Medical schools respond to the opioid epidemic
By Amy Karon
Sales of prescription opioids and deaths from prescription opioid overdoses have nearly quadrupled in the United States since 1999, according to the CDC. But until very recently, medical schools offered little or no training in addiction medicine, leaving many internists to face challenging patients and clinical decisions on their own.
“Both pain medicine and addiction have gotten short shrift in medical school, but of the two, addiction has received much less attention,” said Anna Lembke, MD, director of the addiction medicine fellowship and assistant professor of psychiatry and behavioral sciences at Stanford University in California. Medical students learn more about addiction now than they did 20 years ago, “but not much more,” she said. “A silver lining of the opioid epidemic, if one can be found, is that medical schools are more interested than ever in teaching how to screen and intervene for addiction, particularly opioid use disorders.”
Preclinical and clinical education about proper opioid prescribing can be fit into 40 hours of curriculum, and a remedial program done at Case Western Reserve University in Cleveland showed that a coordinated effort can have a meaningful impact on clinicians. Photo by iStock
External pressure accounts for some of this shift. In March 2016, the White House asked medical schools to pledge to expand their curricula based on the first-ever CDC guidelines on opioid prescribing. Pledges can be controversial, but this one makes sense, Dr. Lembke said. “The medical community, including medical schools, has not responded with the speed and intensity required to meet this crisis. Only when faced with outside pressure from the media, legislation, or public pledges has medicine responded.”
Sea change in Massachusetts
The opioid epidemic rages on in Massachusetts, where deaths from accidental overdose more than doubled between 2012 and 2015, according to the state health department. In response, Gov. Charles Baker convened a working group whose 55 recommendations included the proposal that student clinicians learn the foundations of safe opioid prescribing. As a result, all four medical schools in Massachusetts worked with the state health department and the state medical society to develop 10 “core competencies” in preventing and managing prescription drug misuse, said state health commissioner Monica Bharel, MD, MPH.
“Teaching these competencies in medical school is crucial, while students are developing lifelong practice habits and before they begin prescribing,” she emphasized.
The core competencies are designed so that all medical students in Massachusetts will, by the time they graduate, have learned to evaluate pain, addiction risk, and pharmacologic and nonpharmacologic options for pain management; recognize prescription drug misuse; develop patient-centered addiction treatment plans; identify a case of opioid overdose; and correctly use naloxone rescue therapy. Students also will be asked to place substance abuse disorders within a chronic disease framework and recognize their own internal biases as well as social stigmas against affected patients.
Medical schools in the state are now weaving these competencies into new and existing curricula, Dr. Bharel said. For example, the University of Massachusetts has added relevant cases to its fourth-year final exams and has rolled out a new “Opioid Conscious Curriculum” that spans all four years of medical school. At Tufts University School of Medicine, third-year students now spend a day interviewing standardized patients who exhibit chronic pain and risk factors for prescription drug misuse, first-years are studying a chronic pain case that incorporates basic science and clinical medicine, and faculty are mapping the existing addiction medicine course to the 10 core competencies.
“To be clear, each of our partner medical schools was already teaching components of addiction medicine,” Dr. Bharel noted. But what was taught varied, and in some cases, electives and rotations determined what students knew about opioids and addiction on graduation day, she said. The new approach aims to ensure that prescribers have “the tools they need to balance the need for pain management with the potential for opioid misuse.”
Stepwise progress at Case Western
Change is happening elsewhere, too, albeit more gradually. At Case Western Reserve University in Cleveland, Theodore Parran, MD, FACP, has spent more than 20 years teaching an intensive remedial course on controlled drug prescribing for health professionals, many of whom have been identified as overprescribers by their licensing boards.
“We have had over 2,400 physicians, physician assistants, and nurse practitioners come to this course,” Dr. Parran said. “Nearly all reported that they received little or no education on appropriate patient evaluation, professional boundaries, or careful prescribing of controlled drugs.”
Based on that feedback, Dr. Parran and his colleagues distilled the remedial course into an optional series of in-person and online seminars that fourth-year medical students can take a month before the residency match. About a third of seniors joined the first two pilot versions of the course, and the faculty are now pursuing funding to expand it. Ultimately, Dr. Parran hopes that Case Western can offer this course and a more advanced version for residents to students and trainees from all institutions, he said.
This example shows that educators can make meaningful curricular changes even in the absence of coordinated statewide efforts. “All told, preclinical education could be fit into 20 [classroom] hours or so, if done well,” Dr. Parran said. “Clinical education could be done in a similar amount of time if it were continually reinforced with a clinical addiction consult service.”
