Drs. Marie Patton and Diana Turner approached Tom Baker Cancer Centre (TBCC), in January 2013 urging Pain & symptom management physicians to develop educational material for physicians in Long term Care facilities (LTC). At that time patients discharged from acute care hospitals or ambulatory clinics, on stable dose of methadone could not be transferred to a LTC facility in Calgary, as physicians did not have an exemption to prescribe methadone.
The Canadian Centre for Addiction and Mental Health (CAMH) has excellent educational material for mental health, methadone & buprenorphine for substance use disorder (SUD), but contains little about pain management. It became obvious that there were few if any, educational services for methadone for analgesia in 2013 in Canada.
Drs. Srini Chary and Neil Hagen had collaborated with Drs. Chris Spanswick, Calgary Chronic Pain Centre (CPC), Janet Wright, and Susan Ulan, College of physicians and Surgeons of Alberta (CPSA) and Lara Cooke, CME/CPD, University of Calgary, to develop an educational workshop. The working group strongly felt that the content should include mental health, SUD, principles of pain management and use of methadone in ambulatory care, cancer, non-cancer, palliative and end of life care settings. The above colleagues reviewed the workshop slides and a final set of slides and educational material was prepared.
Physicians and pharmacists from CPC, TBCC and Palliative Care service, AHS, Calgary Zone; some have reviewed the educational material and agreed to mentor participating physicians, following the workshop for a period of six months.
Dr. Jose Pereira and Dr. Kathryn Downer, Pallium Foundation of Canada were in support of the project.
The workshop contents include safe use of methadone and principles of chronic pain management:
1. Methadone use & challenges in general and Calgary setting
2. Methadone: discovery, pharmacology, adverse effects, clinical evidence including Calgary use & experience, safe use of methadone for analgesia through case studies, CDSA & CPSA requirements and a list of mentors from CPC and Palliative Care services in Calgary Zone.
3. Opiophobia, opioiphilia and balanced use along with barriers to chronic pain management
4. Neurobiological mechanisms of mental health and substance use disorder
5. Acute, Chronic pain; Nociceptive, Neuropathic, Mixed pain; the Concept of total pain along with patient and family centered care
6. Assessment & management of chronic pain using appropriate tools including at the end of life
7. Universal precautions for chronic pain, goals, boundary setting and follow-up
8. Canadian Opioid use guidelines & CAMH
9. Reduce, stop opiods through education, rehabilitation and non-pharmacological approaches
10. Pharmacological non-opioidal interventions for analgesia, including classifications of opioids
The intent of this project was to capacity build in our community, collaboratively with safe and best practices; understanding methadone requires additional knowledge and, mentorship is useful in the early phase of a physician’s practice.
The 3 hours workshop was conducted on five occasions with a total of 57 physicians participating. Knowledge quiz before and after the workshop demonstrated improvement and knowledge of the subject matter amongst participants. At the end of the workshop all participants received a certificate of attendance, an application and information how to apply for an exemption through CPSA.
Three months following the workshop a “survey monkey” was sent to all 57 participants to note change of practice and 20 responded. The details of the program can be obtained from schary@ucalgary.ca. All responders felt that the workshop was useful and only 50% of the respondents had obtained an exemption. 30% of the respondents had prescribed methadone and a similar percentage had contacted a mentor. More than 95% indicated that such an educational event will change their practice and around 80% suggested future CPD in the subject. There were no issues in obtaining an exemption from CPSA. There were suggestions to improve the workshop with more time, case scenarios and a shorter course in a hospital setting.
It appears from the survey and data matching from CPSA that a total of 18 physicians out of 57 have obtained general exemption. At present 5 long term care facilities accept patients from acute care hospitals or Tom Baker Cancer Centre Pain Clinic or CPC and at these LTC sites, physicians have general exemption.
Alberta’s population is around 4 million inhabitants with 9,160 physicians in March 2015. There are 578 physicians with MMT exemption, 242 with general exemption and 233 with patient specific exemption for analgesia.
Future plans include continuation of such workshop for physicians in collaboration with CPC and Palliative Care and develop academic faculty in Calgary Zone, to conduct such education. A shorter version of CPD material – refresher course will be developed, for those who have completed such an educational event earlier. An additional workshop to train the trainer will be planned, so that “local champions” can continue creating capacity in Alberta. A web based educational material is being developed by Pallium Canada.
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