Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:10–18. Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2013.873512

ARTICLE

Application of Opioid Analgesia Concepts in a Third-Year Pharmacy Student Skills Laboratory on Three Campuses Michael W. Neville, Amber Bradley Clemmons, and Carolyn S. Hunter AB STRACT The objective of this study was to evaluate the effects of a skills laboratory exercise focused on principles of opioid analgesia on the knowledge, attitudes, and self-perceived skills of third-year (P3) pharmacy students on three campuses of the University of Georgia College of Pharmacy. The study evaluated the effects of a 2-hour skills laboratory exercise focused on technical aspects of opioid analgesia and included three stations: programming a pump to deliver a fentanyl drip/Richmond Agitation Sedation Scale (RAAS) scoring, using an equianalgesic dosing table, and compounding a patient-controlled analgesia syringe. A 12-item, online survey was distributed 2 weeks prior (pre-intervention) to the analgesia skills laboratory. A 2-hour laboratory was delivered on each campus and the survey was administered again (post-intervention) at the conclusion of the laboratory. One hundred and thirty-five students (93%) completed the pre- and post-intervention surveys. Significant changes (P < .05) between pre- and post-intervention scores were observed in two of five (40%) of the knowledge, all four (100%) of the self-perceived skills, and all three (100%) of the attitude items. Intercampus differences between preand post-intervention scores were minor. The authors concluded that skills laboratory exercises can effectively change the attitudes and self-perceived skill level of P3 pharmacy students and reinforce previously acquired knowledge. KEYWORDS equianalgesia, opioids, pain, skills laboratory

4030 (24%) in 1999 to 16,651 (43%) in 2010.2 Deaths from prescribing errors often result from inability to use opioid conversion information.3,4 Many believe the difficulties in understanding opioid calculation and conversion tables to be part of the problem. Although experts in opioid pharmacology have developed a widely acceptable guideline for opioid rotation, it has not been formally assessed nor validated for safety and efficacy.3 Pharmacists could improve the safety and efficacy of pain medication use as auditors of opioid prescriptions, counselors of patients and caregivers, and educators of prescribers. Pharmacy school curricula should be revised to better prepare future pharmacists for these roles. A Google Scholar and a PubMed search were performed using “curriculum, pain, analgesia, and pharmacy” with the following limits: terms appeared in the title of the publication, article published from 2003 to 2013. Eight publications fit these parameters. Most articles focused on chronic pain, palliative care, and interdisciplinary education.5–11 A

INTRODUCTION A 2011 Institute of Medicine (IOM) report estimated the annual cost of pain per person in the United States to be about $2,000, or roughly $560–$635 billion for the country. The incidence of chronic pain (100 million patients) in the United States outpaces other chronic conditions such as diabetes (25.8 million), coronary heart disease (16.3 million), and cancer (11.9 million).1 Drug poisoning deaths in the United States from opioids increased from Michael W. Neville, PharmD, BCPS, FASHP, is a Clinical Associate Professor, University of Georgia College of Pharmacy, Athens, Georgia, USA. Amber Bradley Clemmons, PharmD, BCOP, and Carolyn S. Hunter, PharmD, are Clinical Assistant Professors, University of Georgia College of Pharmacy, Augusta, Georgia, USA. The authors thank Kim Love-Myers, PhD, and Nan Zhang, graduate student, from the Department of Statistics at The University of Georgia for their support of this project. Address correspondence to: Michael W. Neville, PharmD, Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, 250West Green Street, Athens, Georgia, USA (E-mail: [email protected]).

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survey of 28 schools of pharmacy revealed that pain management content was covered in a fragmented manner throughout the latter portion of the curriculum in courses focused on disease management or oncology.12 In another survey, practicing pharmacists in hospital, community, and academic settings were questioned about their attitudes and knowledge about pain and most were satisfied with the provision of care to patients with painful conditions, but many were concerned about opioid abuse, regulatory scrutiny, patient time demands, and dispensing strong opioids.13 The skills laboratory environment is the ideal setting to challenge preconceived ideas, revisit content, and apply principles in mock scenarios. This laboratory exercise is unique because it forces thirdyear (P3) pharmacy students to recall previously acquired knowledge and skills related to aseptic compounding, pharmacokinetics, pharmaceutics, and legal considerations and apply them to an unfamiliar, realistic clinical situation. The students must work through the assignments without direct faculty assistance. This allows all students to learn by doing hands-on activities and independent problem solving. Furthermore, this laboratory session provides to the students activity-based learning for pain management, which is not elsewhere described in the literature. Further, these scenarios more clearly represent real-world pharmacist involvement in these types of patient care activities as compared with didactic teaching methods.

