
8 Employ an integrated, team-based approach to pain and addiction care.
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OBJECTIVES
RATIONALEBeyondtheclinician-patientrelationship,communityiscentrallyimportanttothesustainedrecoveryofpersonswithpainandaddiction.Thiscorecomponentpointedlyfocusesontheneedforfamilyandsocialsupport.
OBJECTIVESA.MESSAGE:Familyandsocialsupportplayanimportantroleinthecareofapersonwithpainand/oraddiction.
A1Describetheimpactsofpain,addictionanddisabilityonfamilymembersincludingpotentialforandconsequencesofcaregiverburnout.
A2Describetheimpactfamilyandsocialsupportcanhaveonrecoveryfrompainandaddiction.
B.MESSAGE:Resourcesandeducationcanempowerfamilyandsocialsupportstocareforthemselvesandbuildhealthyrelationshipswithpersonswithpainoraddiction.B1Detailfamilyresourcesforcare,includingfamilytherapyandcrisisresponsenumbers.B2Describeillnessandwellnessbehaviorsinpersonswithchronicillness,includingtheirsignificancewithinthefamily
andsocialspheres.B3Discusstheimportance/useofnaloxoneforafamilymemberorsocialsupportfigure,andhowtoaccessit.
KEY READING• ArizonaDepartmentofHealthServices.(2017,November20).StandingOrdersforNaloxone.RetrievedMarch27,2018,
fromhttps://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/naloxone-standing-order.pdf
• Duenas,M.,Ojeda,B.,Salazar,A.,Mico,J.A.,&Failde,I.(2016).Areviewofchronicpainimpactonpatients,theirsocialenvironmentandthehealthcaresystem.Journal of Pain Research,9,457-467.doi:10.2147/jpr.s105892
• SubstanceAbuseandMentalHealthServicesAdministration.(2015).Tip 39: Substance abuse treatment and family therapy.Rockville,MD:U.S.DepartmentofHealthandHumanServices,CenterforSubstanceAbuseTreatment.
9 Engage family and social support in the care of pain and addiction.
15THE ARIZONA PAIN AND ADDICTION CURRICULUM | azhealth.gov/curriculum
OBJECTIVES
RATIONALEAnawarenessofandresponsivenesstothelargercontextandsystemofhealthcarehasbeenestablishedinthiscurriculum;thiscorecomponentensuresthatlearnerscanevaluatethesesystemsandfindsolutionstoinevitablebarrierstothesafe,qualitycareofpatients.Thisrequiresthelearnertobeproactiveandreflectiveandtocriticallyevaluatetheevolvingfieldofhealthcare.
OBJECTIVESA.MESSAGE:Systemsandindividualcliniciancarerequirecontinual,criticalevaluation.
A1Explainhowuseofpatientcenteredoutcomescanenhancepainand/oraddictioncare.A2Demonstrateskillinappraisingsources,contentandapplicabilityofevidencewithanemphasisonquality,safety,population
healthandcost-effectiveness.A3Listwaysaprovidercanevaluatehis/herownpractice,includinguseofadataregistryofpatientswithchronicpain,chronic
painworkgroupsandmorbidityreviews.
B.MESSAGE:Qualitypainandaddictioncarerequiresresourcefuleffortstoovercomeobstaclestocare.B1Describeclinicalresourceswithinthehealthcaresystem,governmentalentitiesandprivateorganizationsthatcanassist
withcaremanagementandtreatment.
C.MESSAGE:Pharmaceuticalcompanieshaveanimpactonclinicalcare.C1Listexamplesofhowpharmaceuticalcompaniesinfluencecontinuingmedicaleducation,publishedevidence
andclinicalguidelines.C2Summarizehowpharmaceuticalcompanieshaveimpactedprescribingpracticesandclinicalpractice.C3Detailwaystoreducepharmaceuticalinfluenceonclinicalpracticeatthelevelofindividualclinicianandhealthcaresystems.
