The national opioid epidemic, years in the making, will require more than the effort of government agencies to alleviate.

Deaths from drug overdose last year escalated to an all-time high of more than 63,000 nationwide – killing more Americans than car accidents. These deaths were largely driven by a five-fold increase in deaths involving illicit opioid drugs such as fentanyl and heroin, according to  data released by the Centers for Disease Control and Prevention (CDC) in December 2017. Some of the steepest increases have been in Florida, where Gov. Rick Scott last year declared a public health emergency to draw on federal funding for statewide prevention, treatment and recovery services.

This national opioid epidemic has been years in the making and mitigating its effects will take the effort of more than government agencies. The University of South Florida’s academic medical center has joined medical schools across the country in evaluating and strengthening education and prevention measures needed to help derail the devastating toll taken by the opioid crisis.

Boosting pain management education

In Florida, the USF Health Morsani College of Medicine (MCOM) plays a leading role in providing faculty, residents and students with the tools to address the opioid crisis while caring for patients in acute and chronic pain. USF’s medical college is among nine across the state working together to educate the next generation of physicians in pain management best practices, including appropriate opioid prescribing.  MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group, along with Diane McKay, PsyD, director of behavioral health and assistant professor of psychology at Lake Erie College of Osteopathic Medicine, which has a branch campus in Bradenton, FL.

The group, including members from the state’s six public and three private medical schools, coordinates with Florida’s Surgeon General, policymakers, the state’s allopathic and osteopathic medical associations, and others. Participants are developing a set of core competencies that can be readily integrated into existing curricula to better prepare Florida’s medical students and residents to manage different types of pain, to recognize the risks for addiction and mental health conditions affecting substance abuse, and to safely prescribe opioids when appropriate while keeping pace with changing practice guidelines for pain management.

MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group.

“All our medical schools are already addressing substance abuse and pain management to some extent,” Dr. Bognar said. “Our goal is to fill in any gaps that we find, and also assess that students achieve these competencies, whether through test modules or standardized patient simulations.”

The Florida group has built upon initiatives in Pennsylvania and Massachusetts, states where medical schools have already gone through the exercise of creating core competencies to strengthen pain management education for undergraduate and graduate medical students, Dr. Bognar said.

“Pain management education is an incredibly important pillar in addressing the opioid epidemic,” Dr. Bognar said. “At USF Health, we are teaching future physicians and other health care professionals to be skilled in best practices, so it is incumbent upon us to be part of the solution to this pervasive public health problem.”

“The misuse and abuse of opioids is a serious public health problem because the numbers of individuals, families and communities affected are staggering and the costs are borne by society,” said Donna Petersen, ScD, dean of the USF Health College of Public Health. “Solutions will require a team-based approach to bring various disciplines around the same table for discussion.”

Within a core course taken by all USF public health master’s degree students, Dr. Petersen teaches a new segment on the opioid epidemic that encompasses surveillance of narcotic-related risks and outcomes, effects of opioids on the brain, prescribing practices, roles of law enforcement and the medical community, and changing the conversation of addiction as weakness toward chronic illness.

Donna Petersen, ScD, dean of the USF College of Public Health, says addressing opioid misuse and abuse will require a team approach.

With a focus on interprofessional collaboration among its colleges of medicine, nursing, public health and pharmacy and school of physical therapy, USF Health faculty members are also looking for ways to bring students together as teams to learn about the complexities of substance abuse and pain management within the context of the opioid epidemic. Led by Tricia Penniecook, MD, MPH, vice dean for education at the College of Public Health, an Interprofessional Education Workgroup on Opioids was recently formed at USF Health to develop and implement common teaching modules to address the issue comprehensively.

Taking the lead in opioid prescribing practices

The Morsani College of Medicine is one of the first medical schools in Florida to develop clinical practice guidelines for opioid prescribing, said Charles J. Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine.

The current opioid crisis emerged following substantial increases in per-capita frequency and dosages of prescription opioids, a trend begun in the late 1990s. Researchers hypothesize that this increase was due in part to palliative care experts seeking to address the burden of chronic pain without sufficient evidence of either the long-term effectiveness or risks of opioid dependence. The Joint Commission’s classification of pain as a “fifth vital sign” contributed to hospitals and physicians seeking to improve patient satisfaction scores through aggressive pain relief – sometimes without managing patient and family expectations of a pain-free experience.

