Substance Use and Pain Curriculum Innovation: Establishing a Student-Faculty Partnership for Curricular Change

Abstract

Problem

The opioid overdose crisis had progressed broadly in the United States, with an 21% increase from 2016 to 2017, and specifically in Massachusetts, with a peak rate of 1,374 deaths in 2016. In 2016, students and faculty at Harvard Medical School (HMS) established the Substance Use and Pain Curriculum Committee (SUPCC) to expand substance use and pain education. However, faculty capacity, financial resources, and administrative support were insufficient to implement changes across all phases of the medical school curriculum.

Approach

The HMS SUPCC restructured in 2021 to put students at the forefront of curricular development. This restructuring was done through 3 main innovations: (1) establishment of a student-centered committee structure, ensuring that curricular changes are centered on student interests and needs; (2) student-led curricular development and implementation, reducing faculty workload; and (3) focus on clinically relevant teaching and opportunities to practice learned skill sets.

Outcomes

This student-centered structure facilitated the expansion of the addiction and pain medicine curriculum to more than 30 hours of teaching by 2024. Examples of student-driven initiatives include development of an opioid use disorder management practicum equivalent to the Drug Enforcement Agency X-waiver, increased medical student access to naloxone through a hospital partnership, and integration of case-based opioid use disorder and pain medicine didactics into the clerkship year.

Next Steps

Although this work has established a longitudinal curriculum across all medical training stages, more must be done in clerkship rotations to help students apply their substance use and pain education in the clinical setting. The HMS SUPCC is working to incorporate teaching on nonopioid substances, such as alcohol, cannabis, and ketamine, provide longitudinal clinical experiences so students learn to care for patients with substance use disorder and chronic pain from short-term intervention to long-term recovery, and develop surveys to quantitatively and qualitatively measure curriculum outcomes.

Problem

In 2016, the opioid overdose crisis had rapidly progressed both broadly in the United States and specifically in Massachusetts (Figure 1). Drug overdose deaths in the United States increased 21% from the year prior, the largest annual increase recorded at that time.¹ Synthetic opioids, such as fentanyl, became the leading cause of opioid-related overdose deaths.¹ In Massachusetts, deaths reached a peak of 1,374 deaths in 2016, 75% of which involved fentanyl.² Boston faced a compounding crisis when the sudden closing of its largest homeless shelter in 2014 left hundreds of patients disconnected from safe housing and substance use disorder (SUD) treatment. That year, then Massachusetts Governor Charlie Baker met with the deans and faculty members of the 4 Massachusetts medical schools to develop core competencies for the prevention and management of inappropriate use of prescription drugs.³ It was this combination of a national trend in overdose deaths, a severe crisis in Boston, and state-level political advocacy that motivated Harvard Medical School (HMS) to establish the Substance Use and Pain Curriculum Committee (SUPCC) in 2016.

Figure 1.

Timeline of events that led to the restructuring of the Harvard Medical School (HMS) Substance Use and Pain Curriculum Committee (SUPCC) in 2021. Abbreviations: LCME, Liaison Committee on Medication Education; SUD, substance use disorder.

The original HMS SUPCC consisted of 19 members: medical students, faculty across multiple departments, and medical education leadership. Many of the student members were drawn from an existing student activist group, the Student Coalition on Addiction, which was founded in 2014 by medical students in response to the closure of Boston’s largest homeless shelter.⁴ The SUPCC’s initial goal was to establish a required substance use and pain curriculum that spanned all phases of the curriculum. We incorporated Miller’s⁵ pyramid of clinical competence to inform curricular developments, which guides students through a progressive journey beginning with the acquisition of fundamental knowledge and progressing to hands-on engagement with patients. Using this educational framework, the SUPCC developed a substance use and pain curriculum in 2016 approved by the HMS Curriculum Cabinet (Table 1), the body responsible for the oversight of the medical school curriculum. A more detailed overview of our curriculum with the corresponding HMS competencies and Miller’s pyramid of clinical competencies is shown in Supplemental Digital Appendix 1 (at [WK INSERT LINK]). In its first 5 years, our committee updated foundational teachings in SUP topics in the preclinical curriculum.

Table 1.

