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As the opioid epidemic rages, up-and-coming physicians are seen as part of the solution. Here’s how medical schools are changing their training programs.
Nearly 2 million Americans abused or were dependent on prescription opioids in 2014, according to the CDC. From 1999 to 2015, more than 180,000 people died from overdoses related to prescription opioids. In light of the ongoing epidemic, Managed Healthcare Executive set out to discover what medical schools are doing to address the situation.
Robert Goldberg, DO, director, strategic medical initiatives, Touro College and University System, New York, New York, says physicians are taught the pharmacological aspects of medications, including their mechanisms of action, indications, contraindications, and side effects in medical school. “But there’s a disconnect between the use of opioids and the universe in which they are prescribed-one in which the psychosocial and economic environment may quickly overshadow the pain syndrome that was the reason the narcotic was prescribed,” he says.
John Davis, MD, PhD, associate professor of clinical internal medicine and associate dean for medical education, The Ohio State University Wexner Medical Center, Columbus, Ohio, believes that medical school is the ideal time for budding physicians to learn about issues facing communities, such as the opioid crisis and how social factors contribute to such problems. “It is also the time to learn about responsible opioid use, how to prevent addiction, how to detect addiction, and how to manage it when it occurs,” he says. “Any gaps in this education could lead to physicians not appreciating the importance of this health crisis or being unable to use their diagnostic and therapeutic abilities to address the crisis.”
Talia Puzantian, PharmD, BCPP, associate professor, Keck Graduate Institute School of Pharmacy, Claremont, California, believes clinicians must be adequately trained to accurately assess pain, and to take on a wide and varied approach to treating pain. “They must be well versed in the use of non-opioid pain medications as well as movement-based therapies such as physical and occupational therapy; integrative therapies such as massage, acupuncture, and yoga; and behavioral therapies such as cognitive behavioral therapy, individual therapy, and support groups,” she says.
If it’s necessary to prescribe opioids, physicians should be familiar with and follow the CDC’s Guideline for Prescribing Opioids for Chronic Pain. “This guideline provides recommendations on how to manage patients with pain lasting longer than three months that is not associated with cancer or end-of-life care,” Puzantian says.
Following a call from the White House in early 2016 to help address the national opioid epidemic, the Association of American Medical Colleges and the American Association of Colleges of Pharmacy issued statements emphasizing medical and pharmacy schools’ commitment to opioid-related education and training. “Deans of medical and pharmacy schools across the country pledged to incorporate the CDC’s guideline on pain management into their curricula,” Puzantian says.
Keck Graduate Institute School of Pharmacy’s four-year PharmD program has incorporated the CDC’s guideline into its therapeutics module on pain control-which addresses the assessment and treatment of pain, including opioid, non-opioid, and non-pharmacologic interventions. “We also teach students about the risks and benefits of prescribing opioids and about opioid use disorder-including addiction risk factors,” Puzantian says. Other areas of education include how to:
· Recognize, treat, or refer patients with an opioid use disorder;
· Use prescription drug monitoring programs to monitor a patient’s controlled medication use and recognize misuse;
· Use urine toxicology screens to assess for substance misuse;
· Administer agreements with patients that specify treatment expectations and monitor patients’ use of opioids and other controlled substances;
· Treat with or refer patients to medication-assisted therapies such as buprenorphine or methadone;
· Assess when to prescribe naloxone-a drug that reverses opioid overdose-and educate patients on its proper use; and
· Taper opioids in patients when risks outweigh benefits.
“Many medical schools are incorporating these core competencies into their existing curricula or are developing new curricula,” Puzantian says.
Don J. Selzer, MD, MS, FACS, FASMBS, surgeon, Indiana University Health, and associate professor and chief of the division of general surgery, Indiana University School of Medicine, Indianapolis, Indiana, says more medical schools are recognizing and teaching the potential for development of dependency and training physicians about multimodal pain therapy that uses ancillary medications, including non-steroidal anti-inflammatories, acetaminophen, and local anesthetics.
Davis says medical schools are at different places regarding their interventions targeting the opioid epidemic. “For us, it is important to have a coordinated approach, so that we can teach skills and assess them over time and in multiple contexts-in the classroom, clinic, hospital, and with the participation of other professions such as pharmacy and nursing,” he says. “In most cases, schools have taken into account aspects of the surrounding community and its needs. We are in the process of looking at education statewide to address our community’s needs as the epidemic evolves.”
Davis says training should continue after students graduate. For example, at Ohio State, emergency medicine residents are trained on how to communicate with patients and families affected by opioids. Davis advocates for broad incorporation of such training, including use of simulation, to further the development of patient care skills relevant to the opioid epidemic.
Touro College and University System brings in community members to tell personal stories of use and abuse. “Businessmen and women and ex-convicts alike tell stories to put a personal face on the epidemic,” Goldberg says. “Special U.S. Drug Enforcement Administration prosecutors are invited to talk to the student body about risk management and personal responsibility. They cite the CDC’s statistics to portray the epidemic’s scope.”
Darren Freeman, DO, director of pain management, University of California Riverside School of Medicine, Riverside, California, says training on compliance with state and federal regulations is also helpful. “All providers who prescribe opioids are required to be registered with the Controlled Substance Utilization Review and Evaluation System (CURES) and must check this database of controlled substances quarterly for any potential overdoses as well as administer urine toxicology screening twice annually,” he says. “The goal is to attempt to minimize the need for opioids, and provide multimodel regimens including medications, i.e., non-steroids, antidepressants, anticonvulsants, muscle relaxers, cardiac or blood pressure medications, or topical agents which have all demonstrated great efficacy in pain control. This is based on the understanding that other conservative treatments should be provided, including alternative modalities.”
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.