An evaluation of an inpatient opioid use disorder consult service elective for medical trainees

Abstract

Background

As the opioid epidemic continues to progress, identifying clinical opportunities to train the healthcare workforce is key. Integrating trainees into an existing Opioid Use Disorder (OUD) consult service presents an opportunity to meet this need.

Methods

From 7/2021 to 6/2023, 34 trainees (24 residents/fellows, 10 medical students) completed a 2-week OUD consult service elective. A post-elective survey assessed 4 domains: success meeting learning objectives, preparedness to manage inpatient OUD, clinical exposure to consult scenarios, and attitudes towards people who use drugs (PWUD).

Results

Twenty-five rotators completed the survey (74% response rate). After the elective, most agreed they had adequate training in OUD (80%) and felt prepared to diagnose (96%) and treat (92%) OUD. Learning objectives were met, clinical exposure was “just right” (91%), and rotators generally had positive attitudes towards PWUD.

Conclusions

An OUD consult service elective experience was associated with trainee confidence in managing OUD and little stigma toward PWUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07885-2.

Introduction

As opioid use disorder (OUD) and opioid-related overdoses contribute to a worsening public health crisis [1], opportunities for training a responsive healthcare workforce are needed. While the Accreditation Council of Graduate Medical Education (ACGME) now requires all Internal Medicine (IM) training programs to provide educational experiences in addiction medicine [2], a 2019 survey from the Association of Program Directors in Internal Medicine reported that while most programs (72%) provided didactics in the treatment of OUD, less than 20% offered clinical experiences [3]. Additionally, most IM residents do not feel they have received adequate training in addiction medicine and report a lack of confidence treating OUD [4]. Given the high prevalence of OUD amongst hospitalized patients [5], integrating learners into existing addiction consult services provides an opportunity to address this educational gap.

While knowledge gained by rotating on an inpatient addiction medicine consult service has been previously demonstrated [6], the impact on self-perceived preparedness to treat OUD and attitudes towards people who use drugs (PWUD) has not been reported. The objective of this study was to evaluate a 2-week OUD consult service elective for medical trainees on meeting the elective learning objectives, preparedness to diagnose and treat OUD, exposure to common OUD consult service clinical scenarios, and attitudes towards PWUD.

Methods

Setting and Participants

An inpatient OUD consult service was created at an academic medical center in 2019 to improve care for hospitalized patients with OUD. The consult team, which includes an attending physician or advanced practice provider as well as consultative pharmacists, initiates medications for OUD (buprenorphine and methadone), provides harm reduction counseling, manages inpatient opioid withdrawal, addresses pain management in the context of OUD, guides management of other co-occurring substance use disorders (SUD), and links patients to community-based treatment. The consult service sees 45–60 new consults monthly.

In 2021, the OUD consult service began a 2-week consult service elective for fellows, residents, and medical students. Over two academic years (7/2021-6/2022, 7/2022-6/2023), 34 rotators participated including 24 residents/fellows (20 IM or medicine-pediatrics residents, 3 psychiatry residents, 1 palliative fellow), and 10 medical students (7 third year IM clerkship students, 3 fourth year elective students). Using a cognitive apprenticeship framework, rotators saw new consults and worked one-on-one with OUD consult service attendings (physician or advanced practice provider) [7]. Trainees received a syllabus that contained a list of learning objectives and recommended readings.

Evaluation

A 24-item year-end anonymous post-elective survey was distributed to all rotators (Online Appendix 1) through RedCap [8]. The survey included questions in four primary domains: the degree to which the elective learning objectives were met (preparedness, ability, comfort), preparedness to diagnose and treat OUD in the inpatient setting, clinical exposure to common consult scenarios, and attitudes towards PWUD. Questions were adapted from previously published learner assessments [4], stigma assessment tools evaluating medical trainees’ readiness to work with PWUD [9, 10], and based on course learning objectives. Items assessing preparedness, ability, comfort, and attitudes used four-point Likert-type scales (1 = “very unprepared”; 4 = “very prepared” and 1 = “strongly disagree”; 4 = “strongly agree”). Items assessing prior and current level of instruction used a 4-point Likert-type scale (1 = “none received”; 4 = “too much”). Items assessing clinical exposure used a 3-point Likert-type scale (1 = “too little”; 3 = “too much”). Descriptive statistics were used to analyze the survey.

This study was deemed exempt by the University of Chicago Institutional Review Board (IRB 22-1084). This determination was made under the Federal Regulations (45 CFR 46) category 0.104(d) [1]. Consent was not obtained from subjects given the above exemption.

Results

Of the 34 rotators who completed the OUD consult service elective, 25 completed at least part of the survey and 23 completed the survey fully (74% response rate, 68% completion rate). The two incomplete surveys were included in the analysis. Eighteen of the responses were from residents or fellows and seven responses were from medical students.

Almost all (96%, 24/25) rotators reported they had received inadequate (none/too little) training in OUD prior to the elective. Following the elective, this number decreased to 20% (5/25, X² = 19.0, p < 0.001), with 80% noting an adequate (“just right”) amount of instruction.