KEY READING• Goodnough,A.,&Zernike,K.(2017,June11).SeizingonOpioidCrisis,aDrugMakerLobbiesHardforItsProduct.Retrieved
March27,2018,fromhttps://www.nytimes.com/2017/06/11/health/vivitrol-drug-opioid-addiction.html• Parchman,M.L.,Korff,M.V.,Baldwin,L.,Stephens,M.,Ike,B.,Cromp,D.,Wagner,E.H.(2017).PrimaryCareClinicRe-
DesignforPrescriptionOpioidManagement.TheJournaloftheAmericanBoardofFamilyMedicine,30(1),44-51.doi:10.3122/jabfm.2017.01.160183
• Ridker,P.M.,&Torres,J.(2006).ReportedOutcomesinMajorCardiovascularClinicalTrialsFundedbyFor-ProfitandNot-for-ProfitOrganizations:2000-2005.JAMA,295(19),2270-2274.doi:10.1001/jama.295.19.2270
• ShaughnessyAF,SlawsonDC,BennettJH.(1994).BecominganInformationMaster:AGuidebooktotheMedicalInformationJungle.JFamPract,39(5),489-499.
• Wazana,A.(2000).PhysiciansandthePharmaceuticalIndustry.JAMA,283(3),373.doi:10.1001/jama.283.3.373
10 Critically evaluate systems and seek evidence-based solutions that deliver quality care and reduce pharmaceutical influence in the treatment of pain and opioid use disorder.
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OPERATIONALIZATION
TOOLBOX FOR OPERATIONALIZATION
Dedicatetimeforfacultyfamiliarizationwiththeculturaltransformationembodiedinthiscurriculumandforadaptationtotheirparticularhealtheducationprogram.
DedicatespecificdidactictimefortheArizona Curriculum,asexternalattendingsandprofessorsmaynotyetembodythismodernapproachtopainandaddiction.
Considerhowtofacilitateawarenessofthediscordancebetweenthecurriculumand“hiddencurriculum”instudentexposureduringrotationsparticularlyrelatedtopharmaceuticalinfluenceandanolder,biomedicalapproachtopainandaddiction.
Tag-teaminstructionwithpainandaddictionspecialists.
Involveindividualsinrecoveryinlecturesorinsmallgroups.
Followupwithstudentsafterclinicalrotationstoaddresspossiblemismatchesbetweencurrentbestpracticesandthetraditionalapproachtopain.
Includeinfluentialpublicationsandbooks,includingchaptersfromDreamland,articlesfromtheNewYorkTimes,JaneBallentyne,etc.
Reducetheimpactthatpharmaceuticalcompanieshaveonstudentsandaskstudentsinrotationevaluationsabouttheirinteraction(lunches,swag,lectures)withtheindustry.
Dedicatetimetoassessandreassessthecurriculum,andsharefindingswithotherprograms.
Thefollowingtablelistsdifferentapproachestoteachingthiscurriculumandideasofhowtooperationalizethenewerconceptsintoanexistingprogramstructure.Itisintendedtobealivinglistandwillbeupdatedasprogramsimplementthecurriculumandnewbestpracticesevolve.
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ASSESSMENT
REQUESTED [PROGRAM] METRICS InordertoevaluatetheeffectivenessoftheArizona Curriculum,standardizedmetricswillberequestedbytheArizonaDepartmentofHealthServicestoallundergraduatehealtheducationalprogramsandnursepractitionerprogramsinArizonaonanannualbasis.These metrics should be reported to the Department, in a form determined by the Department, at the end of each training year (between March and July).
FinalizedmetricswillbemadeavailablebytheDepartmentandsenttoprogramswhenrequired.Requestedmetricswillincludequestionssuchasthoselistedinthissample:
FACULTY DEVELOPMENT
[YES/NO]DidarepresentativefromyourprogramattendtheEducationalSummit(Fall2018)orAnnualEducationalFollow-upMeeting(Summer2019,2020,2021)?Pleasedescribethatperson’sjobtitle.
[YES/NO]Arestudentsasked,post-communityrotation,abouttheirobservationsofpainandaddictioncare,andhowitdiffersfromthenewcurriculum?
DEMOGRAPHICS OF STUDENTS
[#]Howmany1st,2nd,3rd(+4th)yearstudentsreceivedcomponentsoftheArizona Curriculumthispastyear?
[#]Howmanystudentsaregraduatingfromyourprogramthisyear?
[#]HowmanygraduatingstudentsareremaininginArizonafortheirnexttrainingoremployment?
IMPLEMENTATION OF CORE COMPONENTS
[YES/NO]WerealltenCore ComponentsoftheArizona Curriculumincludedinyourprogram’scurriculum?
[YES/NO]WasCore Component1,2,3etcimplementedinyourprogram’scurriculumlastyear?[SKIPLOGIC,ifansweredNOabove]
[CHECKBOXES]HowisCore Component1,2,3,etcimplementedintotheprogram:Lectures,Learningmodules,OSCEs,Workshop,Other?Inwhatyearoftraining?