Charles Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine, has written editorials on opioid abuse and how obstetrician-gynecologists can help prevent it for February and March 2018 issues of Contemporary OB/GYN.  Dr. Lockwood is editor-in-chief of the publication.  | Photo by Sandra C. Roa

While doctors now prescribe opioids less often, the overall rates remain high and vary substantially across the country, a recent CDC surveillance report indicates. In 2016 prescribers wrote 66.5 prescriptions for every 100 people, down from 72.4 in 2006; however the prescribing rate remains three times as high as in 1999 and the average days of drug supply for each opioid prescription continues to trend upward.  The explosion of opioid prescribing in this decade has contributed not only to rising emergency department and hospital admissions and overdose deaths — but also to far-reaching psychosocial ills. A USF-led study published in the January 2018 issue of Health Affairs found an association between the rate of opioid prescriptions in Florida and the alarming number of children placed into foster care.

“Physicians can play a critical role in curbing the epidemic by returning to our traditionally stringent criteria for opioid prescriptions, using a multimodality, non-opioid approaches to chronic pain management and by better understanding opioid pharmacology,” said Dr. Lockwood, who, as editor-in-chief of Contemporary OB/GYN, has written editorials on opioid abuse and how Ob-Gyns can prevent it for the publication’s February and March 2018 issues.

The USF Health proposed guidelines clearly lay out for all practitioners who “prescribe, administer or dispense” controlled substances — including opioid medications such as OxyContin, morphine and fentanyl, to name a few — evidence-based standards for safely treating pain. Among other provisions, they specify recommended prescribing limits and exceptions, strongly encourage practitioners to complete approved continuing education training on pain management and addiction, and recommend that conservative and non-drug alternatives be considered to control non-cancer pain.

Mark Moseley, MD, chief medical officer for USF Health Care, says the new guidelines are intended to reinforce prescribing and practicing in a safe and thoughtful way.

The executive board of USF Health Care, the university’s multispecialty faculty practice group, is expected to approve the guidelines in February.  Mark Moseley, MD, chief medical officer for USF Health Care, and Kevin Sneed, PharmD, dean of the USF Health College of Pharmacy, led development of the guidelines with input from faculty leaders in neurology, psychiatry, pharmacy, nursing, physical therapy and legal counsel.

Creating a culture of patient safety

“Our intent is to reinforce evidence based prescribing and practicing in a safe and thoughtful way, given that these (opioid) drugs can be highly addictive in some,” Dr. Moseley said.

“At USF Health we are creating a culture of safety and putting the patient first, and these guidelines are important in setting that expectation,” Dr. Sneed said. “Ultimately, we have to be mindful about not creating an unintended problem while trying to treat a (pain-related) problem. Opioids are not a long-term solution for managing chronic pain.”

When prescribed prudently opioids are useful in helping physicians relieve pain, especially extreme pain or the chronic pain suffered by cancer patients at the end of life.  But research on the long-term effectiveness of these agents for chronic pain relief has been inconclusive or suggests ineffectiveness, and some studies indicate misuse and abuse of the prescription painkillers has led to a rise in addiction and overdose deaths from heroin.

Kevin Sneed, PharmD, dean of the USF College of Pharmacy, says opioids are not a long-term solution for managing chronic pain.

“Opioids as a class of medications are an important tool in our full armamentarium of pharmacological agents,” said Dr. Moseley, an emergency physician. “If you come into the emergency room with a broken bone, I need to have that as an option to give some immediate relief… but for a patient with back pain there may be more appropriate and effective options than prescribing three months of highly potent opiate medication.”

Both Dr. Moseley and Dr. Sneed agree that non-medication alternatives like exercise, physical therapy and biobehavioral treatments should be considered and discussed when evaluating an individual’s condition.

“Patients want their physicians to have an open discussion with them about how to best manage their pain,” Dr. Moseley said. “Most are pretty agnostic of the modality used if you can help alleviate the pain.”

CRNA advanced pain management fellowship among nation’s first

A USF Health College of Nursing postgraduate program for practicing certified registered nurse anesthetists (CRNAs) was granted accreditation in August by the Council on Accreditation of Nurse Anesthesia Educational Programs.

