Redefining Pain and Addiction

With more than 116 overdose deaths occurring every day in the U.S., the seriousness of the opioid epidemic is hard to overstate. Health care professionals across the country are developing strategies to fight the crisis, but Arizona is the first state to take the proactive approach of devising a statewide curriculum designed especially for medical prescriber schools. Earlier this year, University of Arizona College of Nursing professors Angela Brown and S. Renee Gregg joined representatives from 18 Arizona programs (representing prescribing groups such as MD, DO, NP, PA, DMD, ND and DMP) to help craft a curriculum that emphasizes integrative therapies over pharmaceutical options.

When the call came for school representatives to join the effort, Drs. Brown and Gregg didn’t hesitate to sign up. Both have lengthy professional and scholarly interest in integrative health care and felt they could make a significant contribution to the discussion. Additionally, their participation in UA Nursing’s landmark Integrative Nursing Fellowship (INF) expanded their knowledge base of integrative therapies.

“It’s something that’s been close to my heart,” says Dr. Gregg. “I wanted in on it, and Angela was the same. Arizona Department of Health Services wanted to get us all together to have a discussion, with the goal of creating a curriculum we could implement in our schools so that the next generation of providers would come in with better skills and a higher level of preparation to reduce the overall use of opioids.”

“As prescribers, we need to educate our students about the difference between someone with chronic pain and somebody that's just trying to divert, and how to practice providing pain interventions where patients are at a safe level. We wanted to make sure graduates are prepared for that." ~ Dr. S. Renee Gregg 

“As a Nurse Practitioner, I’ve seen people out there really struggle with chronic pain,” says Dr. Brown. “As prescribers, we need to educate our students about the difference between someone with chronic pain and somebody that’s just trying to divert, and how to practice providing pain interventions where patients are at a safe level. We wanted to make sure our graduates are prepared for that.”

Meeting monthly for six months, Drs. Brown and Gregg and their colleagues assisted with the drafting of the Arizona Pain and Addiction Curriculum.  The approach represents a large-scale culture shift in the education of the next generation of prescribers by redefining pain and addiction as interlinked, complex, public health processes requiring interprofessional care and involvement of the community. Although use of the curriculum is optional, it is nonetheless part of a bold move to make a wide-sweeping change to pain and addiction education. The final document, which rolled out this summer, is a standardized educational tool for all medical prescriber schools in the state.

Thanks to Drs. Brown and Gregg, the UA College of Nursing has already implemented the new curriculum into its Doctor of Nursing Practice Family Nurse Practitioner program. This summer the clinical management course, Advanced Primary Care (620B), featured two weeks of instruction focused on chronic pain. One week zeroed in on the relation between chronic pain and substance abuse and the second highlighted integrative interventions for chronic pain.

“We taught 10 integrative interventions, some in a hands-on immersion that students could try, and we also implemented a hands-on effective communication through a Zoom small-group case study,” says Dr. Gregg, who found that students are more likely to utilize integrative interventions for chronic pain or stress management if they’ve actually experienced the interventions themselves. Students gained knowledge of such therapies as massage, acupuncture, yoga, mindfulness, guided imagery and Tai Chi.

“That changed the way that we teach students,” elaborates Dr. Brown. “If they’re more likely to experience these techniques, then they’re apt to utilize them when they’re out there in practice.”

Drs. Brown and Gregg give credit to their INF experience for giving them a broader frame of reference for their integrative knowledge. “A great thing that happened with the INFF was each of us focused on different techniques,” says Dr. Brown. “Instead of learning about yoga, we learned about different therapies, and really incorporated some diversity there, teaching different modalities. The INFF gave us permission to pursue these other things, and find people that are thinking likewise in relationship to education for nurse practitioners.”

That wide body of knowledge came in handy when the pair was enmeshed in drafting the statewide curriculum – and gave them a unique perspective when it came to understanding the connection between pain and addiction. Opioids misuse, points out Dr. Gregg, trigger a dopamine response that mirrors the feel-good response to chocolate or exercise. “But you have to work for it more than just popping a pill,” she says.

“Another important piece about integrative interventions is they help with the mind-body experience,” says Dr. Brown. “Pain is mind-body experience and so is addiction. So if we’re teaching people to have coping mechanism and deal with stress effectively and deal with issues like depression and anxiety, then they’re less likely to grab that drug to help alleviate those situations.”

The statewide curriculum is an important first step in proactively combating Arizona’s opioid epidemic, but Drs. Brown and Gregg see opportunity for growth. In the future, they envision integrative therapies being taught in other DNP courses and eventually becoming a thread through every course in the program. But for now, the upshot is simple. “I really hope that we’re preparing the future generation of nurse practitioners to be leaders and strong providers in response to chronic pain,” says Dr. Brown. “We want people to have positive outcomes rather than the negative outcomes associated with the opioid crisis.”