Instructor Guide

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The Patient with Chronic Pain


A PGY-3 resident will be able to evaluate and develop a treatment plan for a patient with a history of addiction or medication misuse presenting with low back pain.

ACGME Core Competencies:

Patient Care/Interpersonal Communication Skills

  • Demonstrate a comprehensive history and physical examination on an uncomplicated standardized patient with low back pain.

Patient Care/Medical Knowledge

  • List red flag signs, symptoms, and findings following a standardized patient encounter
  • Discuss a plan to work up and treat back pain in a standardized patient with low back pain at high risk for substance abuse which incorporates regular monitoring and screening
  • Engage in a group discussion about medications and therapies to be used and avoided in patients with chronic back pain, as well as the principles of the WHO Analgesic Ladder

Medical Knowledge

  • Generate a differential diagnosis specific to a patient presenting with low back pain

Systems-Based Practice / Medical Knowledge

  • Develop a treatment plan which incorporates regular monitoring/screening for substance abuse and diversion
  • Engage in a group discussion about the epidemiology of substance abuse and diversion

Professionalism / Interpersonal Communication Skills

  • Watch a video, engage in a group discussion and/or role play relating to boundary setting techniques and troubleshooting


Session Guide


Time Needed: 3-4 hours total. One hour for didactic lecture on low back pain, one half-hour to review and practice the physical exam, half an hour for Assertiveness Training video and one hour for discussion.

Equipment Needed:

  • Computer with projector as well as DVD player
  • Room with several chairs and tables which can support residents as they practice the physical exam
  • DVD by VideoArts: “Straight Talk.”
  • Examination rooms for the standardized patients during the separate standardized patient interaction (generally scheduled the day after this session is taught)

Suggested online modules:, module “Identifying and Meeting Challenges,” as well as any other modules they would like to review.

Instructor Script and Notes

  1. Introduce Pain Management Specialist co-teacher. Describe a challenging case experience trying to treat a patient with chronic pain at high risk for substance abuse.
  2. Ask residents about their struggles and successes managing chronic pain with similar patients. Elicit questions.
  3. Demonstrate the LBP physical exam (PGY1 handout), and have residents practice on one another.
  4. 28 minute DVD, “Straight Talk.” If there is time and interest, role play patient scenarios the residents come up with.
  5. Group discussion: what questions were left unanswered? What other questions have come up? What resources are available if questions arise in the future (people, online references such as the Johns Hopkins Opioid Calculator, VCU Online Modules)?
  6. Alternate Activity/Conversation Starter: Defense Against the Dark Arts.  This activity can be useful if students wish to explore the difficult interpersonal interactions that can make treating chronic pain uncomfortable for the provider.  It takes approximately 30 minutes to complete.