University Times

Almost 100 million Americans suffer from chronic pain, which costs $635 billion annually in treatments and lost workdays, according to the National Institutes of Health (NIH).

Debra Weiner

Despite this tremendous expenditure, “we’re not improving people’s function,” says Debra Weiner, faculty member in Pitt’s medical school and director of the NIH Health Pain Consortium’s newly designated Center of Excellence in Pain Education here. Pain management is not a major subject in the curriculum of health profession schools, she adds, and clinicians approach pain diagnosis and treatment inconsistently.

The Pitt center, one of 12 in the nation, will bring together five schools of the health sciences — dental medicine, health and rehabilitation sciences, medicine, nursing and pharmacy — to help ameliorate what Weiner calls “the serious gap in pain education for providers that is causing a lot of current problems with health care and pain management.”

NIH has charged the center to develop enduring web-based materials that educators from across the country can use to educate their own students. The interactive modules are case-based. They emulate what happens when health-care professionals — pharmacists, physicians and others — encounter patients complaining of pain, “what errors are made if you don’t know what to do, and what should be done. The overall mission is to advance pain education in the University and nationally. The modules are the vehicles for infusing information into courses,” Weiner explains. Some course directors in Pitt’s five participating health-sciences schools have approved incorporating the modules into courses and clerkships.

“Even though the materials are focused on pre-professional students,” Weiner says, “we’re hoping to eventually develop the materials for residents, fellows and providers who are already in practice.”

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Teams from the pain education center will tackle different pain problems commonly seen by primary care physicians. Pitt’s module topics, chosen because they represent the expertise of Pitt faculty and do not duplicate the work of the other centers nationwide, are:

• Evaluation and management of chronic lower-back pain in older adults, led by medicine faculty member Natalia Morone;

• Evaluation and treatment of widespread pain, primarily fibromyalgia, in middle-aged persons, led by Cheryl Bernstein in anesthesiology and neurology, and

• Prevention, recognition and treatment of opioid misuse in teenagers, led by Michael Zemaitis, pharmaceutical sciences faculty.

The modules will combine graphics, print, videos, audio narration and quizzes, allowing health-care professionals to choose different ways to proceed as a particular patient’s case unfolds, and then see the consequence of those choices.

Natalia Morone

Morone’s module, for instance, is aimed at medical students in their first through third years; advanced undergraduates and first- and second-year master’s degree candidates in nursing; third-year dental and pharmacy students, as well as physical therapy students. Narrated by Weiner and module-team member Jordan Karp, a faculty member in psychiatry, anesthesiology and clinical and translational science, it follows the case of Edna, 82, who has suffered from low-back pain for three years. The pain has gotten worse over the past six months, students learn. The module then details Edna’s living conditions and medical complications as well as the location of the worst pain and the results of medical tests she has undergone. It also points out that low-back pain is the most common and costly pain problem in America. Weiner notes that this condition often is misdiagnosed and thus treated incorrectly.

The module will attempt to show health-care professionals the common points where patient visits, interviews and examinations often fail to turn up enough information for caregivers to formulate the proper treatment; appropriate treatment targets and expectations, and the stepped-care treatment approach. In stepped care for pain, consideration first is given to patient education, exercise, weight loss and manual therapies, moving up in treatment severity through local injections to opioid drugs as the last choice.

The goals of the module are to reduce physician reliance on imaging tests for diagnosis and patient reliance on riskier procedures and medications for treatment, and improve patients’ treatment outcomes, as well as relations between the patient and the health-care professional.

After taking a quiz about cases similar to Edna’s, students using this module will encounter Edna and her case in the way a real patient visit usually unfolds. Students will be required to pick out the assumptions and errors most commonly encountered in this situation.

In the course of seeing good and bad examples of pain diagnosis and treatment play out on screen, students will learn how to take a patient history, with specific questions to ask, symptoms to note and gaps in patient knowledge to fill. They also will learn procedures for doing the physical exam in specific body regions and treatment-decision methods for specific pain presentations. The module shows students effective consultations between care providers and best practices for follow-up patient visits.

