How Is Health Science Education Tackling the Opioid Crisis?

The Winter 2020 Webcast Audio Seminar Series of the International Association of Medical Science Educators (IAMSE), “How is Health Science Education Tackling the Opioid Crisis?” highlighted innovative health professions’ curricula which focused on different aspects of the opioid crisis. These curricula, developed by a wide range of health professions educators, underscored the socio-economic and political impact of the current opioid crisis on health care and explored multiple options for the ongoing prevention and treatment of opioid substance use disorder. Leading health science education experts presented each of the five webinars and each webinar was broadcast live, weekly from January 9th through February 6th, 2020, to an international audience.

Responding to the Opioid Crisis: An Educator’s View

Presenter: Lisa Graves of the Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA

Dr. Lisa Graves introduced the series by identifying a 1980 Letter to the Editor in the New England Journal of Medicine (NEJM) [1] which is widely believed to be responsible for advancing the opioid crisis through misinterpretation and misinformation. Dr. Graves posited that the antecedents of the opioid crisis in the medical education literature provide a unique educational opportunity for all medical educators to better interrogate and evaluate the literature used in clinical decision-making. She noted the paucity of peer-reviewed medical literature, which specifically targets opioids, and encouraged medical educators to fill this gap through timely and rigorous research. Dr. Graves introduced webinar participants to a competency-based, online curriculum entitled “AFMC (Association of Faculties of Medicine of Canada) Response to the Opioid Crisis” [2], which is currently under development in Canada. The curriculum is designed to be spiraled, integrated, and interleaved across all years of medical school training. The anticipated completion date for this curriculum is 2021. Dr. Graves then reviewed current medical education strategies for addressing the opioid crisis. These strategies included naloxone training for medical students, Drug Addiction and Treatment Act 2000 (DATA) waiver training programs in the undergraduate (UME) and graduate medical education (GME) curricula, and the 2019 AAMC Opioid Crisis Summit. Dr. Graves concluded her presentation with recommendations for the development of a comprehensive substance use disorder curriculum that covers the physician training continuum. These recommendations were as follows: (1) engaging a broad swath of stakeholders in the development of the curriculum; (2) creating a non-stigmatizing lexicon and structured behaviors to communicate, teach, and interact with all members of the substance use disorder team; (3) linking the perspectives of substance abuse treatment providers and pain management providers to address the many psycho-social and economic complexities associated with the opioid crisis; (4) building upon existing curricular interventions; (5) sharing methods, strategies, and approaches that are both successful and unsuccessful in order to create a more informed curriculum; and (6) ensuring the curriculum can be adapted to UME, GME, and CPD (Continuing Professional Development).

Integrating Opioid Use Disorder and Medication Based Treatment into Undergraduate Medical Education

Presenter: Paul George of the Warren Alpert Medical School (AMS) of Brown University, Providence RI, USA

During the second webinar in this series, Dr. Paul George highlighted the negative impact of the opioid crisis on life expectancy in the USA. He also examined physician opioid prescribing habits, noting that they have recently tapered off, but remain a contributing factor to opioid overdose deaths. In response to a Rhode Island (RI) state government mandate that all RI medical students be DATA waiver trained, Dr. George described how the AMS curriculum had been adapted to enable graduates to meet this requirement. He provided further details of the AMS 4-year substance/opioid use disorder thematic curriculum which includes the following key features: exploring the science of pain, investigating non-opioid and non-pharmacologic pain treatments, screening and behavioral intervention and referral for treatment (SBIRT), interactive workshops on pain and pain management, didactic sessions on medically assisted treatment (MAT), interprofessional workshops on creating a team-based plan of care, and collaboration with the Academy of Addiction Medicine (AAAM) to include elements of provider clinical support systems. Based on his expertise and experience, Dr. George made the following recommendations for creating a substance/opioid use disorder curriculum for physician trainees: (1) make the curriculum integrated, longitudinal, and interprofessional; (2) partner with key stakeholders; (3) use a variety of teaching modalities; and (4) link curricula across UME, GME, and CPD and include private practice and community physicians. Dr. George concluded the webinar with a call to include opioid education as part of the Liaison Committee for Medical Education (LCME) and the Accreditation Committee for Graduate Medical Education (ACGME) accreditation standards.

Methods for Incorporating Opioid Education in Health Professions Curricula

Presenters: Sherry Jimenez and Jeremy Buchanan of Lincoln Memorial University (LMU), DeBusk College of Osteopathic Medicine, Harrogate TN, USA

In the third webinar in this series, Dr. Sherry Jimenez and Mr. Jeremy Buchanan provided a detailed overview of the interprofessional opioid curriculum implemented at LMU. Dr. Jimenez explained that the goals for this curriculum were to integrate opioid education across all the health professions at LMU and to connect students directly with the community as part of experiential learning. A key component of this curriculum is an interprofessional symposium developed by the LMU Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), and Nurse Practitioner (NP) health professions schools. In 2018, this day-long symposium was rolled out and focused on best practices for substance use disorder prevention and non-prescription treatment options. Evaluation data collected from this symposium demonstrated the following learning outcomes: increased knowledge about widespread controlled drug misuse, and increased awareness about controlled drug misuse in the health professions and the greater LMU community. In 2019, LMU revised the symposium structure to a half-day format with a 15-min simulation. This symposium, entitled “Synthetic Opioid Surge,” focused on understanding the difference between opioids and synthetic opioids and describing different treatment models that contribute to positive health outcomes. Dr. Jimenez provided an overview of the proposed 2020 symposium which will underscore the relationship between adverse childhood events and opioid use. Dr. Jimenez and Mr. Buchanan highlighted the value of interprofessional curriculum collaboration by showing a video developed by the LMU health professions schools. The video focused on interprofessional communication and team-centered patient care for a vehicular collision scenario. Mr. Buchanan noted that this video is available to anyone who is interested [3].