The distinction makes the nursing school’s Simulation-Based Academic Fellowship in Advanced Pain Management one of four such specialty fellowship programs for nurse anesthetists in the United States and the only one in Florida, said John Maye, PhD, CRNA, the fellowship program’s coordinator. The program, combining online courses with an intensive simulation clinical experience at the USF Health Center for Advanced Medical Learning and Simulation (CAMLS), will graduate its first class of 25 fellows this spring, including some from rural areas of America hit hard by the opioid epidemic.

John Maye, PhD, right, coordinator of the USF College of Nursing’s Simulation-Based Academic Fellowship in Advanced Pain Management, with Erik Rauch, DNP, center, and Alan Todd, DNP — all members of the college’s nurse anesthesia faculty. In this simulation exercise they are evaluating vertebral column anatomy. | Photo by Ryan Noone

CRNAs work with physicians to provide anesthesia and related care to patients before, during and after diagnostic, surgical or obstetric procedures. They can order and administer controlled substances based on state law and/or facility-specific protocols.

New research reported last year in JAMA Surgery cited an under-recognized complication of perioperative care among certain patients who never used opioids before surgery – whether they undergo minor or major procedures, some prescribed these painkillers for postsurgical relief may face a risk for developing opioid addiction.

Health care practitioners traditionally receive minimal exposure to the science of pain medicine, yet education is a “huge part” of preventing or reducing pain without inadvertently promoting opioid dependence, Dr. Maye said. “Our fellowship program focuses on educating CRNAs to understand the transmission of pain within the central and peripheral nervous systems and how specific drugs other than opioids can be used to help control that pain perioperatively.”

But last October, she toured USF’s soon-to-open Center for Advanced Medical Learning and Simulation (CAMLS). Tour guides for the framed out space promised suites filled with state-of-the-art equipment for learning and practicing a range of medical procedures. They noted how the $38 million facility was the only one of its kind and that the 90,000-square-foot building would bring an unprecedented level of technical and teamwork training, simulation and competence assessment under one roof, as well as significant research and device innovation capability.

Lloyd Ohls and Hayley Suratt practice critical operating room skills at CAMLS.

So when USF asked her to join its CRNA program, her choice was easy, she said.

“CAMLS solidified my decision that USF is where I want to go,” said Marciano, who is currently a nurse at Shands Hospital in Gainesville. “I know the level of education I’ll receive at USF will put me way above other programs. The training I’ll get is incomparable. How can you even compare?”

Marciano is one of 33 students who will start the graduate-level course this fall. This CRNA group is the College of Nursing’s largest since it recently added 13 spaces to the 6-year-old program –a 40 percent increase from last fall. To help meet the demand, the College has added three new graduate level simulation courses and doubled its faculty.

A STRONG REPUTATION FOR QUALITY
In 2011, USF’s CRNA program received a full 10-year reaccreditation from the Council on Accreditation of Nurse Anesthesia Educational Programs. The program’s graduates have an overall licensure exam pass rate of 100 percent with a first-time pass rate of 89 percent. In addition, the program boasts an employment rate of 100 percent for its graduates.

Those milestones, coupled with the move to CAMLS, have pushed the recent surge in growth and meant a spike in the number of applications, said Erik Rauch, DNP, CRNA, assistant professor and director of the Nurse Anesthesia Concentration at the USF College of Nursing.

“Word is definitely getting out about the quality of our program and our connection with CAMLS has really put us in the national spotlight,” Dr. Rauch said. “We’re drawing a lot of interest and have seen a huge increase in the number of applications, especially from beyond our state. Nearly half of this new class of 33 is from outside of Florida, representing nine other states, as well as Guam.”

“The USF College of Nursing is nationally recognized for our cutting-edge research, and innovative educational programs,” said Dianne Morrison-Beedy, PhD, RN, WHNP-BC, FNAP, FAANP, FAAN, senior associate vice president for USF Health and dean of the College of Nursing. “We are proud to have one of only 112 accredited nurse anesthesia programs in the nation. With the recent move to USF CAMLS, our nurse anesthesia faculty and students have access to world-class simulation technology, including both civilian and military patient simulators, that establishes USF as the leader for nurse anesthesia education and training in the Southeastern United States.”

