Interprofessional Education for the Dentist in Managing Acute and Chronic Pain

Dental education is at the intersection of affordable health care, opioid-abuse crisis, and collaborative practice benefits. Students must engage in interprofessional education (IPE) for pain management. Graduates must recognize appropriate management of acute dental pain and understand the dentist’s role in interprofessional treatment of chronic disease, including management of temporomandibular disorders and orofacial neuropathic pain, chronic pain in general, and the consideration of opioids. This article reviews accreditation standards, compares these standards with recommendations from the International Association for the Study of Pain and regulatory boards, and presents examples of enhanced pain education.

Key points

  • A symbiotic relationship exists between control of chronic disease and dental health, especially pain management; neither can be achieved without the other.

  • Health care members in collaborative practice must understand the diagnosis and evidence-based treatment standards for patients and the roles of fellow health care collaborators in meeting those standards.

  • The treatment standards for pain management build on educational standards, such as those of the Commission on Dental Accreditation, to create collaborative practice standards, such as those of the International Association for the Study of Pain.

  • Faculty development is necessary for teaching effective pain management skills in an interprofessional education program.

  • Licensure and accreditation requirements should reinforce an interprofessional focus for pain management education in preparation for collaborative practice of patient-centered care.

Collaborative practice in health care occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, insurance carriers, communities, and each other to deliver the highest quality of care across clinical settings. Interprofessional education (IPE) is defined as 2 or more professions learning from and about each other to improve collaboration and the quality of care. IPE is in contrast with a more traditional model involving different departments within the same profession (eg, medical departments of surgery, anesthesia, neurology; or dental departments of oral surgery, restorative dentistry, and periodontics) potentially teaching the same subject but from different disciplinary perspectives.

IPE is today’s buzzword in health care education. At a time when effective collaborative practice is a target for addressing the opioid crisis. Pain management is complex, often requiring collaborative approaches that exceed the expertise of any single profession. As such, IPE is a critical advancement for effective pain management education and practice. Guidelines for pain management education to prepare health professionals to function in a collaborative practice are available and summarized in Box 1 .

Box 1

  • 1.

    Work with individuals of other professions to maintain a climate of mutual respect and shared values.

  • 2.

    Use the knowledge of one’s own role and the roles of other professions to appropriately assess and address the health care needs of the patients and populations served.

  • 3.

    Communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease.

  • 4.

    Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient-centered care that is safe, timely, efficient, effective, and equitable.

Interprofessional collaborative practice competencies
Data from Barr H, Freeth D, Hammick M, et al. Evaluations of interprofessional education: a United Kingdom review for health and social care. London: Centre for the Advancement of Interprofessional Education with the British Educational Research Association; 2000. Available at: caipe.org.uk/silo/files/evaluations-of-interprofessional-education.pdf . Accessed March 30, 2016.

This article reviews how national, state, and local institutions are influencing pain management standards and the teaching of these standards, specifically in response to the opioid crisis, for dentistry and other health care disciplines. Innovations in IPE pain management education at Boston-based health care institutions are presented. In addition, current and proposed accreditation standards and their influence on the preparation of health care providers to implement effective pain management are discussed as supportive evidence for an IPE collaboration to manage pain.

From where does this movement for interprofessional education in pain management arise?

Standards for both acute and chronic pain management are being reviewed and updated at the national, state, and local level. The Federal Drug Administration, National Institutes of Health (NIH), and organizations such as the International Association for the Study of Pain (IASP), the American Academy of Pain Medicine (AAPM), and the American Dental Association (ADA), have outlined goals for pain management education involving IPE.

At the national level, and in response to the Institute of Medicine (IOM) 2011 report calling for a transformation in pain prevention, care, education, and research, the NIH commissioned a National Pain Strategy report that was released in 2015 ( iprcc.nih.gov/docs/drafthhsnationalpainstrategy.pdf ). In particular, this report outlines professional education and training principles in pain management, as well as highlights the core competencies in pain education developed by an interprofessional consensus summit in 2013. As stated in the National Pain Strategy draft report, “The intent of the professional education and training component of the National Pain Strategy is to anchor an attitudinal transformation toward pain and a reorganization of pain management by the health care system, in the education… and training of health professionals. The mission includes grounding the pain-related education and training of physicians, nurses, clinical pharmacists, dentists, clinical health psychologists, physician’s assistants, nurse practitioners, and other health professionals in core competencies, and making available easily accessible, evidence based information for educators to work toward this goal.”