But very few academic teaching hospitals have such a service, which strips students and residents of one of best ways to learn addiction medicine hands-on, Dr. Parran said. “This is a shame,” given the substantial rates of drug and alcohol addiction among inpatients nationally, he added. “Not having an addiction consult service is an extremely serious gap in student and resident medical education.”
Insights from the field
Howard Heit, MD, FACP, suffered years of severe, disabling pain after an automobile accident ended his career in gastroenterology. Convinced that physicians needed a much better understanding of pain medicine and its “dark side,” addiction, he subsequently retrained in both fields. Dr. Heit then helped create an American Society of Addiction Medicine course that “brought pain and addiction doctors into the same room to talk and learn from one another” and spent nearly two decades treating patients with pain, addiction, or both.
Medical students need to learn to listen deeply to these patients, talk to them, and treat them as “good people with a serious medical problem, not bad people,” he said. “Pain should be treated as a disease and an illness. Treating the disease is the science of medicine, but what has to be taught in medical schools is the art of medicine, the human experience and the suffering.”
But compassion is only a start. Medical school graduates also need to have mastered the appropriate use of opioid risk assessment tools, written treatment agreements, urine drug tests, and most importantly how to interpret an unexpected positive or negative result. They must learn appropriate documentation in the medicolegal record, Dr. Heit said. They need to know how to convey realistic expectations for treatment response and consistently assess patients based on “the 4 A's”: analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors.
Medical schools also need to teach students never to prescribe opioids without clear “exit strategies” for stopping therapy if needed, Dr. Heit and other experts said. “Amazingly, most prescribers [of controlled drugs] do not know how to wean or taper their patient off an opioid,” Dr. Parran said. “Like flying an airplane, if you do not know how to land, you should not take off.”
Dr. Lembke agreed. “One of the myths that fueled the opioid epidemic was the idea that as long as doctors were prescribing the drug and the patient was being treated for pain, there was a miniscule chance of addiction. Now we know this to be false.”
Consequently, medical students and residents must learn to say “no” when pressured to prescribe opioids against their better judgment, Dr. Parran said.
“Communication skills [can enable the physician] to give bad news but de-escalate the encounter, maintain boundaries and still legitimize and respect the patient's perspective, stop prescribing but not dismiss the patient from your practice,” he said. “These are some of the most difficult conversations in clinical practice, but they can be managed gracefully and in a spirit of patient-centeredness if they are practiced and mastered.”
10 universal precautions in pain medicine
Pearls of pain medicine fall into the 10 “universal precautions” that Howard Heit, MD, FACP, and fellow addiction specialist Douglas Gourlay, MD, MSc, described in the March-April 2005 Pain Medicine. They recommend following these steps whenever treating a patient in pain, regardless of personal impressions of addiction risk. Doing so can help minimize stigma, improve patient-centered care, and lessen the inherent risks of opioid therapy, Dr. Heit emphasized.
“All patients have risks with prescribing a controlled substance,” he said. “If the patient has a pulse, there is a risk. The question is what is that risk?”
1. Make a diagnosis with appropriate differential
2. Psychological assessment including risk of addictive disorders
3. Informed consent
4. Treatment agreement
5. Pre- and post-intervention assessment of pain level and function
6. Appropriate trial of opioid therapy with or without adjunctive medication
7. Reassessment of pain score and level of function
8. Regularly assess the “4 A's” of pain medicine
9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders
10. Documentation (medicolegal record)
Adapted from Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-12. [PMID: 15773874] doi: 10.1111/j.1526-4637.2005.05031.x
Antman KH, Berman HA, Flotte TR, Flier J, Dimitri DM, Bharel M. Developing core competencies for the prevention and management of prescription drug misuse: a medical education collaboration in Massachusetts. Acad Med. 2016 Aug 16. [Epub ahead of print] [PMID: 27532868] doi: 10.1097/ACM.0000000000001347
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65:1-49. [PMID: 26987082] doi: 10.15585/mmwr.rr6501e1
Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-12. [PMID: 15773874] doi: 10.1111/j.1526-4637.2005.05031.x
Massachusetts Department of Public Health Governor's Medical Education Working Group on Prescription Drug Misuse. Medical education core competencies for the prevention and management of prescription drug misuse. Accessed on Sept. 13, 2016.
Passik SD, Kirsh KL, Whitcomb L, Portenoy RK, Katz NP, Kleinman L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004;26:552-61. [PMID: 15189752] doi: 10.1016/S0149-2918(04)90057-4
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