Pain does not always have a purely physical cause or cure, says Morone. “Pain is also an emotional experience and a psychological experience. This is something we’ve found pretty consistently gets missed in people’s early training.”

As it turns out, acetaminophen and physical therapy reduce Edna’s pain. But during her follow-up physician visit she seems to be depressed — a common but often hidden occurrence, the module teaches. It then offers proper screening questions and treatments for this eventuality.

Finally, students see how Edna responds to combined physical and psychological treatments. A final quiz assesses student knowledge of the module’s lessons.

Heiko Spallek

Morone’s team includes Heiko Spallek, an associate dean in the School of Dental Medicine, who is co-director of the pain education center. He brings his instructional technology expertise to the creation of these interactive video-based cases. For instance, medical students and other future health-care professionals will be shown how diagnosis is aided by asking the patient to point out an area in pain, rather than relying on a verbal description.

“So the student not only reads about it but sees it and can model the behavior,” Spallek says. “I’m extremely excited about this project. My own research is about how to translate scientific knowledge into practice, into the real world.” Finding better pain diagnoses and treatments is important, he says, but “there’s no point in figuring something out if nobody’s using it.”

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Michael Zemaitis

Modules being devised by Cheryl Bernstein’s team and by three teams that will be assembled this fall are similar to Morone’s module in that they will focus on a particular type of pain in a particular patient demographic. While all the modules have the same online format, the sixth module, being created by Michael Zemaitis’s team, is different in focus. It teaches proper opioid misuse prevention, recognition and treatment in a teenage patient and should be applicable to a broad range of health-care professionals.

In Zemaitis’s module, a teen visits an oral surgeon who removes the child’s wisdom teeth and writes a prescription for 10 Vicodin. When the teen’s mother goes to the pharmacy to fill the Vicodin prescription, she also asks the pharmacist for her own refill of another psychoactive drug, Xanax. Looking at the family’s makeup (there are three teenagers at home) and prescription history, the pharmacist then must decide whether and how to counsel this family about safe drug storage, and what actions to take.

Then the module teaches a lesson about prescription drug diversion. A short time after the prescriptions have been filled, the mother claims most of her son’s Vicodin spilled out of its bottle into the toilet. She asks her doctor for a replacement prescription. Upon receiving the paper prescription, she changes the 10-pill order to 40 tablets and attempts to get it filled at a different pharmacy.

As students progress through this module, they learn to recognize red flags concerning forged prescriptions and other improper efforts to obtain opioids. For instance, when encountering the faked prescription for 40 Vicodin, do they refuse to fill it, counsel the patient that there may be a problem, or just fill it and get rid of the patient?

Later, students see the mother at home throwing multiple pill bottles into a drawer, rather than a locked storage container. Later, a hand reaches in. Is it the mother, her son, one of her other teenagers or someone visiting the home? The scene ends in the emergency room, proving that poor decisions “could lead to a bunch of end products, all of them bad,” Zemaitis says.

The goal of this module is to teach not only proper use of opioids but alternatives to their use, he says. For instance, students learn about the prevalence of acetaminophen use among patients on opioids, which may result in too much acetaminophen, given that this common pain reliever is contained in many opioids. Vicodin, for instance, until recently contained 750 mg of acetaminophen, although new rules will reduce that to 250 mg in the future.

Zemaitis’s team includes Paul Moore, faculty member in dental anesthesiology; Julie Childers, faculty member in the Department of Medicine; Michael Mangione, faculty member in the medical school’s anesthesiology department, and Carol Washburn, Center for Instructional Development and Distance Education.

The first three curriculum-module teams are expected to complete their work by summer’s end, after which center teams will tackle three other modules: management of headaches; management of pain in older persons with dementia, and management of pain associated with metastatic cancer in older persons.

—Marty Levine