On a state level, one can appreciate recent changes in such guidelines when comparing the Washington State Guidelines of 2015 to those of 2010 ( Table 1 ). The guidelines now refer to management of all phases of pain (eg, acute, perioperative, chronic, special populations) and stress a diagnosis-based pharmacotherapy for pain treatment. The state of Massachusetts also updated its advisory for dentists prescribing controlled medications in 2011 and issued a Special Report on Prescribing in Dentistry in 2015. The advisory stresses the principles associated with effective pain management, identification of patients at risk for misuse of controlled medications, and informed consent for the use of opioids in the patient’s treatment plan. The special report outlines the Massachusetts Prescription Monitoring Program. The Massachusetts Boards of Medicine and Dentistry now require continuing education in pain management for license renewal ( Box 2 ). The goals and objectives are given in a lecture that fulfills this licensure requirement. Recently, the governor of Massachusetts convened a working group of educators, Governor’s Medical Education Working Group on Prescription Drug Misuse, and tasked them to develop improved pain education standards for the states’ medical schools. Dental educators from the Boston dental schools also contributed to this effort.

Table 1
Comparison of Washington state agency medical directors’ group’s interagency opioid guidelines from 2010 to 2015
2010 Guideline 2015 Guideline
Primary focus on chronic noncancer pain Expands focus to include opioid use in acute, subacute, and perioperative pain phases, and in special populations
Includes sections on tapering and opioid use disorder
  • 2 main sections

    • I.

      Initiating, transitioning, and maintaining patients on COAT with principles of safe prescribing

    • II.

      Optimizing treatment of patients on >120 mg daily MED with brief sections on getting consultations, aberrant behaviors, tapering, and discontinuing COAT

  • New and modified sections

    • 1.

      Recommendations for all pain phases

      • a.

        Clinically meaningful improvement in function

      • b.

        Expanded discussion on dosing threshold

      • c.

        Nonopioid options for pain management

    • 2.

      Opioids in the acute and subacute phases

    • 3.

      Opioids for perioperative pain

    • 4.

      Opioids for chronic noncancer pain (similar to previous guideline)

    • 5.

      New section on reducing or discontinuing COAT

    • 6.

      New section on recognition and treatment of opioid use disorder

    • 7.

      New sections on opioid use in special populations (during pregnancy and neonatal abstinence syndrome, in children and adolescents, in older adults, and in cancer survivors)

  • Appendices

    • A.

      Opioid dose calculations & calculator

    • B.

      Screening tools

    • C.

      Tools to assess pain and function

    • D.

      Urine drug testing for COAT

    • E.

      Consultative assistance for Washington state payers

    • F.

      Patient education resources

    • G.

      Sample doctor-patient agreement for COAT

    • H.

      Additional resources to streamline clinical care

    • I.

      Emergency department opioid guidelines

  • Appendices

    • A.

      Opioid dose calculations & calculator

    • B.

      Renamed: Validated risk factor screening tools and combined former appendices B and C

    • C.

      How to use the prescription monitoring program

    • D.

      Urine drug testing for COAT

    • E.

      Chronic pain syndromes in cancer survivors

    • F.

      Diagnosis-based pharmacotherapy for pain

    • G.

      Patient education resources (updated)

    • H.

      Renamed: Clinical tools and resources and combines former appendices G, H, and I

    • I.

      Guideline development and Agree II criteria

Recommended 120 mg daily MED as a yellow-flag dose as a strategy to prevent adverse events and overdose by advising providers to seek a consultation with a pain specialist Remains the same, plus adds guidance for safe prescribing at any dose, based on new studies showing significant risks occurring at lower doses
Organized as narrative information and recommendations with evidence in citations Organized with each section having specific clinical recommendations with supporting narrative evidence sections with citations
Abbreviations: COAT, chronic opioid analgesic therapy; MED, morphinr equivalent dose.
From Washington State agency medical directors’ group’s interagency opioid guidelines (AMDGO). Available at: www.agencymeddirectors.wa.gov/guidelines.asp .

Box 2

  • The attendee should

  • 1.

    Understand the principles of acute pain management

  • 2.