THE ADVANTAGE IS THE TRAINING
Although the young CRNA program has always had simulation built into its curriculum, its new home at CAMLS offers an entirely new environment with more simulation equipment offering greater specialization, including training suites with 20 anesthesia scenarios.

CRNA student Charlotte Symonds uses CAMLS simulation to perfect skills under watchful eyes of CRNA program Director Dr. Erick Rauch and fellow student Chad Koerlin.

“USF nurse anesthesia students train on the most advanced, high-fidelity patient simulation in the nation through CAMLS,” said Rita F. D’Aoust, PhD, ANP-BC, CNE, FAANP, associate dean for Academic Affairs, director for Interprofessional Initiatives at the USF College of Nursing.

“And through CAMLS, our students also have opportunities for interprofessional experiences that will give them a decided advantage when they enter their profession. Training with those additional scenarios will help our graduates feel very comfortable when they get to a real hospital setting and the OR. And it’s not just about the scenarios, but about building and practicing strong communications and teamwork skills that will truly make the difference.”

That is exactly the feeling of Michael Lupari, who is a senior in the USF CRNA program.

“Simulation provides the backbone for training anesthetic providers by creating real-life scenarios for rehearsing common and life-threatening problems without any risk to a real patient,” said Lupari, who was a critical care nurse in Fort Lauderdale before moving to Tampa to attend USF.

“As nursing and medical education changes its paradigm to a competency-based curriculum it has become increasingly important to evaluate ability using simulation. On a much larger scale, the public has been the major impetus for these changes as they demand more qualified and competent providers in the medical industry.  One way to meet these changes head-on is through the use of simulation.”

Joanna Bailey, Lloyd Ohls, Hayley Suratt, and Chad Koerlin build important team communication skills at CAMLS

Bolstering that training are three new simulation courses the College was recently approved for and will incorporate into its curriculum starting Fall 2012.

“These new courses complement our desire to offer a unique simulation addition to our anesthesia didactic courses that are already in place,” Dr. Rauch said. “They will allow students to apply everything they are learning in their courses to a simulation operating room environment prior to ever stepping foot in a real operating room. This is a huge benefit to promoting a higher quality education and preparing the most qualified nurse anesthetists upon graduation, which ultimately equates to higher quality care and patient safety.”

A HIGH-DEMAND JOB OPPORTUNITY
A nurse anesthetist is a nurse who has acquired graduate-level education for the administration of anesthesia and is board certified.

CRNAs practice in every setting in which anesthesia is delivered, from traditional hospital surgical suites and obstetrical delivery rooms to offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists, as well as with the U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities. CRNAs are the sole anesthesia providers in nearly half of all hospitals and more than two-thirds of the rural hospitals in the United States. Nurse anesthetists also serve our country by providing 100 percent of all anesthetics for the United States Army frontline facilities.

“CRNA’s are in high demand and carry a heavy load of responsibility, but they can expect to be compensated accordingly,” Dr. D’Aoust said. “There are great job opportunities, high autonomy and responsibility, and compensation.”

“Not only do CRNA’s provide more than half of the anesthesia in the nation, they are also the main providers of anesthesia care to U.S. military personnel on the front lines,” Dr. Morrison-Beedy said. “At USF, we have veterans and reservist faculty in our nurse anesthesia program who bring their knowledge and skills of military health issues to train CRNA’s in high demand by all the military services.”

Training nurses for all of these environments before they graduate is the differentiating factor for the USF program. And that difference comes directly from CAMLS, Dr. Rauch said.

“Almost everything we do in the classroom will be coupled with simulation training at CAMLS,” he said. “CAMLS is now THE greatest resource in the country for nursing.”

That fact is front and center for incoming student Marciano. She said she knows her choice to go with USF will help her stand out when it comes to finding a job because the program is that much better.

“I have several friends who are heading to CRNA programs all across the country,” she said. “After hearing about my decision and about USF and about CAMLS, now they’re all saying ‘I wish I had known about that!’ “

Story by Sarah A. Worth, USF Health Office of Communications.
Photos by Ashlea Hudak, USF College of Nursing Communications.