[NARRATIVE]What,ifany,specificCore ComponentsorObjectiveswerechallengingtoteachorimplement?Pleasedescribe.
[NARRATIVE]WhatuniqueimplementationsoftheArizona Curriculumwouldyouliketoreport?Pleaseelaborate.
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PHARMACEUTICAL INFLUENCE
[#]Howmanystudentslastyearweretaughtthroughspecificdidacticsabouttheinfluenceofpharmaceuticalcompaniesoncliniciansandprescribingpractice?
[CHECKBOX]Wasthisdidacticadministeredin:1st,2nd,3rdor4thyearoftraining?
[YES/NO]Arestudentsasked,postrotations,abouttheirinteractionwithpharmaceuticalcompanies?
[NARRATIVE]What,ifany,areuniqueimplementationsofthistopicinyourprogram?
FREE FORM
[NARRATIVE]PleasecommentontheimplementationoftheArizona Curriculumandtheimpactonyourlearners.
ASSESSMENT
Thecollecteddatamaybepresentedpubliclyinaggregateformbyprogramtype;specificnarrativeswouldbepresentedatthelevelofprogram-typeonlyiffurtherpermissionfromtheschoolisgranted.
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KNOWLEDGE
[SCALE]Howconfidentdoyoufeeltreatingsomeonewithacutepain?
[SCALE]Howconfidentdoyoufeeltreatingsomeonewithchronicpain?
[SCALE]Howcomfortabledoyoufeelevaluatingforaddiction?
[SCALE]Howconfidentdoyoufeelthatopioidsareeffectiveforlong-termtreatmentofchronicpain?
[SCALE]Howconfidentdoyoufeelthatthereisaneffectivetreatmentforopioidusedisorder(opioidaddiction)?
[SCALE]Howconfidentdoyoufeelwiththeindicationsfororderingimagingforpatientswithbackpain?*
[SCALE]Howconfidentdoyoufeelwiththehigh-value,evidence-basedtherapiesforchronicbackpain?*
[SCALE]Howconfidentdoyoufeellistingtestsandtherapiesforlowbackpainthathavelimitedevidenceandareoverusedatapopulationlevel?
REQUESTED [LEARNER] METRICS InordertoevaluatetheeffectivenessoftheArizona Curriculumonstudents,standardizedmetricswillberequestedbytheArizonaDepartmentofHealthServicestoallundergraduatehealtheducationalandnursepractitionerstudents.These metrics should be gathered from all learners after the first and last years of training and submitted to the Arizona Department of Health Services between April and August of each year.
FinalizedmetricswillbemadeavailablebytheDepartmentandsenttoprograms.Requestedmetricswillincludequestionssuchasthoselistedinthissample:
ASSESSMENT
ATTITUDES
[SCALE]Iknowsomeonewithchronicpain.
[SCALE]Iknowsomeonethathasopioidusedisorder(opioidaddiction).
[SCALE]Iplanontakingcareofpatientswithacutepaininthefuture.
[SCALE]Iplanontakingcareofpatientswithchronicpaininthefuture.
[SCALE]Iplanontakingcareofpatientswithaddictioninthefuture.
[SCALE]Ihaveinternalbiasestowardspersonswithpain.
[SCALE]Ihaveinternalbiasestowardspersonswithaddiction.
[SCALE]Iseepainasapublichealthproblem.
[SCALE]Iseeaddictionasapublichealthproblem.
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ASSESSMENT
REQUESTED PROGRAM FOLLOW-UP ImplementationofthisStatewideCurriculumconstitutesamajorshiftinpainandaddictioneducation.Thisattempttoredefinepainandaddictionisbeingdoneatawidespread,generationallevel,andstrugglesandadjustmentsaretobeexpected.
There will be an annual meeting hosted by the Arizona Department of Health Services for the next three years after implementation, to be held in the summer of 2019, 2020 and 2021. Acurriculumrepresentativefamiliarwiththeprogram’scurriculumandimplementationisexpectedtoattend,havingpreviouslysubmittedtheprogram’smetricstotheDepartment.Thegoalofparticipationistolearnfromthesuccessesandchallengesofotherprograms.
PRACTICES + PLANS
[YES/NO]IwastaughtabouttheFDABlackBoxWarningagainstusingopioidandbenzodiazepinestogether.