Overview of the Topics Included in the Substance Use and Pain Longitudinal Curriculum Developed by the Original Harvard Medical School Substance Use and Pain Curriculum Committee in 2016^a

Topic	Content
Substance use curriculum
Epidemiology and public health aspects of substance use and SUD	•Historical trends in the United States and evolution of public attitudes •Risk factors for SUD and differences in prevalence by demographics, including age, gender, race, and ethnicity •Economic and political impact of SUD
Neurobiology	•Neural targets of specific drug classes •Neuroanatomical regions associated with addiction and relapse
Clinical features and street names used for psychoactive substances	•Clinical pharmacology Clinical features of intoxication and withdrawal •Medical and psychiatric complications for SUD
Basic approaches to treatment	•History and physical exam •Motivational interviewing •Review of treatment interventions
Prevention and brief interventions	•Screening, Brief Intervention, Referral to Treatment •Early intervention in youth
Stigma, advocacy, and professional stance	•Self-assessment of medical students’ attitudes toward substance users and substances •Need for advocacy with policymakers
Pain curriculum
Multidimensional, subjective nature of pain experience	•Biological significance of pain •Pain as a public health problem •Overlap of pain, substance abuse, and mood disorders
Epidemiology and public health aspects	•Biological significance of pain •Pain as a public health problem •Overlap of pain, substance abuse, and mood disorders
Basic neuroscience	•Nociceptive pathways •Genetics of pain perception and of opioid addiction
Psychology of pain	•Affective, cognitive, behavioral, and developmental aspects •Gate Control Theory
Ethics of pain	•The right to receive treatment for pain •Pain disability •Pain as fifth vital sign (cost-benefit)
Clinical features and approaches to treatment	•Interviewing and pain assessment •Review of treatment interventions •Safe prescribing and prescription drug misuse

Abbreviation: SUD, substance use disorder.

^aFor a more detailed review of the topics within this curriculum coupled with the relevant competencies from both Harvard Medical School and Miller’s Pyramid of Clinical Competence,⁵ please refer to Supplemental Digital Appendix 1 at [WK INSERT LINK].

However, as we transitioned our focus in 2021 toward providing opportunities to put that knowledge into action during clinical clerkships, we realized that our group lacked the faculty bandwidth, financial resources, and administrative capacity to implement clinical teaching. These challenges forced our group to consider how we could restructure our efforts to focus faculty time on key curriculum content updates and advocating for institutional support. Given the long history of student advocacy in the creation of the HMS SUPCC, in 2021 our committee started the process of exploring how we could establish a larger role for students, freeing up faculty time for institutional advocacy and high-level curricular input. In this article, we describe how we established a horizontal leadership structure among students and faculty and how this accelerated our curriculum innovation in substance use and pain.

Approach

In 2021, the SUPCC restructured to establish a horizontal leadership structure among students and faculty. We now have 2 committee leads: an overall faculty lead chosen by HMS administrators and a student lead chosen by student committee members. The 2 work together to establish the committee’s mission, goals, and projects. We also have 2 faculty subleads in charge of overseeing core content within our 2 themes: substance use and pain medicine. This shared leadership structure allows faculty to focus their efforts on areas where expertise is vital for curricular development, while centering student perspectives.

Medical students of all years apply to join the committee on an annual basis, regardless of their experience with addiction and pain medicine. General student members can individually or in groups choose a project to pursue and are assigned a faculty mentor from the committee, who provides guidance on the content and format for the project. Examples of projects have included creating a focused lecture on core substance use and pain topics incorporated into the preclinical curriculum, an interactive case-based session during clerkship rotations to teach how to put substance use and pain knowledge into clinical practice, or initiatives to distribute harm reduction resources to students and patients, such as naloxone. The students for each project progress through their work independently of committee meetings, reporting to the larger committee for feedback and assistance with implementation.

We have 2 sets of committee meetings: student working group meetings focused on the details and timelines of specific projects and full-committee meetings focused on committee-wide projects and individual project feedback. This scheduling structure cuts meeting obligations for faculty in half and focuses their efforts on providing necessary expertise.

The student-led committee structure helped SUPCC overcome several key challenges to the implementation of the curriculum. To characterize the implementation context of our curricular changes, we used the Consolidated Framework for Implementation Research.⁶ The combination of a public health crisis and state mandate (outer setting) and long-standing student advocacy for additional training (inner setting) facilitated rapid faculty and institutional leadership engagement in curriculum development. However, several inner-setting factors presented barriers. First, substance use and pain topics span multiple medical specialties and are not consolidated into a single course. Therefore, the SUPCC could not access the same resources as course faculty, such as funding, administrative support, and faculty development. It also left the decision to incorporate our teachings into courses in the hands of individual course directors. Second, faculty were usually only affiliated with one of the Harvard-affiliated teaching hospitals, making it difficult for them to coordinate didactics with other teaching sites.

