Simulation and immersive learning techniques appear to be particularly effective and powerful for teaching safe opioid prescribing, according to a new study.

The research involved pain medicine fellows and anesthesiology residents at Stanford University—all trainees at the graduate level—working in a simulated outpatient pain clinic. There, a standardized patient actor played the role of a patient who meets the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for an opioid use disorder, and is asking for an opioid refill to prevent withdrawal, having presented to the clinician with only one tablet of hydromorphone left.

“In this immersive experience, faculty video records the trainees’ ability to determine the appropriate opioid-related diagnosis and risk stratification, to discuss the risk and benefits of providing an opioid, and the safety of their therapy plan,” said author Jordan L. Newmark, MD, associate division chief for education, and pain medicine associate program director at Stanford University School of Medicine, in California.

The trainees finish by writing a simulated dictated patient care note for the medical chart, and these are reviewed, said Dr. Newmark, who is also clinical assistant professor in the Division of Pain Medicine/Department of Anesthesiology, Perioperative & Pain Medicine, Division of Addiction Medicine, at Stanford. Then the patient actors provide validated feedback on the trainees’ clinical skills.

“The path of least resistance would be to provide a refill per the patient’s request, without addressing the opioid use disorder,” Dr. Newmark said. “However, the trainees who verbalized to the patient their concerns about the opioid use disorder, and asked the patient to see an addiction medicine specialist for comanagement, were rated as having the highest clinical skills and satisfactory interactions with the patient,” Dr. Newmark said. “These trainees were also more restrictive with opioid prescribing as a safety factor, given the presence of the patient’s DSM-5 diagnostic criteria for an opioid use disorder.”

Dr. Newmark said, “I would have expected the opposite, that honoring the patient’s request for more opioid would have made them perceive the trainee in a better light.”

These results indicate that clinicians should address all opioid- and patient-related concerns “in an empathic manner without fear that they will be perceived as poorly skilled or without empathy,” Dr. Newmark said.

“I think this is an innovative program that is attuned to several needs: the need to help develop skills in younger physicians early in their careers with the complex diagnostic, cognitive and communication aspects of opioid risk management,” said Steven Passik, PhD, vice president of scientific affairs, education and policy at Collegium Pharmaceuticals, in Canton, Mass. The method “is experiential, in concert with principles of adult learning and allows physicians to develop skills in a situation without actual consequences for a real person. It shows how even a very apparently simple request for a refill or an increase requires a complex thought process, the development of a differential diagnosis about what is driving the request, and then learning how to use resources and skills to proceed safely.”

Dr. Passik also said, “All health care providers need more training of this nature, and then a health care system that routinely allows them to alter their practice flow and patterns so that these common but high-impact clinical situations can be dealt with in full appreciation of their complexity.” He added, “We also need the system to recognize how much thought and effort goes into the proper management of these situations and adequately reimburse practitioners.”

The study results were presented at the 2017 annual meeting of the American Academy of Pain Medicine (poster 159).

—David C. Holzman

（Presented by International Exchange Center of CSPC,translated from ASPE，16.Aug,2017)