Informing Pain Management Curriculum: A Multi-Disciplinary Discussion on Alternatives to Opioids

Presenters: Suzanne D. Lady of Western States Chiropractic College, Portland OR, USA; Narda G. Robinson of CURACORE VET and CURACORE MED, Ft. Collins, CO, USA

Dr. Suzanne Lady introduced the fourth webinar in this series by drawing attention to the 1999 “Pain as the Fifth Vital Sign” initiative by the American Pain Society (APS) which sought to create an awareness that patients experiencing pain were being undertreated. She further highlighted the 2007 guidelines disseminated by the American College of Physicians (ACP) and APS for non-addictive, over-the-counter (OTC) pain medications for low back pain which were developed in response to the opioid crisis. She noted that recent studies do not necessarily support the efficacy of these suggested OTC pain medications, especially in light of their side effects. Dr. Lady then reviewed the recommended complementary and alternative medicine (CAM) treatments for pain. She explained that pain is influenced by a person’s biology, pain beliefs, and attitudes, as well as the availability of a social support system. Due to the complexities of pain management, Dr. Lady recommended teaching and approaching pain management from a bio-psycho-social perspective. Dr. Lady then discussed the benefits of “spinal manipulation” therapy as an alternative to medications. She concluded her presentation with a comprehensive review of international and interdisciplinary guidelines for low back pain.

Dr. Narda Robinson focused her presentation on integrative medicine, a field that uses practices which traditionally have not been a part of conventional medicine. She reiterated that evidence demonstrates that manipulation enhances function while medications do not. She stressed that pain care is evolving into a multi-modal, evidence-informed model and, as an example, described Pain Rehabilitation and Integrative Medicine Advantage (PRIMA), a parallel training pathway for human and veterinary medicine. Dr. Robinson made the following global recommendations for addressing pain management: (1) adopt a team-based approach to pain management by bringing together conventional, complementary and other health care professionals who treat pain; (2) include pain management and integrative medicine learning experiences as required components of the medical school curriculum; (3) create integrated clinical preceptorships and residencies to promote interdisciplinary learning opportunities; (4) include patient palpation beginning in year 1 and continuing throughout the UME curriculum; and (5) build a healthier workplace culture for overworked and overstressed practitioners. Dr. Robinson pointed out the following challenges associated with incorporating integrative therapies with conventional medicine: (1) lack of faculty support, (2) insufficient awareness of scientific support for integrative therapies, (3) prescribing habits of practitioners, (4) reimbursement, and (5) corporate influence over curricula. Dr. Robinson ended her presentation by suggesting that moving away from opioid reliance involves learning new ways to heal and be healed by integrative therapies in order to help patients take control of their lives and be well.

Marijuana and Medical Trainees: Complex…

Presenter: Lee Jones of the University of California San Francisco, San Francisco (UCSF), CA, USA.

In the fifth and final webinar of this series, Dr. Lee Jones provided a comprehensive overview of the physical, legal, and professional effects of marijuana use by physicians and physician trainees. Dr. Jones noted that marijuana is the most commonly used psychotropic drug by young adults in the USA. He also pointed out that in the USA, state laws that govern marijuana use are different from state to state and add another layer of complexity to the issue. In addition, on a federal level, US institutions that receive federal research or financial aid monies must have policies that comply with federal drug laws which consider marijuana to be illegal. Dr. Jones outlined the physical effects of marijuana use based on a study by Crean et al. [4] that showed impaired cognitive functions on many levels including basic motor coordination and more complex executive function tasks. He further noted that these deficits vary depending on the quantity, recentness, age of onset, and duration of the marijuana use. In his discussion about marijuana use within the profession of medicine, Dr. Jones highlighted the following issues that apply to physician trainees who use medical and recreational marijuana: (1) ADA (Americans with Disabilities Act) protections for protected disabilities do not extend to the use of non-FDA (Federal Drug Administration)approved medications, which include marijuana; (2) institutions that employ residents are within their right to deny employment because of a positive cannabinoid screen for marijuana use; (3) residency match in a state that has legalized medical marijuana use does not protect medical school graduates from adverse consequences (such as match revocation) related to the use of legalized and/or medical marijuana; (4) an increasing number of clinical rotations, including medical school clinical sites, are requiring substance abuse screening, including marijuana; and (5) instead of using medical marijuana for treatment purposes, consider using FDA-approved treatments and, (6) although controversial, second-hand marijuana smoke exposure can potentially produce a positive screening result. Dr. Jones concluded his webinar by recommending repeated dissemination of information to medical students as it relates to the potential consequences of medical and/or recreational marijuana use and the residency match. He included an article from UCSF as a guide for developing support systems for substance abuse disorders during physician training [5].

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Conflict of Interest

The authors declare that they have no conflict of interest.