Some of these inner-setting barriers were alleviated when our institution created societal themes that focused on priorities for curricular development in response to the Liaison Committee on Medication Education accreditation introducing standard 7 (curricular content) and element 7.5 (societal problems).⁷ Our committee’s long-standing history of student advocacy led to substance use and pain education being chosen as one of the societal themes at HMS, providing the financial support for our faculty leads, legitimacy, and access to curriculum stakeholders to affect our curricular changes. We also realized that students could help mitigate the obstacles of distributing our didactics to all parts of the medical school curriculum and across all teaching hospitals because they work across hospitals in a way that faculty do not. Students can highlight the opportunities and limitations students have on a medical team during clerkship rotations within a specific hospital, connect our committee with the clerkship directors and instructors they meet during rotations, and provide feedback on how didactics fit into existing curricula. This process also provides students with the opportunity to develop their teaching skillsets, receive one-on-one mentoring with faculty, and contribute to academic publications and conference presentations.

Outcomes

Student and faculty engagement

After implementing our student-centered structure in 2021, the SUPCC increased its student membership from 2 students in 2020 to more than 20 in 2024. Students expanded the number of active projects from 1 or 2 at a given time to more than 7 concurrent projects. The opportunity to engage in medical education scholarship helped motivate student engagement: in the 2023 to 2024 academic year the SUPCC published 2 articles, submitted 2 manuscripts for peer review, gave an oral conference presentation, and had 3 conference poster abstracts accepted. The action-based didactics created through student projects transformed our addiction and pain medicine curriculum from covering the basics of SUD treatment and pain management to more than 30 hours of didactics spread across the medical school curriculum (Table 2). Below we describe 3 of the student-led initiatives incorporated into our substance use and pain curriculum.

Table 2.

Overview of the Implemented Substance Use and Pain Curriculum at Harvard Medical School at Each Stage of Medical Student Education as of 2024^a

Course name	Substance use curriculum content	Pain curriculum content
Preclerkship education
Basic life support training	•How to administer naloxone and opportunity to receive doses for personal carry
Preclerkship neuroscience course	•Pathophysiology of addiction •Obtaining a substance use history, exam, and objective clinical data •Basics of pharmacotherapy for SUD, including medications for OUD •Psychobehavioral treatments of SUD	•Neuroscience and psychology of pain •Education on types of pain •Ethics of pain treatment and opioid use •Pain as a public health problem
Preclerkship medical skills course	•Motivational interviewing in the context of patients with prior and present substance use •Introduction to harm reduction in the context of patients living with SUD
Preclerkship rotations preparatory course	•Interview and evaluation of patient with SUD •Medication-assisted treatment for opioid, alcohol, and tobacco use •Stigma, advocacy, and professionalism when treating for SUD	•Clinical assessment of pain •Introduction to medication and psychobehavioral treatments of pain •Lecture on the impact of chronic pain and motivations for pain management among all clinical practitioners
Social science and medical ethics course	•History of the opioid overdose crisis in the United States	•History of the opioid overdose crisis in the United States
Clerkship education
Medicine rotation	•Interactive case covering the fundamentals of OUD epidemiology, diagnosis, and management with an emphasis on harm reduction	•Recorded lecture on inpatient pain medication management •Lecture on common forms of pain seen in primary care, including lower back pain
Radiology rotation	•Interactive case on the common radiologic findings caused by extended substance use	•Lectures on the common imaging modalities and corresponding findings for common causes of pain, such as lower back pain
Surgery rotation		•Acute pain interactive case with overview of acute interventions in the context of anesthesia
Pediatrics rotation	•Recorded lecture on motivational interviewing with adolescents regarding substance use and openness to treatment
Postclerkship education
Medications for OUD practicum	•Overview of how to treat patients with OUD and provide medications for OUD treatment
Postclerkship social medicine course	•Historical trends and epidemiology of substance use and impact to health care infrastructure •Risk factors for SUD, including genetics, psychiatric, environment, and social determinants	•Ethical issues related to the use of opioid medications •Social and structural factors affecting the experience of pain

Abbreviations: OUD, opioid use disorder; SUD, substance use disorder.

