Heather Klusaritz sat down with two of the University of Pennsylvania’s leaders in designing educational models to train primary care residents in medication assisted treatment (MAT) care delivery. Robin Canada, MD is the Associate Program Director for the Primary Care Residency Program and Rani Nandiwada is the faculty lead for opioid use disorder care in the Division of General Internal Medicine at the Perelman School of Medicine, University of Pennsylvania. In response to the opioid epidemic in Philadelphia, where more than 1,200 lives were claimed by drug overdoses in 2017, Drs. Nandiwada and Canada spearheaded the development of an MAT program at the Penn Center for Primary Care. This program works collaboratively with the State of Pennsylvania-supported, Opioid Center of Excellence at Penn Presbyterian Medical Center, to care for patients with opioid use disorder (OUD) in a primary care setting. Both Drs. Canada and Nandiwada are committed to expanding access to evidence-based treatment for OUD through the training primary care providers and enhancing the capacity of primary care sites to provide high-quality patient care.
Heather: How did you first become interested in caring for patients with opioid use disorder?
Robin: After residency I worked with the Indian Health Service where we had a prescription opioid crisis. I went out there and had no idea what I was doing, because we had had no formal training in how to manage prescription opioids as a resident. I was there 2006 to 2009, and sort of had to jump right in and learn how to do controlled medication agreements and urine drug testing. After 2 years I came back here and saw the faces of my residents as they were trying to help people on prescription opioids and they had no guidelines, no training, and were feeling very uncomfortable. That’s sort of what inspired me to work here on developing an opioid protocol with partner practices. We all met for over a year with folks from pain management, anesthesia, and the VA to learn best practices for opioid prescribing. And at that point we developed a controlled medication agreement. We developed urine drug screening and a protocol and started to really learn about the opioid crisis.
Heather: How did the policy work that you did with your colleagues translate into education?
Robin: We did several opioid case management conferences, both with the interns and with the residents. Some of it was didactics and some of it was case-based. They were able to think about "What are you monitoring?" You should be monitoring function, not just pain level. You should be monitoring urine drug screening, you should be looking for adverse opioid related behaviors, and sort of have a goal in mind when talking to patients. We also taught them some counseling practices and advanced planning with patients. We did a lot of education, and I think residents in general felt much better about how to talk to patients in the room and to meet their expectations.
Heather: Tell me a little bit more about what your own training was like for opioid management, and how that shaped your initiatives and the frame that you bring to educating your residents now.
Robin: As a resident, mostly because it was not recognized at the time, I did not get training on how to monitor patients on chronic opioids, how to taper them off, how to discontinue use, or how to have those difficult conversations. Most of my early training was from national conferences, learning from what other institutions were doing, attending workshops to learn how to actually talk to patients, what to monitor and how often. That was how I really started to learn about it, because we hadn’t done it before. We were kind of the first in general medicine.
Heather: Rani, can you tell me a little bit about your own training in managing opioids in patient populations, and how you used that as a lens to develop Med Ed strategies for your own learners now?
Rani: My background is in medical education. I did a two year general medicine fellowship and have a Master’s in Med Ed. I think it’s really important from an educator’s standpoint that my pathway and how I got involved with Suboxone wasn’t necessarily all about the Suboxone. I think that’s part of what distances educators from saying "this is something that I want to do, that I’m interested in." They feel the need to say "this isn’t the driving force behind my passion and education", and if we’re talking about transitioning a lot of this into academic centers for training, you need to have champions and people who are interested in it, but if you don’t I don’t think it’s actually the biggest deal in the world. From my own background in training – I was a primary care resident at NYU – we did actually have an addiction block covering opioids, alcohol, smoking, and the education and training were fairly intensive. Even then, you’re still learning as you go because it’s a challenging patient population that can cause some stress, especially when you’re in training and learning how to have a conversation with a patient. Dealing with it in real life is very different than dealing with it in the classroom. I think as I moved on through training in terms of having more background in education, what I’ve learned is that there are so many transferrable skills when you think about education as a whole – both in opioid education and also in Suboxone education in particular.
[When starting a training program] I think that it’s important to consider educators who don’t necessarily have a lot of expertise, because if you only say "we need someone who is really passionate with opioids and Suboxone and is really comfortable about them", you’re losing out on reaching out to a lot of people who could look at this as a broader picture in terms of residency education.
For me, the residents really wanted it, and they were very excited for it and actually asked for this training. And truly, that’s all that you need.
If you think about the skillsets from an education perspective, so many of them are complex communications skills that residents need not just for patients with addiction or behavioral health issues, but also in their everyday practice. There are so many hard negotiations and conversations that they don’t get deliberate practice for throughout their training. Some patients are great and it’s an easy conversation, but I think about our Suboxone mornings as drill training for complex communications skills.
Heather: What are emerging educational issues for educators in primary care who want to do integrated behavioral health? Do we need to spend more time focused on drilling residents in complex conversations?
Rani: The skillset is actually not that hard. I think it’s interesting that we’re made to do an 8 hour training session for Suboxone, yet no one makes you do 8 hours of training to sign the prescription for the opioid. I think that builds up some of the anxieties around it.
Robin: Doctors are really nervous about getting burnt out working with this population, but working with residents who are passionate about social justice and about helping patients with addiction really makes the mornings more enjoyable. I look forward to them. Integrating education not only teaches these skills, but also helps the provider feel like going to work the next day and feel better about working with this population, and I think it’s a really nice model.