Post-elective, when assessing readiness to care for patients with OUD, most felt prepared to diagnose OUD (96% Agreed (A)/Strongly Agreed (SA)) and treat OUD (92% A/SA) (Table 1). In assessing learning objectives, all (100% A/SA) rotators agreed they could take a SUD history and distinguish SUD from substance use. Almost all were comfortable using pharmacologic treatments for OUD (92% A/SA) and OUD withdrawal (92% A/SA), and they felt confident describing the signs and symptoms of opioid withdrawal (92% A/SA). Most also felt confident describing harm reduction (92% A/SA).

Table 1.

Resident and medical student preparedness to diagnose and treat OUD and attitudes towards people who use drugs

Preparedness	Very Unprepared (1) n (%)	Somewhat Unprepared (2) n (%)	Somewhat Prepared (3) n (%)	Very Prepared (4) n (%)	Mean	SD	Median
I feel prepared to diagnose OUD.	1 (4%)	0 (0%)	8 (32%)	16 (64%)	3.56	0.71	4
I feel prepared to treat OUD.	0 (0%)	2 (8%)	7 (28%)	16 (64%)	3.56	0.65	4
Learning objectives	Strongly Disagree (1) n (%)	Disagree (2) n (%)	Agree (3) n (%)	Strongly Agree (4) n (%)	Mean	SD	Median
I can take a substance use disorder history.	0 (0%)	0 (0%)	6 (24%)	19 (76%)	3.76	0.44	4
I can describe the common signs and symptoms of opioid withdrawal.	0 (0%)	0 (0%)	2 (8%)	23 (92%)	3.92	0.28	4
I can distinguish a substance use disorder from substance use.	0 (0%)	0 (0%)	2 (8%)	23 (92%)	3.92	0.28	4
I feel comfortable using pharmacologic treatments for opioid use disorder.	0 (0%)	2 (8%)	10 (40%)	13 (52%)	3.44	0.65	4
I feel comfortable using pharmacologic treatments for opioid withdrawal.	0 (0%)	2 (8%)	11 (44%)	12 (48%)	3.40	0.65	3
I can describe harm reduction.	0 (0%)	2 (8%)	10 (40%)	13 (52%)	3.44	0.65	4
Resident and student attitudes towards people who use drugs	Strongly Disagree (1) n (%)	Disagree (2) n (%)	Agree (3) n (%)	Strongly Agree (4) n (%)	Mean	SD	Median
I can distinguish between stigmatizing and non-stigmatizing terms used to talk about drug use.	0 (0%)	0 (0%)	8 (33%)	16 (67%)	3.67	0.48	4
I feel as comfortable talking to a person with substance use disorder as I do talking to a person without substance use disorder.	0 (0%)	1 (4%)	14 (61%)	8 (35%)	3.65	0.56	3
Patients with substance use disorders have challenging medical and social issues from which I can learn.	0 (0%)	0 (0%)	1 (4%)	22 (96%)	3.96	0.49	4
People with substance use disorder can never recover enough to have a good quality of life.	18 (78%)	5 (22%)	0 (0%)	0 (0%)	1.22	0.21	1
If I had a substance use disorder, I would never admit this to any of my colleagues for fear of being treated differently.	1 (4%)	11 (48%)	8 (35%)	3 (13%)	2.57	0.42	2
People with substance use disorders who complain of physical symptoms (such as chest pain) get treated as seriously as those without it.	7 (30%)	13 (57%)	2 (9%)	1 (4%)	1.87	0.79	2
People should not expect to be treated for opioid withdrawal when they are in the hospital for another reason.	20 (87%)	3 (13%)	0 (0%)	0 (0%)	1.13	0.34	1
People with active opioid use disorder should not receive opioid analgesics to treat pain in the hospital.	18 (78%)	5 (22%)	0 (0%)	0 (0%)	1.22	0.42	1
Someone being prescribed buprenorphine or methadone for their opioid use disorder is replacing one addiction with another.	21 (91%)	2 (9%)	0 (0%)	0 (0%)	1.09	0.29	1

Legend: OUD = opioid use disorder

Clinical exposure to common OUD consult service scenarios is shown in Table 2. After the elective, almost all (91%) reported the level of clinical exposure to evaluating and starting patients on buprenorphine-naloxone (generally and using low-dose induction protocols) and methadone was “just right”. Most reported the level of exposure to patients with both acute pain and possible or confirmed OUD was “just right” (78%).

Table 2.