DESIGN Although the analgesia skills laboratory had been delivered on the main campus for several years and on one satellite campus for 2 years, its effects had never been formally studied. In addition, the college expanded from one to two satellite campuses in the fall semester of 2012. Skills laboratory course coordinators on each campus were expected to achieve similar learning outcomes with students. One faculty member on each campus was responsible to deliver the laboratory content and provide feedback to the students; neither pharmacy practice residents nor teaching assistants were available to support the laboratories. The coordinators collaborated for approximately 4 hours in the summer of 2012 to discuss how to best standardize the analgesia laboratory across all campuses and to identify potential barriers to content delivery. For example, intravenous (IV) drug delivery pumps were initially available on only one campus. Another campus had access to an electronic medical record system at a nearby hospital and could gener C

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ate realistic IV labels. The same IV pumps, IV labels, and other supplies were made available on each campus before the semester began and the coordinator on the main campus provided training about pump operation to distance campuses via electronic teleconference (Skype).TM Students on all campuses were assigned the same homework readings and all were required to print the same laboratory handout from the same learning management software (LMS). All students had equal access to electronic drug information resources (e.g., Micromedex [Thomson Healthcare, Greenwood Village, CO], LexiComp [LexiComp, Hudson, OH], and Facts & Comparisons [Wolters Kluwer Health, St. Louis, MO]). Students on the main campus (Athens, n = 110) as well as the two satellite campuses (Albany, n = 5; and Augusta, n = 30) were expected to complete two homework assignments before attending the analgesia laboratory. A 10-page continuing education review article provided a succinct overview of pain pathophysiology, common opioid adverse events, opioid allergies, opioid cross sensitivity, an equianalgesic table, and several application case studies.14 A link to a short YouTube video that reviewed concepts of patient controlled analgesia (PCA) and PCA pumps was also posted on the LMS.15 Finally, students were provided a handout for the in-laboratory activities: Station 1 (fentanyl drip station/Richmond Agitation Sedation Scale [RAAS]16 ), Station 2 (equianalgesic dosing), and Station 3 (hydromorphone PCA compounding). A brief five-question quiz was posted to the course management site on all campuses to assess whether or not students had completed the homework. The skills laboratory was 2 hours in length. Skills laboratory faculty members took 25 minutes at the beginning to review the homework and provide an overview of the laboratory. The hands-on portion of the laboratory was about 60 minutes in length. Students were divided into small groups (one group of five students in Albany, three groups of six students in Athens, and three groups of 10 students in Augusta). Each group was expected to rotate between the three stations every 25 minutes. The laboratory was created to intentionally allow students to struggle and make mistakes. Faculty members on each campus moved between the three stations during the laboratory to observe, answer questions, and provide formative feedback. Students were not formally assessed or graded during the laboratory exercise for two reasons: From a practical standpoint, the faculty members were facilitating the laboratories by themselves and quickly moving from group to group to listen and observe. Additionally, the laboratory was not

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designed to assess competence per se, but instead formatted to force students to consider the ramifications of errors in practice. The final 20 minutes were used by the faculty members to debrief students about successes and challenges as well as the potential consequences of the most commonly occurring mistakes. The postintervention survey was also administered online during this time. Timing of activities between campuses varied slightly because of differences in course enrollments.

Station 1—Fentanyl Drip/RAAS (Appendix 1) This station was staged with an IV pump, an IV stand, and four mock parenteral medications labeled as follows:

• midazolam 100mg/100mL NS – infuse @ 2mL/hr; • fentanyl 5000mcg/250mL NS – infuse @ mL/hr (weight based—see Appendix 1); • doripenem 500mg/100mL NS – infuse over 1 hour; and • pantoprazole 80mg/100mL NS – infuse @ 10mL/hr. Each bag was spiked with a peripheral IV line. A B-Braun Vista (Braun Medical, Bethlehem, PA) IV pump was mounted to the stand; all students had received previous training for pump programming during second-year laboratory. Students were required to evaluate and discuss the short case scenario, respond to the questions, and program the IV pump.

