Controlling the Swing of the Opioid Pendulum The opioid crisis has led some clinicians to discontinue prescribing of opioid analgesics. The fallout is a growing pool of patients forced to navigate their transition off prescribed opioids, often with little assistance, with the potential for disastrous results.

Continuing education in Crisis Intervention Team (CIT) principles and best practices are limited. In 2015, the Albuquerque Police Department became the first law enforcement agency in the country to provide extended learning for CIT and case debriefings related to behavioral health through videoconferencing technology. The project, known as CIT ECHO, connects law enforcement agencies across New Mexico and the country to an online classroom where CIT experts and psychiatrists review behavioral health topics, and debrief complex cases with officers. An overview of CIT ECHO is provided including key elements, implementation challenges, and how we are evaluating its reach and effectiveness.

Problem: This study was designed to develop a deeper understanding of the learning and social processes that take place during the simulation-based medical education for practicing providers as part of the Project ECHO® model, known as Mock ECHO training. The ECHO model is utilized to expand access to care of common and complex diseases by supporting the education of primary care providers with an interprofessional team of specialists via videoconferencing networks. Intervention: Mock ECHO trainings are conducted through a train the trainer model targeted at leaders replicating the ECHO model at their organizations. Trainers conduct simulated teleECHO clinics while participants gain skills to improve communication and self-efficacy. Context: Three focus groups, conducted between May 2015 and January 2016 with a total of 26 participants, were deductively analyzed to identify common themes related to simulation-based medical education and interdisciplinary education. Principal themes generated from the analysis included (a) the role of empathy in community development, (b) the value of training tools as guides for learning, (c) Mock ECHO design components to optimize learning, (d) the role of interdisciplinary education to build community and improve care delivery, (e) improving care integration through collaboration, and (f) development of soft skills to facilitate learning. Outcome: Mock ECHO trainings offer clinicians the freedom to learn in a noncritical environment while emphasizing real-time multidirectional feedback and encouraging knowledge and skill transfer. Lessons Learned: The success of the ECHO model depends on training interprofessional healthcare providers in behaviors needed to lead a teleECHO clinic and to collaborate in the educational process. While building a community of practice, Mock ECHO provides a safe opportunity for a diverse group of clinician experts to practice learned skills and receive feedback from coparticipants and facilitators.

Chronic pain is a common problem in the United States. Health care professions training at the undergraduate and graduate levels in managing chronic pain is insufficient. The Chronic Pain and Headache Management TeleECHO Clinic (ECHO Pain) is a telehealth approach at Project ECHO (Extension for Community Healthcare Outcomes), which supports clinicians interested in improving their knowledge and confidence in treating patients with chronic pain and safe opioid management. It is a vehicle for educating practicing clinicians (at the "spoke") based on work-place learning with cases selected by participants from their patient panels combined with short lectures by experts (at the "hub"). ECHO Pain has designed an innovative, interprofessional longitudinal curriculum appropriate for individual and team-based clinicians which includes relevant basic and advanced pain topics. The specific design and delivery of the curriculum enhances its relevance and accessibility to busy clinicians in practice, yet also satisfies statutory requirements for CME in New Mexico. Specific features which balance hub-and-spoke needs are presented in this descriptive article, which is intended to serve as a guide to other clinician educators interested in developing or implementing similar telehealth curricula.

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based model that provides high-quality medical education for common and complex diseases through telementoring and comanagement of patients with primary care clinicians. In a one to many knowledge network, the ECHO model helps to bridge the gap between primary care clinicians and specialists by enhancing the knowledge, skills, confidence, and practice of primary care clinicians in their local communities. As a result, patients in rural and urban underserved areas are able to receive best practice care without long waits or having to travel long distances. The ECHO model has been replicated in 43 university hubs in the United States and five other countries. A new replication tool was developed by the Project ECHO Pain team and U.S. Army Medical Command to ensure a high-fidelity replication of the model. The adoption of the tool led to successful replication of ECHO in the Army Pain initiative. This replication tool has the potential to improve the fidelity of ECHO replication efforts around the world.