[FREQSCALE]Iwasexposed,aspartofmytraining,tocommunityresourcestotreatpeoplewithpainand/oraddiction?
[FREQSCALE]Pharmaceuticalcompaniesboughtmemeals,swag,otheritemsduringmytraining.
[FREQSCALE]Duringmytraining,peopleusedthewords“drugaddicts”,“dirtyurine”and/orotherstigmatizinglanguage.
[SCALE]IplantostayinArizonapost-training.
*Metrics for medical programs only
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MAP TO EPAs
Mapping Statewide Curriculum to the Association of American Medical Colleges Core Entrustable Professional Activities
CoreEntrustableProfessionalActivitiesforEnteringResidency(EPAs)consistofprogressivesequencesofstudentbehaviorthatmedicaleducatorsmayencounteratstudentsengageinthemedicalschoolcurriculumandbecameproficientinintegratingtheirclinicalskills.WrittenbytheAssociationofAmericanMedicalColleges,MDandDOcurriculumcomponentsarebestmappedtotheseEPAs.
EPA-MAPPED CORE COMPONENTS
1 Definepainandaddictionasmultidimensional,publichealthproblems.EPA1:GatheraHistoryandPerformaPhysicalExamination,KP1,KP4,KP5
2Describetheenvironmental,healthcaresystemsandcaremodelfactorsthathaveshapedthecurrentopioidepidemicandapproachtopaincare.EPA1:GatheraHistoryandPerformaPhysicalExamination,KP4,KP5
3
Describetheinterrelatednatureofpainandopioidusedisorder,includingtheirneurobiologyandtheneedforcoordinatedmanagement.EPA1:GatheraHistoryandPerformaPhysicalExamination,KP1,KP2,KP5EPA9:CollaborateasaMemberofanInterprofessionalTeam,IPC2,SBP2
4
Useasocio-psycho-biologicalmodeltoevaluatepersonswithpainandopioidusedisorder.EPA1:GatheraHistoryandPerformaPhysicalExamination,ICS7,P1,P3,KP1EPA2:PrioritizeaDifferentialDiagnosisFollowingaClinicalEncounter,PC2,PC3,PC4,KP2,KP3,KP4,PPD8EPA3:RecommendandInterpretCommonDiagnosticandScreeningTests,PC5,SBP3,PBL19,KP1,SBP3,PC5,PC7EPA10:RecognizeaPatientRequiringUrgentorEmergentCareandInitiateEvaluationandManagement,PC2,PC3
5
Useasocio-psycho-biologicalmodeltodevelopawhole-personcareplanandpreventionstrategiesforpersonswithpainand/oropioidusedisorder.EPA2:PrioritizeaDifferentialDiagnosisFollowingaClinicalEncounter,ICS2EPA4:EnterandDiscussOrdersandPrescriptions,KP4,KP5,PC6EPA5:DocumentaClinicalEncounterinthePatientRecord,PC4,ICS1,ICS2
6Reversethemedicalizationofchronicpainbyempoweringpersonswithself-managementstrategies,andincludeanawarenessofchemicalcoping.EPA4:EnterandDiscussOrdersandPrescriptions,PC7
7
Useandmodellanguagethatdestigmatizesaddiction,reflectsawhole-personperspective,buildsatherapeuticallianceandpromotesbehaviorchange.EPA5:DocumentaClinicalEncounterinthePatientRecord,PC6,ICS1,ICS1,ICS7EPA6:ProvideanOralPresentationofaClinicalEncounter,P1,P3,PPD4
8
Employanintegrated,team-basedapproachtopainand/oraddictioncare.EPA2:PrioritizeaDifferentialDiagnosisFollowingaClinicalEncounter,ICS2,IC3,ICS4EPA6:ProvideanOralPresentationofaClinicalEncounter,ICS1,ICS2,PBL1EPA7:FormClinicalQuestionsandRetrieveEvidencetoAdvancePatientCare,ICS1,PBLI8,PBLI9,PC7EPA8:GiveorReceiveaPatientHandovertoTransitionCareResponsibility,ICS2,ICS3,PC8EPA9:CollaborateasaMemberofanInterprofessionalTeam,IPC2,SBP2,ICS3,IPC1
9
Engagefamilyandsocialsupportinthecareofpainand/oraddiction.EPA4:EnterandDiscussOrdersandPrescriptions,ICS1,PC7EPA6:ProvideanOralPresentationofaClinicalEncounter,ICS1,PPD7,P3,P1,PPD4,EPA8:GiveorReceiveaPatientHandovertoTransitionCareResponsibility,P3
10
Criticallyevaluatesystemsandseekevidence-basedsolutionsthatdeliverqualitycareandreducepharmaceuticalinfluenceinthetreatmentofpainandopioidusedisorder.EPA7:FormClinicalQuestionsandRetrieveEvidencetoAdvancePatientCare,PBLI6,KP3,KP4,PBLI1,PBLI3,PBLI7EPA13:IdentifySystemsFailuresandContributetoaCultureofSafetyandImprovement,PBLI4,PBLI6,PBLI10,SBP4,P4,SBP4,SBP5,KP6
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MAP TO EPAs
CompleteEPAguidelineslistedataamc.org.initiatives.coreepas/.
