Peers Helping Peers

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Opportunities for guidance in pain management

The Ontario Partnered Support Table is a group of health system agencies intent on ensuring physicians have the support they need to feel more confident caring for patients with pain. In this issue, we examine the services offered by Project ECHO, the Centre for Effective Practice, and the Ontario College of Family Physicians’ Medical Mentoring for Addiction and Pain Network.

Caring for patients with opioid addiction and chronic pain can be challenging in the context of a family practice. A physician with limited experience could understandably feel overwhelmed and discouraged when trying to provide the best care for patients with these issues.

There is reason to feel heartened, however. The following organizations have developed opportunities to connect family physicians to other health-care professionals who can offer the guidance they need.

Project ECHO

Since its inception in 2014, nearly 400 health-care professionals across the province have taken advantage of the “think tank” known as Project ECHO.

The heart of the ECHO model is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point videoconferencing to conduct virtual clinics with community providers. In this way, primary care doctors, nurses, and other clinicians learn to provide excellent specialty care to patients in their own communities.

Here’s how it works. A team of experts in chronic pain (the hub) conduct weekly two-hour videoconferences for primary care professionals (the spokes) using the Ontario Telemedicine Network. The two academic hubs involved are Queen’s University and the University Health Network. Along with MDs, the experts include allied health professionals like a pain psychologist, physiotherapist, social worker, occupational therapist, pharmacist and nurse. The spokes present de-identified cases and get treatment suggestions. In any given session, as many as 25 partner health-care sites attend. Spokes can be individuals or teams, including doctors, nurse practitioners, nurses, pharmacists and physician assistants. The sessions are educational as opposed to being a clinical consultation and there are 20 sessions in each curriculum cycle.

Aside from weekly ECHO sessions, evening sessions on opioid tapering are also offered.

Medical Mentoring for Addiction and Pain (MMAP) Network

The Ontario College of Family Physicians launched the Collaborative Mentoring Networks (CMN) in 2001 to create opportunities in mentorship for Ontario’s family physicians. After the successful launch of the Collaborative Mental Health Network (CMHN), which focuses on mental health, there was high demand and interest from family physician members for a mentoring network focused on chronic pain and addictions. These two areas have been — and continue to be — consistently identified by family physicians as extremely challenging clinical issues. With the emergence of the opioid crisis in recent years, the importance and value of the knowledge and mentoring within the Medical Mentoring for Addictions and Pain (MMAP) Network has only intensified.

The MMAP Network was launched in 2007, providing mentoring support that connects family physicians anywhere in Ontario with regional experts in chronic pain and addictions. Advice, mentorship and support from these experts are available at network members’ convenience to help navigate complexities in managing chronic pain, addictions and the current challenges around opioid prescribing.

The mentees can choose to engage in a one-to-one format, or in small or large groups. These interactions can take place in person, via telephone, email or an online community of practice, in addition to regional conferences and meetings that take place throughout the year in Ontario. The format of the mentoring sessions can also be adjusted throughout the mentoring relationship to account for the guidance needed, frequency, location and schedules as well.

“The element that makes our Collaborative Mentoring Networks so powerful and unique is the way we construct the mentoring relationship; we’re able to make the mentoring experience dynamic and responsive to our network members’ individual needs, creating a supportive, safe and compassionate space for them,” said Dr. Arun Radhakrishnan, a family physician with a clinical focus on chronic pain who is the co-chair of the MMAP network and the Clinical Lead of the CMN.

Currently, MMAP has 32 mentors and 336 mentees in communities across Ontario, including urban, rural and remote settings. Many of the mentees also choose to become mentors. With additional government funding, MMAP is looking to bring in more mentees and mentors over the next 18 months.

Mentees can use the mentorship services at no cost whenever they need to, at their convenience and earn continuing professional development credits in the process. It is entirely up to the mentees as to how long they want to stay in the networks, in fact, there are many mentees who have been enrolled in the program since it launched almost 12 years ago.

Centre for Effective Practice

Academic Detailing for primary care and the Knowledge Translation in Primary Care Initiative are two projects led by the Centre for Effective Practice (CEP) to help primary care providers deliver high-quality care to their patients. The Knowledge Translation in Primary Care Initiative focuses on the development of evidence-based clinical tools for primary care providers, some of which have been downloaded by more than half of Ontario’s primary care providers. The academic detailing service is a natural extension to implement these clinical tools.

Academic Detailing

In effect since March 2018, CEP’s primary care academic detailing service is unique from other forms of educational outreach or continuing professional development with its emphasis on an interactive discussion style that focuses on the specific needs and questions of the participating family physician. Academic detailing service visits are scheduled at a time and place convenient to the physician (e.g. usually in their clinic office).

