Addressing Complex Chronic Pain Conditions in Care Delivery | Juliette M. Perzhinsky, MD, MSc, FACP

This is a very complex situation from a public health perspective and what we don't see in most primary care based residency and training programs is, we don't get a lot of behavioral health training, we don't really have the ability to give our future health care workforce the competencies to effectively manage patients that have complex chronic pain conditions.


Juliette Perzhinsky, MD, MSc, FACP Associate program Director, Internal Medicine, Associate Program Director Michigan University College.


Background & Roles

I've taken on a few roles, by background, I'm an internal medicine physician with training in patient safety, one thing that I do at my academic institution at CMU is I teach in a variety of settings in the clinical teaching environment in the clinic. I teach residents, and medical students. Last year I had expanded with the interprofessional education curriculum to other health professional students including, PA’ and NP students. So more specifically, the expansion of the project to me is really hinged on a patient safety framework of which we're trying to address the opioid crisis by instilling the skill sets to manage complex patients that may be suffering with chronic pain, mental health comorbidity and trying to also help them develop the self-efficacy, to also address opioid use disorders in patients.

Behavioral Health Programs in Residency Training Programs


I was very fortunate to be able to pilot this curriculum this past academic year, and it was basically through the support of the Arnold P Gold Foundation. I had re-submitted a proposal for a picker Gold GME challenge grant and I had formed a team to work on this curricular project that was professionally designed to bring trainees, not just within the residency programs but other trainees that are going to inherit the complexities of dealing with an opioid epidemic as we're facing in the United States. In essence, about a year ago we received the announcement that we had some funding through the Gold foundation, to implement this curriculum that would hopefully help curtail some of the mortality that we're seeing with the opioid crisis.

This is a very complex situation from a public health perspective and what we don't see in most primary care based residency and training programs is, we don't get a lot of behavioral health training, we don't really have the ability to give our future health care workforce the competencies to effectively manage patients that have complex chronic pain conditions, and again those who also may be suffering with opioid addiction. In essence the IPE pilot curriculum served as at least a foundation to provide some of that necessary education in a very much inter-professional setting where we brought trainees, not just from residences but trainees from other health disciplines like the PA and NP programs to learn together on how to develop the teamwork and expertise to hopefully have greater self-efficacy with managing this crisis that we are seeing.

In essence, we were able to pilot this curriculum last year, we offered five distinct IPE sessions over a six-month time frame. We couldn't do one in February because of scheduling, the logistical issues, but we were able to start it in December of 2017 and continued up until May of which we had a variety of content, what we felt was high-impact content that is needed to instill in our trainees to have better capabilities with managing the complexity of these situations.

We used a pre and post curriculum design and so we actually assessed baseline self-perception that the learners had in terms of where they are with managing chronic pain, where they feel they are with managing mental health conditions, in addition where they are with their self-perception of how they work in teams and identify themselves as a member of a team. With the questionnaire that we did at baseline, we then repeated it at the end of the IPE curriculum so after May after the last session we then disseminated the questionnaire again to see if there would be a change in those self-efficacy scores, in those perceptions of working in a team. We don't have the full analysis completed yet, but so far we are seeing the preliminary interim data analysis, some differences in those participants who participated in the curriculum, versus the trainees that did not, there seems to be improved self-efficacy for the trainees who actually participated in some of these training sessions that we offer.

Whole Person Care

On of the collaborators on this project is an addiction psychiatrist at John Hopkins who I actually connected to through The Gold Foundation. Dr. Meg Chisolm, has done a lot of research on the opioid addiction and pregnancy. She actually facilitated our March IPE session by addressing the four perspectives of psychiatry. There's a lot of data on using the perspective of psychiatry to approach substance use disorders and opioid use disorders. The focus was on understanding the nature of addition. We need to be able to do a good social history which was one of the take home points that she addressed. Also, the family history. When one starts delving into family history from a clinical perspective we can actually get a lot of information because if there's a substantial family history of depression, that it self could be a linkage to why the patient may have been predisposed to addiction.

Again, it just comes down to appreciating the unique approaches that we can take as clinicians who are trying to help our patients that are suffering. Some of our patients are just suffering from chronic pain and using the opioids but we need to be able to dissect is it truly chronic pain or is there something else that's going on thats complicating this like, mental health comorbidity or a possible opioid use disorder that may have complicated the patient situation. I think bringing awareness to our trainees was an important feature of the IPE curriculum. I do believe that those who participated took something away. Even if we can't expand it in the absence of full funding although we're doing something at the medical school level in the next year. At least the trainees that have participated have gain some additional skill set. If anything recognition that we need to treat addiction as a chronic disease.

Equipping Frontline Clinicians with Skills to Address Complex Chronic Pain Conditions In Care Delivery

I think that is it's very humbling when we see the sequela of opioid addiction to the point where patients lose their families, they lose their homes, and they lose their livelihoods. There's no clear-cut, there are some prediction factors that we can see especially the genetic predisposition that if there's a family history that can increase the likelihood of that. In terms of like taking a step back and trying to make it practical the training that we're offering I think a lot of it came down to bringing recognition to this public health issue, this substantial public health issue, as a health issue.

As a chronic condition and that there are effective treatment modalities that are available like through medication assisted treatment. I'm not here to misrepresent who I am, I'm a primary care physician, I'm a primary care educator, I don't have full expertise in addiction medicine. I'm not here from that angle of being an addictionologist who has vast experience of managing patients with this. But what I do come in was with is with this real experience of being on the frontlines of care and seeing patients come to their primary care clinic as their first stop and asking us to help them, when we don't even have the existing infrastructure in our communities to effectively do that in a cohesive fashion.