Rani: Some of those barriers set you up to be afraid to prescribe Suboxone. Part of how this all came together is that we do have a grant from the State Center of Opioid Excellence (COE), so we’re fortunate to have some more of the integrated health component, which makes it easier. However, I don’t think that not having a COE should be a reason to not do this. We have patients with a lot of behavioral health issues and addiction issues anyway, and it’s just a matter of doing it for more patients. You just have to think about planning ahead and seeing if you can get a pathway with someone who’s willing to link with you for that. We’re fortunate that we do have the COE, so we have a care coordinator who helps to plug in with the addiction assessment center to do intensive outpatient work. She comes to all the appointments, sits with the patients, and provides support.
Prescribing medication and giving it to the patient, once you have a step-wise process, is much better and easier. As part of that, we created a best practice guide where we laid out all of our work algorithms, our flows, how many weeks we do everything, it’s all written out. We also made template notes so that a resident who had never been to a Suboxone training at all could walk through the template with zero knowledge and still be comfortable prescribing it. All the REM scores are built in so that it hits documentation criteria. It has information about dosage, about how you tell the patient to take it, what method you should do whether it’s home induction or outpatient induction. We then created a smart set on EPIC that has everything in it from an induction template to a maintenance template. It has all the orders including Hep C and HIV screening. It has all the urine drug orders so you don’t have to search through EPIC. It has patient instruction handouts that are very patient-friendly and easy to understand.
Part of our goal in working with the COE was that, if we’re going to be a Center of Excellence, everybody should be doing the same thing. Why should every office be reinventing the wheel and starting anew? We tried to make it so that it’s as streamlined as possible.
So, in terms of learning, I don’t think a barrier should be prescribing. If you can get templates and things set up, the residents do it without issue. The other part about communication, I think, is a barrier that people are worried about but never voice. What happens if a patient says they didn’t take anything but their urine comes up positive for something? How do you negotiate with the patient to both understand that it’s an honest relationship but also understand that it’s a recovery process and there are going to be bumps in the road? That gets very gray very quickly and people get uncomfortable with it.
Heather: There’s a lot of talk nationally about whether we need to develop integrated behavioral health or opioid specific milestones and EPAs. Is that the way that we push more people to do training at the UME and GME levels? Is that a need or a strategy worth pursuing?
Rani: I think that’s hard. There are so many EPAs and milestones and so much need in so many different areas that if we were to pick and choose certain topics to push an EPA or milestone on, it would just create more pressure for program directors and course directors to check a box rather than do something really meaningful. But if we were to take a step back and say, "These are communications skills that they need no matter what" and then say "here are opportunities for where and why they’re going to need it", I think that actually is more meaningful than saying "this is something they’ll have to deal with". These are communications skills that are transferrable to all patients.
Heather: How do you think that the current context here in Philadelphia in particular is driving what the residents are asking for or what the care needs are that you need to meet as you think about training them? Is there something unique about what we have here, and if so, is that translatable to places that might not have the same environment as Philadelphia?
Rani: I feel as though everyone feels the opioid epidemic. I don’t think there’s a resident anywhere who hasn’t been impacted by it, felt it, or been challenged by it in their training. Philadelphia, I think, is probably similar to most major cities where you see it all the time and you know it’s a problem. The primary care residents here, their hearts are into vulnerable populations, community health and outreach, and I think that’s part of what drives them. Part of successful training is distinguishing between people who are going into general medicine and primary care versus a categorical program. It’s hard to get buy-in from learners if they don’t see how it’s going to impact them or they don’t see how they fit into that on a larger scale. Rather than dilute it and try to sell it to everyone with various degrees of buy-in, we should target our residents who actually want to do it. The time and energy that you devote to them will have more of an impact than trying to give everyone a sprinkle of knowledge.
Heather: Is there a foundation of knowledge centered on opioid use disorder risk or Suboxone training/knowledge that you would recommend for everybody?
Rani: So when I say sprinkle, I actually mean an intensive Suboxone clinic experience. I think everybody is going to need to know how to use this drug because it will affect them at some point in their career. I think these are conversations that will happen no matter what with opioid use disorder. Everyone needs to be aware of that. From an education perspective, you can teach them about opioids, but you should also make them realize that these are skills they can use no matter what. That’s a huge skillset now instead of a narrow skillset. Communications, negotiations, knowing about weaning, tapering, and safety guidelines are essential knowledge. But in terms of more intensive experiences, that’s when targeting and focusing on those who already have interest comes in.
Heather: How do we ensure that providers are coming into residency with the necessary foundation? Where do we do this in undergraduate medical education?
Rani: It’s something that should be started in UME, but it needs to travel into GME and it’s a skillset that should keep growing with the learner. It makes more sense in clinical years because then the residents feel it, and you have to feel the struggle of the conversation, and you have to see the patient and the challenges of their life and what they’re going through, and then you get buy-in because you understand that you need it. But until you see why you need it, it’s hard. When I’m with my medical students and residents and we have a difficult patient, in the past they’ve felt very disempowered. In a very interesting way, Suboxone has empowered them to say that they can do something to help the patient. So when they see and understand that, they know that they have another tool in their belt to use in situations where they’ve felt helpless before.
Heather: Any thoughts or recommendations for programs who are thinking about doing this?
Rani: I think if you already have someone who is super excited and interested and is already a champion, that’s fabulous. Even if you don’t, it’s a great way to spend time and coach and work with residents on such a different and rewarding level. I think you need to find friends in other institutions or clinics in the community to go to in order to ask questions. There are a lot of nuances that make this challenging, so it’s important to have a network with someone who is a mentor. And SAMHSA and a lot of other programs do provide mentorship links, and I would take advantage of them. We were all fortunate enough that we had gone and hunted down people who were doing things that were similar so that we could learn from them. I would explore, I would meet people and see how it’s done, because until you see it done, it seems really intimidating. I found so many things that were rewarding with working with residents in this format, and also in seeing patients do so much better, it’s amazing. You don’t realize that until you do it.
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