^aThis table outlines the progress as of 2024 in implementing the longitudinal substance use and pain curriculum created by the Harvard Medical School Substance Use and Pain Curriculum Committee in 2016 (Table 1). For a more detailed review of the topics within this longitudinal curriculum coupled with the relevant competencies from both Harvard Medical School and Miller’s Pyramid of Clinical Competence,⁵ please refer to Supplemental Digital Appendix 1 at [WK INSERT LINK].

Buprenorphine prescribing

When we first began to outline areas in the curriculum that covered substance use and pain topics, students pushed to take this one step farther to see if the curriculum could satisfy the Drug Enforcement Administration (DEA) X-waiver requirements to prescribe buprenorphine for opioid use disorder (OUD). Students and faculty created a medication for OUD practicum that was incorporated into the postclerkship curriculum. This practicum includes asynchronous prework reviewing foundational teaching on medication for OUD and a 2-hour in-person didactic with 4 interactive patient cases spanning age, gender, and special populations. This practicum, combined with preclerkship addiction training, provided sufficient training for students to meet requirements for their DEA X-waiver. As of 2024, more than 600 students in 4 graduating classes had received X-waiver equivalent training. Although recent changes in X-waiver requirements no longer necessitate this training, these didactics remain in the curriculum because the DEA maintains required OUD and SUD training.

Access to and training on naloxone rescue

Before the inception of the committee, students from the Student Coalition on Addiction had led efforts for naloxone to be included in basic life support training for each medical student.⁸ However, when students went to their local pharmacy to procure doses to distribute to the medical school as part of the Massachusetts standing prescription order, they were hindered by supply shortages and cost-prohibitive price tags for over-the-counter kits. Students on the SUPCC worked with the outpatient pharmacy at an affiliate teaching hospital to establish an expedited pathway for medical students and residents to obtain naloxone processed through insurance and shipped directly to their homes.⁹ This pathway was established in 2022 and as of 2024 has distributed 150 doses of naloxone to medical students and 150 to residents and hospital staff.

Case-based acute pain management training

Despite the presence of foundational teaching on pain medicine, the curriculum lacked education on practical aspects of pain management in clinical scenarios. In 2024, we introduced didactics in both the core medicine and surgery clerkships to prepare students to provide effective pain management across a variety of clinical scenarios. In the core medicine clerkship, we developed a primer on the various forms of medical pain management, enabling students to engage more critically in discussions about optimal pain regimens. We have also created an interactive case aimed at providing students with the fundamentals of OUD epidemiology, diagnosis, and management with an emphasis on harm reduction. Four pilot sessions for this didactic conducted from February to October 2024 included more than 30 clerkship students, and validated assessments completed before and after the sessions demonstrated significant improvement in knowledge about managing acute pain in patients with OUD, identifying examples of harm reduction, and counseling patients on medication for OUD. For the core surgery clerkship, our team developed an interactive case session taught in small groups to review different methods of acute pain management used by the perioperative team.

Next Steps

During the 3 years after our restructuring in 2021, the SUPCC deployed a student-centered approach that allowed us to develop curricular improvements that extend beyond knowledge acquisition and into clinical practice. The primary innovation of our work, however, is the student-led model of curriculum development, an implementation strategy that helped overcome several institutional implementation barriers while providing important learning and career development opportunities for students. We believe this curriculum and change-making process can serve as a blueprint for other medical schools on how they can establish workflows where students and faculty work as peers to bring about lasting and impactful curricular improvements.

The Substance Abuse and Mental Health Services Administration released a report in April 2024 outlining a core curriculum on SUDs for medical education programs.¹⁰ Through the efforts of our committee, the HMS has already incorporated many of the suggested topics and championed their push to include students as stakeholders in curricular change.

Although our work has established a longitudinal curriculum across all stages of medical training, we believe more must be done in clerkship rotations to help students apply their substance use and pain education in the clinical setting. Students are working to incorporate teaching on nonopioid substances, such as alcohol, cannabis, and ketamine. We are also developing longitudinal clinical experiences so students learn to care for patients with SUD and chronic pain from short-term intervention to long-term recovery. We are working to develop surveys to quantitatively and qualitatively measure the outcomes of our curriculum, including the acquisition of core knowledge in addiction and pain medicine, preparedness of graduating medical students to treat patients with SUDs and chronic pain, and the number of students pursuing careers with a focus in addiction and pain medicine.