1. PATIENT CARE (PC): Provide patient-centered care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
1.1 Performallmedical,diagnostic,andsurgicalproceduresconsideredessentialfortheareaofpractice1.2 Gatheressentialandaccurateinformationaboutpatientsandtheirconditionthroughhistory-taking,physicalexamination,and
theuseoflaboratorydata,imaging,andothertests1.3 Organizeandprioritizeresponsibilitiestoprovidecarethatissafe,effective,andefficient1.4 Interpretlaboratorydata,imagingstudies,andothertestsrequiredfortheareaofpractice1.5 Makeinformeddecisionsaboutdiagnosticandtherapeuticinterventionsbasedonpatientinformationandpreferences,up-to-
datescientificevidence,andclinicaljudgment1.6 Developandcarryoutpatientmanagementplans1.7 Counselandeducatepatientsandtheirfamiliestoempowerthemtoparticipateintheircareandenableshared
decisionmaking1.8 Provideappropriatereferralofpatients,includingensuringcontinuityofcarethroughouttransitionsbetweenprovidersor
settingsandfollowinguponpatientprogressandoutcomes1.9 Providehealthcareservicestopatients,families,andcommunitiesaimedatpreventinghealthproblemsormaintaininghealth1.10 Provideappropriaterolemodeling1.11Performsupervisoryresponsibilitiescommensuratewithone’sroles,abilities,andqualifications
2. KNOWLEDGE FOR PRACTICE (KP): Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care
2.1 Demonstrateaninvestigatoryandanalyticapproachtoclinicalsituations2.2 Applyestablishedandemergingbiophysicalscientificprinciplesfundamentaltohealthcareforpatientsandpopulations2.3 Applyestablishedandemergingprinciplesofclinicalsciencestodiagnosticandtherapeuticdecisionmaking,clinicalproblem
solving,andotheraspectsofevidence-basedhealthcare2.4 Applyprinciplesofepidemiologicalsciencestotheidentificationofhealthproblems,riskfactors,treatmentstrategies,
resources,anddiseaseprevention/healthpromotioneffortsforpatientsandpopulations2.5 Applyprinciplesofsocial-behavioralsciencestoprovisionofpatientcare,includingassessmentoftheimpactof
psychosocial-culturalinfluencesonhealth,disease,care-seeking,carecompliance,andbarrierstoandattitudestowardcare2.6 Contributetothecreation,dissemination,application,andtranslationofnewhealthcareknowledgeandpractices
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MAP TO EPAs
3. PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI): Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning
3.1 Identifystrengths,deficiencies,andlimitsinone’sknowledgeandexpertise3.2 Setlearningandimprovementgoals3.3 Identifyandperformlearningactivitiesthataddressone’sgapsinknowledge,skills,orattitudes3.4 Systematicallyanalyzepracticeusingquality-improvementmethods,andimplementchangeswiththegoalofpractice
improvement3.5 Incorporatefeedbackintodailypractice3.6 Locate,appraise,andassimilateevidencefromscientificstudiesrelatedtopatients’healthproblems3.7 Useinformationtechnologytooptimizelearning3.8 Participateintheeducationofpatients,families,students,trainees,peers,andotherhealthprofessionals3.9 Obtainandutilizeinformationaboutindividualpatients,populationsofpatients,orcommunitiesfromwhichpatientsaredrawn
toimprovecare3.10 Continuallyidentify,analyze,andimplementnewknowledge,guidelines,standards,technologies,products,orservicesthat
havebeendemonstratedtoimproveoutcomes
4. INTERPERSONAL AND COMMUNICATION SKILLS (ICS): Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals
4.1 Communicateeffectivelywithpatients,families,andthepublic,asappropriate,acrossabroadrangeofsocioeconomicandculturalbackgrounds
4.2 Communicateeffectivelywithcolleagueswithinone’sprofessionorspecialty,otherhealthprofessionals,andhealth-relatedagencies(seealsointerprofessionalcollaborationcompetency,IPC7.3)