    Understand how to recognize the problem patient (drug seeker, at-risk patient)

  • 3.

    Be able to address acute pain for a patient with chronic pain

  • 4.

    Understand principles of pain management for the elderly and pediatric dental patient

Goals and objectives for mandatory dental pain management continuing education
From O’Neal M, editor. The ADA practical guide to substance use disorders and safe prescribing. Hoboken (NJ): Wiley-Blackwell; 2015; with permission.

From where does this movement for interprofessional education in pain management arise?

Standards for both acute and chronic pain management are being reviewed and updated at the national, state, and local level. The Federal Drug Administration, National Institutes of Health (NIH), and organizations such as the International Association for the Study of Pain (IASP), the American Academy of Pain Medicine (AAPM), and the American Dental Association (ADA), have outlined goals for pain management education involving IPE.

At the national level, and in response to the Institute of Medicine (IOM) 2011 report calling for a transformation in pain prevention, care, education, and research, the NIH commissioned a National Pain Strategy report that was released in 2015 ( iprcc.nih.gov/docs/drafthhsnationalpainstrategy.pdf ). In particular, this report outlines professional education and training principles in pain management, as well as highlights the core competencies in pain education developed by an interprofessional consensus summit in 2013. As stated in the National Pain Strategy draft report, “The intent of the professional education and training component of the National Pain Strategy is to anchor an attitudinal transformation toward pain and a reorganization of pain management by the health care system, in the education… and training of health professionals. The mission includes grounding the pain-related education and training of physicians, nurses, clinical pharmacists, dentists, clinical health psychologists, physician’s assistants, nurse practitioners, and other health professionals in core competencies, and making available easily accessible, evidence based information for educators to work toward this goal.”

On a state level, one can appreciate recent changes in such guidelines when comparing the Washington State Guidelines of 2015 to those of 2010 ( Table 1 ). The guidelines now refer to management of all phases of pain (eg, acute, perioperative, chronic, special populations) and stress a diagnosis-based pharmacotherapy for pain treatment. The state of Massachusetts also updated its advisory for dentists prescribing controlled medications in 2011 and issued a Special Report on Prescribing in Dentistry in 2015. The advisory stresses the principles associated with effective pain management, identification of patients at risk for misuse of controlled medications, and informed consent for the use of opioids in the patient’s treatment plan. The special report outlines the Massachusetts Prescription Monitoring Program. The Massachusetts Boards of Medicine and Dentistry now require continuing education in pain management for license renewal ( Box 2 ). The goals and objectives are given in a lecture that fulfills this licensure requirement. Recently, the governor of Massachusetts convened a working group of educators, Governor’s Medical Education Working Group on Prescription Drug Misuse, and tasked them to develop improved pain education standards for the states’ medical schools. Dental educators from the Boston dental schools also contributed to this effort.

Table 1
Comparison of Washington state agency medical directors’ group’s interagency opioid guidelines from 2010 to 2015
2010 Guideline 2015 Guideline
Primary focus on chronic noncancer pain Expands focus to include opioid use in acute, subacute, and perioperative pain phases, and in special populations
Includes sections on tapering and opioid use disorder
  • 2 main sections

    • I.

      Initiating, transitioning, and maintaining patients on COAT with principles of safe prescribing

    • II.

      Optimizing treatment of patients on >120 mg daily MED with brief sections on getting consultations, aberrant behaviors, tapering, and discontinuing COAT

  • New and modified sections

    • 1.

      Recommendations for all pain phases

      • a.

        Clinically meaningful improvement in function

      • b.

        Expanded discussion on dosing threshold

      • c.

        Nonopioid options for pain management

    • 2.

      Opioids in the acute and subacute phases

    • 3.

      Opioids for perioperative pain

    • 4.

      Opioids for chronic noncancer pain (similar to previous guideline)

    • 5.

      New section on reducing or discontinuing COAT

    • 6.

      New section on recognition and treatment of opioid use disorder

    • 7.

      New sections on opioid use in special populations (during pregnancy and neonatal abstinence syndrome, in children and adolescents, in older adults, and in cancer survivors)

  • Appendices

    • A.

      Opioid dose calculations & calculator

    • B.

      Screening tools

    • C.

      Tools to assess pain and function

    • D.

      Urine drug testing for COAT

    • E.

      Consultative assistance for Washington state payers

    • F.