The CEP’s academic detailers are all clinical pharmacists with strong foundational experience in pharmacotherapy and clinical evidence appraisal. The detailers undergo comprehensive training in clinical evidence relevant to the topics they deliver as well as skills development to assess and understand physicians’ clinical needs and practice barriers.

Because the service has, to date, focused on topics with a strong pharmacology component, pharmacists were identified as the best equipped to deliver this knowledge to family physicians, many of whom do not have regular access to a pharmacist.

During each visit, academic detailers concentrate on understanding the physician’s specific needs and tailoring the information accordingly. The information covered during a visit can include talking tips for leading challenging conversations with patients regarding their management options and treatment expectations, approaches to initiating, monitoring and tapering medications, putting in place safeguards and harm reduction strategies for patients on medications, or navigating local resources for patients that are geographically and financially accessible. Academic detailers also equip participating family physicians with relevant clinical tools developed by the CEP.

There are currently 18 academic detailers who have provided visits to more than 590 family physicians across eight LHINs including Erie St. Clair, South West, Waterloo Wellington, Hamilton Niagara Haldimand Brant, Mississauga Halton, Toronto Central, North West and North East LHINs. CEP is also seeing referrals into the service, from participating physicians to their colleagues, and information sharing within practices, which is a positive effect as a result of the program.

The service is free for family physicians. Interested family physicians can learn more and sign up for a visit here.

Knowledge Translation in Primary Care Initiative

In addition to creating an academic detailing network, the CEP continues to provide clinical tools and health information resources for physicians through its work with the Knowledge Translation in Primary Care Initiative, which is a collaboration with the Ontario College of Family Physicians (OCFP) and the Nurse Practitioners’ Association of Ontario (NPAO).

From updating the CORE Back Tool to introducing the Management of Chronic Non-Cancer Pain Tool and integrating it into EMRs, the CEP’s work helps further address the management plans by Ontario doctors. All of the tools below can be found on the website of the Centre for Effective Practice. The CPSO’s website also includes links to these resources and others in order to provide support and assistance to physicians.

The Management of Chronic Non-Cancer Pain Tool

This tool is designed to assist primary care providers develop and implement a management plan for adult patients living with chronic non-cancer pain. This tool encourages primary care providers, where appropriate, to use a combination of non-pharmacological and pharmacological options to build a comprehensive and personalized plan that incorporates the patient’s goals.

The tool reflects recommendations from the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain and provides supporting materials and resources for patients and providers.

Opioid Manager

The Opioid Manager is specifically designed to support primary care providers prescribe and manage opioids for patients with chronic non-cancer pain. This is an update of the original Opioid Manager tool which includes feedback from primary care providers and recommendations from the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain.

Opioid Tapering Template

This tool recognizes that opioid tapering is a complex process, and is designed to assist primary care providers develop tapering plans with their patients and adjust those plans as their patients’ needs change due to pain, function and withdrawal symptoms. Throughout the tool, providers will find helpful talking points, fillable forms and links to relevant resources including those created by the CEP as part of its pain management suite of clinical tools.

Opioid Use Disorder (OUD) Tool

This tool was developed to walk primary care providers through screening, diagnosing, treating and communicating with patients who have, or are at risk of developing, OUD. The tool emphasizes a stigma-free and empathetic approach that acknowledges OUD as a chronic illness requiring long-term chronic disease management.

In order to navigate difficult conversations about opioid misuse, the CEP has included talking points throughout the tool that address patient education, safety, expectations and goals.

Clinically Organized Relevant Exam (CORE) Back Tool

This tool builds from the Ministry of Health and Long-Term Care Low Back Pain Strategy, which began in 2012. The goal of this initiative was to reduce the number of unnecessary diagnostic tests, improve wait times and enhance patient care. Feedback from primary care providers about the CORE Back Tool 2012 has informed revisions to a 2016 update.

The CORE Neck Tool and Headache Navigator

Headache and neck pain are challenging to treat, especially when presented together. The CORE Neck Tool and Headache Navigator was developed to assist primary care providers in differentiating and assessing neck pain or headache. Because neck pain and headache often have overlapping presentation of symptoms, this tool uses discrete approaches that help rule out other underlying conditions.

Osteoarthritis Tool

The Osteoarthritis Tool was developed for primary care providers managing patients with new or recurrent joint pain consistent with osteoarthritis of the hip, knee or hand. This tool can help clinicians identify symptoms and provide evidence-based, goal-oriented non-pharmacological and pharmacological management while identifying triggers for investigations or referrals.

The CPSO’s website includes links to these resources and others.