Background: Chronic non-cancer pain (CNCP) affects millions of people and is a leading cause of disability. The progression of chronic pain is closely tied to anxiety and depression but less is known about the relationship between chronic pain and adverse childhood experiences (ACE). Two commonly used pain assessments, the Short Form-McGill Pain Questionnaire-2 (McGill) and the Brief Pain Inventory Short Form (BPI), have been validated in populations witih CNCP patients but have not been validated in populations of CNCP patients with ACE. In addition, we wanted to assess the test-retest reliabilty and internal consistency of the Brief Adverse Childhood Events Survey (BRACES), an original instrument developed by the authors, with CNCP patients,. Methods: This study enrolled 123 patients with CNCP from an academic multidisciplinary pain clinic at the Clinical Trials Unit of our Clinical and Translational Science Center. ACE was not an inclusion criteria. All patients had one of five CNCP pain diagnoses. We adminstered the three instruments twice, separated by two weeks.. The anaysis compared psychometric properties of the instruments in patients who had ACE and those who did not. Results: There was significant correlation of the scores between the two participant visits (r=[0.68,0.85]) and internal consistency was high (Cronbach-α=[0.68,0.85]). Seventy percent of the study participants endorsed one or more categories of ACE, and 30% of study participants endorsed four to six ACE categories. Agreement between visits for reported ACE categories was high (κ=[0.72,0.85]). Demographic and pain characteristics were not different between patients reporting ACE and those who did not. Conclusions: The McGill, BPI and BRACES instruments were reliable and internally consistent in both populations. They also appear to be useful in evaluating the relationship between the quality (McGill), severity and interference (BPI) of CNCP in individuals with a history of ACE. Future research studying the relationship between ACE and chronic pain syndromes in adults can confidently utilize these instruments to help understand the role that ACE may play in the course of chronic pain and potential treatments.

Background: The epidemic of lethal prescription opioid overdose is one of the most pressing public health problems in the United States. In an ambulatory clinic setting, current practice guidelines suggest that health care providers should screen patient's aberrant drug-related behaviors. Given the difficulty of predicting which patients on chronic opioid therapy (COT) will experience opioid overdose, a new paradigm of harm reduction is called for. In previous studies, naloxone, an opioid antagonist, was given only to high-risk patients. However, if naloxone is co-prescribed in a Universal Precautions manner for all patients receiving COT, this may have a significant impact on intentional and unintentional opioid overdose deaths. Methods: Adult patients treated with COT for chronic noncancer pain are eligible study participants at the University of New Mexico Pain Center. The primary goal of this 1-year study was to develop an efficient Universal Precautions model for co-prescribing of naloxone with COT in the ambulatory clinic setting. Outcome measures included demographic data, detailed medical and substance use history, current morphine equivalent dose (MED), other high-risk medications used, and opioid misuse risk. Results: One hundred and sixty-four patients were enrolled in this study. All subjects were educated about the risks of opioid overdose and provided naloxone rescue kits. No overdoses occurred in the study population. Follow-up data illustrated that approximately 57% of the cohort had depressive disorder, the median MED was 90 mg/day, and the median Current Opioid Misuse Measure score (COMM) was 5.0. Conclusions: The ambulatory co-prescribing of naloxone in a Universal Precautions model for all patients prescribed COT can be adopted as a useful public health intervention. This study illustrates a model that can be used to educate patients, caregivers, and an interdisciplinary team of health care professionals in an academic medical center.

INTRODUCTION:Project ECHO Pain, the innovative telementoring program for health professionals, was developed in 2009 at the University Of New Mexico Health Sciences Center to fill considerable gaps in pain management expertise. Substantive continuing education for clinicians who practice in rural and underserved communities convenes weekly by means of telehealth technology. Case-based learning, demonstrations, and didactics are incorporated into the interprofessional program that helps to improve pain management in the primary care setting.METHOD:Three different approaches were used to evaluate the program over a 3-year period: (1) evaluation of all weekly continuing medical education surveys; (2) aggregation of annual clinic data; and (3) assessment of practice change in clinicians who joined Project ECHO Pain for at least 1 year.RESULTS:Between January 2010 and December 2012, 136 Project ECHO Pain clinics were held, with 3835 total instances of participation, representing 763 unique individuals from 191 different sites. Sixty percent self-identified as advanced practice or other nonphysician health professional. Statistically significant improvements in participant self-reported knowledge, skills, and practice were demonstrated. Focus group analyses of 9 subjects detailed specific practice improvements.DISCUSSION:Project ECHO Pain is a successful continuing professional development program. The telementoring model closes the large knowledge gap in pain education seen in primary care and other settings. Expertise is delivered by implementing effective, evidence-based, and work-based education for diverse health professionals. Project ECHO Pain serves as a model for interprofessional collaborative practice.

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico.New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and post-course surveys of knowledge, self-efficacy, and attitudes.Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

In summary, adolescent substance use is associated with a variety of risks. Using a nonjudgmental and collaborative approach to treating adolescent substance users can yield positive results. Motivational interviewing and the adolescent community reinforcement approach are evidence-based, nonpharmacologic treatments for teens with substance use disorders.

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.