4.3 Workeffectivelywithothersasamemberorleaderofahealthcareteamorotherprofessionalgroup(seealsoIPC7.4)4.4 Actinaconsultativeroletootherhealthprofessionals4.5 Maintaincomprehensive,timely,andlegiblemedicalrecords4.6 Demonstratesensitivity,honesty,andcompassionindifficultconversations(e.g.,aboutissuessuchasdeath,end-of-life
issues,adverseevents,badnews,disclosureoferrors,andothersensitivetopics)4.7 Demonstrateinsightandunderstandingaboutemotionsandhumanresponsestoemotionsthatallowonetodevelopand
manageinterpersonalinteractions
5. PROFESSIONALISM (P): Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles
5.1 Demonstratecompassion,integrity,andrespectforothers5.2 Demonstrateresponsivenesstopatientneedsthatsupersedesself-interest5.3 Demonstraterespectforpatientprivacyandautonomy5.4 Demonstrateaccountabilitytopatients,society,andtheprofession5.5 Demonstratesensitivityandresponsivenesstoadiversepatientpopulation,includingbutnotlimitedtodiversityingender,
age,culture,race,religion,disabilities,andsexualorientation5.6 Demonstrateacommitmenttoethicalprinciplespertainingtoprovisionorwithholdingofcare,confidentiality,informed
consent,andbusinesspractices,includingcompliancewithrelevantlaws,policies,andregulation
6. SYSTEMS-BASED PRACTICE (SBP): Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care
6.1 Workeffectivelyinvarioushealthcaredeliverysettingsandsystemsrelevanttoone’sclinicalspecialty6.2 Coordinatepatientcarewithinthehealthcaresystemrelevanttoone’sclinicalspecialty6.3 Incorporateconsiderationsofcostawarenessandrisk-benefitanalysisinpatientand/orpopulation-basedcare6.4 Advocateforqualitypatientcareandoptimalpatientcaresystems6.5 Participateinidentifyingsystemerrorsandimplementingpotentialsystemssolutions6.6 Performadministrativeandpracticemanagementresponsibilitiescommensuratewithone’srole,abilities,andqualifications
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7. INTERPROFESSIONAL COLLABORATION (IPC): Demonstrate the ability to engage in an interprofessional team in a manner that optimizes safe, effective patient- and population-centered care
7.1 Workwithotherhealthprofessionalstoestablishandmaintainaclimateofmutualrespect,dignity,diversity,ethicalintegrity,andtrust
7.2 Usetheknowledgeofone’sownroleandthoseofotherprofessionstoappropriatelyassessandaddressthehealthcareneedsofthepatientsandpopulationsserved
7.3 Communicatewithotherhealthprofessionalsinaresponsiveandresponsiblemannerthatsupportsthemaintenanceofhealthandthetreatmentofdiseaseinindividualpatientsandpopulations
7.4 Participateindifferentteamrolestoestablish,develop,andcontinuouslyenhanceinterprofessionalteamstoprovidepatient-andpopulation-centeredcarethatissafe,timely,efficient,effective,andequitable
8. PERSONAL AND PROFESSIONAL DEVELOPMENT (PPD): Demonstrate the qualities required to sustain lifelong personal and professional growth
8.1 Developtheabilitytouseself-awarenessofknowledge,skills,andemotionallimitationstoengageinappropriatehelp-seekingbehaviors
8.2 Demonstratehealthycopingmechanismstorespondtostress8.3 Manageconflictbetweenpersonalandprofessionalresponsibilities8.4 Practiceflexibilityandmaturityinadjustingtochangewiththecapacitytoalterbehavior8.5 Demonstratetrustworthinessthatmakescolleaguesfeelsecurewhenoneisresponsibleforthecareofpatients8.6 Provideleadershipskillsthatenhanceteamfunctioning,thelearningenvironment,and/orthehealthcaredeliverysystem8.7 Demonstrateself-confidencethatputspatients,families,andmembersofthehealthcareteamatease8.8 Recognizethatambiguityispartofclinicalhealthcareandrespondbyusingappropriateresourcesindealingwithuncertainty
MAP TO EPAs
Contact:[email protected]
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