The level of exposure to consult clinical scenarios

	Too Little (1) n (%)	Just Right (2) n (%)	Too Much (3) n (%)	Mean	SD	Median
Evaluating and starting patients on buprenorphine-naloxone (Suboxone)	2 (9%)	21 (91%)	0 (0%)	1.91	0.29	2
Evaluating and starting patients on methadone	2 (9%)	21 (91%)	0 (0%)	1.91	0.29	2
Evaluating and starting patients on buprenorphine through low dose/micro-induction protocol	2 (9%)	21 (91%)	0 (0%)	1.91	0.29	2
Evaluating patients with acute pain and possible or confirmed OUD	5 (22%)	18 (78%)	0 (0%)	1.78	0.42	2

Legend: OUD = opioid use disorder

When assessing attitudes towards PWUD, most rotators agreed (80% A/SA) that patients with SUD who complain of physical symptoms are not attended to as seriously as those without it (Table 1). The majority (52% A/SA) would not admit to colleagues that they had a SUD for fear of being perceived differently. All respondents believed (13% A, 87% SA) that hospitalized people with SUD should expect to be treated for opioid withdrawal and that people with active OUD should receive opioid analgesics to manage pain in the hospital (22% A, 78% SA). Post-elective, almost all rotators reported feeling as comfortable talking to a person with a SUD as a person without a SUD (61% A, 35% SA). All agreed that patients with SUDs have challenging medical issues from which they can learn. Rotators disagreed (22%) or strongly disagreed (78%) that patients with SUD will never recover enough to have a good quality of life.

Discussion

While current clinical training in addiction medicine is variable and often inadequate, a 2-week elective on an inpatient OUD consult service was successful in meeting learning objectives, resulted in high rates of self-reported comfort in managing OUD, and demonstrated favorable attitudes towards PWUD.

The impact of substance use on patient health is increasingly visible in the hospital with more opioid-related admissions and complications of substance use leading to hospitalization [5]. Thus, it is imperative that trainees are prepared to address the needs of hospitalized patients with substance use disorders. Addiction consult services are instrumental in improving the care of hospitalized PWUD by initiating medication to treat OUD, improving engagement in outpatient treatment for OUD, and reducing 90-day all-cause mortality [11, 12]. The clinicians who lead these teams are uniquely situated to both address the needs of hospitalized PWUD and provide addiction medicine education to trainees.

Most trainees receive inadequate training to manage the medical and social complications of substance use. There has long been a call to increase the integration of addiction medicine education into graduate medical education [13]. Prior educational initiatives have shown improved knowledge acquisition from direct instruction [14] and asynchronous online modules [15]. Our study reinforces addiction consult services are effective in addressing the educational needs of trainees to prepare them to treat PWUD [6].

Integrating trainees into clinical addiction work also has the potential to counteract stigma towards PWUD. Addressing stigma is a priority when treating patients with OUD due to the relationship between stigma and significant disparities in health outcomes [16]. Based on the survey results, rotators recognize that there is public stigma towards patients with SUD that extends into our health system. However, after rotating on the OUD consult service, trainees expressed high levels of comfort working with patients with OUD and reported that learning from PWUD is valuable to their training. They also universally agreed that these patients deserve treatment for pain, withdrawal, and the opportunity to initiate medication for OUD during hospitalization.

Trainees self-selected to participate in the elective, which limits generalizability. There was also a small sample size due to the number of trainees completing the rotation. Data was collected at the end of each academic year to maintain anonymity, so variable amounts of time had passed between the rotation and the survey completion. Additionally, there was no pre-data collected to directly compare individual change resulting from the rotation. Future assessments would ideally be completed in a standardized timeframe after rotation completion and include a pre-elective survey for comparison.

Future directions include incorporating more and different types of trainees into the elective (anesthesia and infectious diseases fellows, and emergency medicine residents), building and assessing additional curricula to support the clinical experience of trainees, and assessing actual changes in clinical practice. A better understanding of how required clinical experiences impact skills, confidence and stigma for trainees with broad clinical interests is also needed. As scaling this clinical experience could be challenging, future research could also focus on comparing knowledge, attitudes, and skills gained in learners who have participated in this type of experience to other educational opportunities (DEA-mandated MATE training, etc.).

Conclusions

Given the prevalence of OUD, it is important for all physicians to feel confident managing the presentation and complications of OUD. The ACGME and DEA have highlighted the need for broader educational programs to provide clinical experiences in addiction medicine. A hospital-based OUD consult service elective resulted in increased adequacy of amount of OUD instruction, high trainee confidence in managing OUD, and little stigma towards patients with OUD.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

MP contributed to the conception/design of the curricular innovation, was responsible for data analysis and drafted the original manuscript. MA was responsible for conception/design of the curricular innovation, data acquisition and analysis, and drafted the original manuscript. GW, JPM, SD, and AJL contributed to conception/design of the curricular innovation and substantively revised the manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval

This study was deemed exempt by the University of Chicago Institutional Review Board (IRB 22-1084). This determination was made under the Federal Regulations (45 CFR 46) category 0.104(d) which is for “Research, conducted in established or commonly accepted educational settings, that specifically involves normal educational practices that are not likely to adversely impact students’ opportunity to learn required educational content or the assessment of educators who provide instruction. This includes most research on regular and special education instructional strategies, and research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.” All experimental protocols were approved as above. Consent was not obtained from subjects given the above exemption. This research study adhered to the ethical principles of the Declaration of Helsinki.

Consent for publication

N/A.

Competing interests

The authors declare no competing interests.