The lessons that we offered or these IPE sessions that we offer to the trainees were a way of bringing awareness to the fact that we should not stigmatize mental illness and substance use disorders are mental health conditions sometimes it's hard to tease out you, you can't always determine what came first, but the fact that a lot of patients who suffer with opioid use disorders do have a complicating factor of a comorbid mental health condition, lends to the fact that in order for them to recover we need to be able to effectively address the mental health aspect, the behavioral health aspect.

We need to build the healthcare infrastructure to effectively address that. That's where I feel some of the communities are not successful at and I can speak personally to the community where I practice and I teach. So the sessions in itself the curriculum at least provided some awareness to the challenges and I think one of the most powerful takeaway points that the trainees had talked about, when we actually brought a select few in for a focus group discussion, was the fact that we brought in a patient who gave a testimonial a testimonial to how she was dealing with chronic pain, and she was judged, the healthcare system the healthcare clinicians that she would see judged her. She got to the point where she couldn't get the care she needed in our community, and she actually sees a specialist, a pain specialist 90 miles away because she couldn't get the help that she needed.

This could have been somebody who although being very highly functional and successful in her career, if she didn't seek the help elsewhere may have ended up in a very dire situation. To me that's very heartbreaking, that we see these patients that have no support, they don't have social support, we see the social determinants of health having a critical impact in their outcomes and so the curriculum, although not perfect we were far from being perfect we didn't have a lot of time to implement this. What I take away and what my team and I take away is that we actually did something - hopefully impact kind of clinical practice change for the future healthcare workforce.

Again that's going to inherit this opioid crisis, and so at least bringing that recognition and one of our the final session by the way, I thought was also very powerful was the one on implicit bias. We had a speaker, of one of my collaborators and colleagues Dr. Joffe Saqqara, who's from Western University in Ontario came. We had the funding to sponsor him to come to Saginaw to actually facilitate one of the sessions on implicit bias especially when dealing with patients with chronic pain or even those with opioid use disorders. We have to get rid of the stigma, there's no way we're going to be able to curtail this and the alarming statistics we're seeing if health care clinicians on the frontlines don't recognize that there is stigmatization to this, and recognize that we all may harbor some implicit bias. So when patients come in, I mean the point of the Planetree conference here today is to really build that relationship centered care.

That concept of having that relationship that patient clinician relationship for the longitudinal time frame, to be compassionate and empathic in our delivery of care. I think that at least, we were successful in that regard, giving the trainees that additional knowledge on recognizing chronic pain, recognizing opioid addiction as a chronic disease, as opposed to perceiving it as a moral failing. Which is what our previous US Surgeon General had brought to the attention to the public domain with the Turn The Tide Campaign. So, again we're just revisiting what has already been talked about and trying to disseminate that to those trainees who are more impressionable at their level of training, trying to get them to open up their eyes.

Practical Ways to Avoid Compromising Excellent Care Delivery

The appropriate infrastructure is having an actual dynamic healthcare team that can help manage that. When I talk to the addiction recovery clinics, the opioid treatment centers that we have we have a few in the community, we don't have a lot but we do have a few in the community. The resources that they have are not just a clinician and an MA, they offer peer support in the clinic, there’s social support, they have peer recovery coaches that help that patients.There's a lot of community programs in Michigan that have been launched Hope Not Handcuffs is a huge one started by families against narcotics which is a non-profit community organization that's been disseminating across Michigan, decriminalizing patients and people that are using. It is an important aspect of that and that's not my legal avenue that I want to take but I think that we need to take a step back and recognize that this is a chronic disease and we should not judge people for the fact that they are dealing with a chronic disease.

I'm not going to pass judgment against the patient with congestive heart failure, that may have had uncontrolled hypertension. I am not going to have that same amount of bias, but I recognize that sometimes culturally we label patients that are suffering with addiction and I think being cognizant of it. Recognizing that if we can bring attention to our own biases, when we go to see that patient saying I know that I may not be as fair or objective to this patient but I need to be cognizant that this is still a human being coming to seek help for me.

Creating Lasting Impact Through Curriculum Program Implementations

Well, I wish I could say that it's adapted elsewhere I know that there's a lot of academic institutions doing a variety of program implementation, curricular project implementation to address the opioid crisis and many programs have done one-day workshops, as a way of addressing the opioid crisis. At this point in time, this is a pilot curriculum that we literally just finished a few months ago and we're now trying to assimilate the data and to actually package the information to disseminate it to hopefully have it gained traction in some regards. I don't know what the ultimate success of this project will be there are a lot of shortcomings with really taking a risk and launching right into this with a very short timeframe to do it, and recognizing that the curriculum may have been deficient in some regards but I think in hindsight, the team that I assembled to help me and to help our institution launch this curriculum did the best we could with the time commitment required.

With the funding that we fortunately had through the Gold Foundation and hopefully that impact will continue in some capacity but I can't predict the future. I don't know how that would necessarily translate into other healthcare settings but I'm open to ideas and I'm open to collaboration maybe even pondering getting other institutions together to see if we can do something more broad scale obviously funding is a grate limiting factor for a lot of these projects because they do take an immense amount of time and they're very challenging from a multitude of perspectives.