      Patient education resources

    • G.

      Sample doctor-patient agreement for COAT

    • H.

      Additional resources to streamline clinical care

    • I.

      Emergency department opioid guidelines

  • Appendices

    • A.

      Opioid dose calculations & calculator

    • B.

      Renamed: Validated risk factor screening tools and combined former appendices B and C

    • C.

      How to use the prescription monitoring program

    • D.

      Urine drug testing for COAT

    • E.

      Chronic pain syndromes in cancer survivors

    • F.

      Diagnosis-based pharmacotherapy for pain

    • G.

      Patient education resources (updated)

    • H.

      Renamed: Clinical tools and resources and combines former appendices G, H, and I

    • I.

      Guideline development and Agree II criteria

Recommended 120 mg daily MED as a yellow-flag dose as a strategy to prevent adverse events and overdose by advising providers to seek a consultation with a pain specialist Remains the same, plus adds guidance for safe prescribing at any dose, based on new studies showing significant risks occurring at lower doses
Organized as narrative information and recommendations with evidence in citations Organized with each section having specific clinical recommendations with supporting narrative evidence sections with citations
Abbreviations: COAT, chronic opioid analgesic therapy; MED, morphinr equivalent dose.
From Washington State agency medical directors’ group’s interagency opioid guidelines (AMDGO). Available at: www.agencymeddirectors.wa.gov/guidelines.asp .

Box 2

  • The attendee should

  • 1.

    Understand the principles of acute pain management

  • 2.

    Understand how to recognize the problem patient (drug seeker, at-risk patient)

  • 3.

    Be able to address acute pain for a patient with chronic pain

  • 4.

    Understand principles of pain management for the elderly and pediatric dental patient

Goals and objectives for mandatory dental pain management continuing education
From O’Neal M, editor. The ADA practical guide to substance use disorders and safe prescribing. Hoboken (NJ): Wiley-Blackwell; 2015; with permission.

Why is understanding the management of the chronic pain patient important for dentists?

Opioid treatment is an increasingly common form of therapy for patients with a history of chronic pain. Ninety percent of physicians who specialized in pain medicine (pain physicians) reportedly maintain patients with nonmalignant pain on opioids. As many as 40% of patients with temporomandibular disorder (TMD) seen in a tertiary care setting can be refractive to treatment. This compares with 30% to 40% of facial neuralgia patients who do not respond to medical management with medications and/or surgery. Providers, with the goal of improving function and quality of life for these patients, must consider the use of opioids in the patient’s management regimen.

Dentists are in a unique position to have an impact on managing chronic disease because they have regular contact with their patients and commonly address issues of preventive health and wellness. This places the dental provider in a critical decision-making role for the treatment of these patients because oral health care is intimately associated orofacial pain diagnosis and treatment. They must advise the pain physician; the rheumatologist; the ear, nose, and throat surgeon; and/or the primary care provider (PCP) on appropriate interventions. They must provide care and management as necessary and decide when maximum medical benefit of physical treatments for these patients is reached. PCPs, pain physicians, and other medical providers often do not have the dental and facial pain expertise to properly evaluate these patients. Dental providers with appropriate training in pain management are best positioned to provide the service of assessment for opioid therapy on orofacial pain patients not responsive to treatment.

Chronic opioid prescribing for nonmalignant pain is controversial. The arguments for and against are compelling. However, even though a provider is not prescribing controlled medications to the patient, all providers must understand the current standards of care for opioid prescribing, the use of screening devices to identify those at risk for substance abuse, and the protocols for getting an at-risk patient the treatment needed. Following these standards of care for opioid prescribing can give confidence to the provider and remove the angst associated with treating patients who are on these medications.

Therefore, dentists have a prominent role in managing a significant part of society’s pain burden; in particular, the diagnosis and treatment of acute dental pain and chronic orofacial pain problems, such as TMDs, trigeminal neuralgia, tension headaches, and neuropathic pain affecting oral tissues. Dental education must promote the ability for both students and graduates to function in today’s collaborative practice, with the goal that all health care providers will have confidence when treating patients who suffer from these dental pain problems. An IPE approach in the principles of pain management allows this goal to be achieved.

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Oct 25, 2016 | Posted by in General Dentistry | Comments Off on Interprofessional Education for the Dentist in Managing Acute and Chronic Pain
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