Station 2—Using an Equianalgesic Dosing Table (Appendix 2) This station challenged students to review a hydromorphone PCA order as well as the equianalgesic dosing table from their homework reading to make conversions beginning with the same hydromorphone PCA order that they compounded at Station 3. Students were asked to convert from parenteral hydromorphone to oral morphine and ultimately to oral OxyContin. The case scenario assumed that the patient received 24 mg/24 hours to lessen confusion, allow all students to begin the conversion process from the same point, and facilitate discussion. Each of the other elements such as 4-hour limit, lockout, PCA dose, and continuous infusion were discussed with each group to increase understanding. They were then challenged to conclude by considering the hospital discharge process and how to write the discharge prescription.

Station 3—Compound a Hydromorphone PCA Syringe A PCA order form from University Medical Center Health System was provided at this station.17 The order read as follows: “hydromorphone 0.2mg/mL. Loading dose 0.4mg, PCA dose 0.2mg, lockout interval 10 minutes, 4 hour limit 4 mg, and continuous rate 0.2mg/hr.” Parameters for dose, lockout, and other limits for hydromorphone and other opioids were printed at the bottom of the PCA order and could be used by students to evaluate the appropriateness of the dose. Ten-milliliter vials of normal saline, labeled as hydromorphone for injection 2 mg/mL, 60-mL Luer lock syringes, and liter bags of normal saline with which to dilute to the desired final concentration, were made available. All other necessary supplies for sterile compounding were made available. Students were asked to use aseptic technique to correctly compound a 50-mL hydromorphone PCA syringe as directed by the PCA order. Students were expected to conclude this station by hand writing the accompanying IV label that should be affixed to the syringe in a realistic hospital setting. Faculty members asked students to consider how this syringe would be loaded into a PCA pump and used by the patient according to the PCA order.

EVALUATION AND ASSESSMENT The online survey was completed by students using Qualtrics survey software (Qualtrics, Provo, Utah) before (pre-intervention) and after (postintervention) the analgesia skills laboratory. The survey consisted of 12 evaluation statements: 5 assessed knowledge, 4 assessed self-perceived skill level, and 3 assessed attitudes. Knowledge questions were written in a multiple choice and true-false format. Self-perceived skill and attitude questions were written using a 5-point Likert scale format (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). Students were asked to provide the last five digits of their cell phone numbers; these were used as anonymous survey identifiers to match pre- and post-surveys. Knowledge-based responses were recoded from their original raw scores to either correct or incorrect prior to data analysis. A McNemar test was used to evaluate the pre- and post-intervention change in frequencies of these dichotomous values. Selfperceived skill and attitude responses yielded Likertscale data that were compared using the Wilcoxon signed-rank test. Additionally, investigators wished Journal of Pain & Palliative Care Pharmacotherapy

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TABLE 1. Comparison of Pre-intervention and Post-intervention Correct Scores on Knowledge-Based Items for All Students (N = 135) Correct responses, % Item The more potent opiates are more therapeutically superior Patients who receive opiate analgesics are more at risk to develop drug addictions Patient KC has metastatic prostate cancer and has been taking oxycodone 10 mg, one tablet every 6 hours around the clock for 2 weeks with minimal relief (pain score average 7, range 6–8 throughout the day). What is an appropriate long acting-opiate dose? The general rule of thumb for calculation the dose of breakthrough medication is what percent of the total daily dose of the long-acting agent? Allergies to opiates occur in approximately what percentage of patients? a

Pa

Pre-intervention

Post-intervention

82.2 28.1

88.1 79.3

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Application of opioid analgesia concepts in a third-year pharmacy student skills laboratory on three campuses.

The objective of this study was to evaluate the effects of a skills laboratory exercise focused on principles of opioid analgesia on the knowledge, at...
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