Innovative Approaches to Educating Future Clinicians about Opioids, Pain, Addiction and Health Policy

Abstract

Background:

Opioid use disorder and overdose have reached unprecedented levels in many countries across the globe, including the United States, and pain is one of the most common reasons American adults seek healthcare. To address the interrelated public health crises of opioid use disorder and chronic pain, it is vital that clinicians practicing in diverse roles and settings possess the ability and knowledge to effectively manage pain, responsibly prescribe and monitor opioid analgesics, educate patients about harm reduction techniques, and treat opioid use disorder. However, future healthcare professionals are not receiving the training needed to competently provide this care. This gap in curriculum may lead to clinicians being unwilling and unprepared to address the current opioid and overdose crises, which requires a clinical understanding of pain and substance use disorders as well as knowledge about public health and policy interventions. To address this gap, we designed and are teaching an innovative transdisciplinary elective course titled “Opioids: From Receptors to Epidemic” for undergraduate nursing and premedical students.

Aim:

In this paper, we present the course curriculum in detail, with the hope that educators at other institutions will design similar courses for their health professions students.

Opioid use disorder and overdose have reached unprecedented levels in many countries across the globe, including Canada, Scotland, Russia, and the United States (Government of Canada, 2018; National Records of Scotland, 2019; Mathers et al., 2008; Centers for Disease Control, 2018). From 1999 to 2017, the number of overdose deaths in the United States involving opioids increased from 8,050 deaths to over 47,000, becoming the leading cause of accidental death (Centers for Disease Control, 2018; Scholl et al., 2019). Concurrently, pain is a serious health concern, with chronic pain being one of the most commonly cited conditions that leads US adults to seek care (Dahlhamer et al., 2018). Opioid control efforts and clinician fears surrounding prescription opioids have created barriers for some patients seeking chronic pain treatment, which may lead to unmanaged pain, risky attempts to self-medicate, and self-harm (Demidenko et al., 2017; Dowell et al., 2019; Rothstein, 2017). To address the public health crises of opioid use disorder and chronic pain, it is vital that clinicians practicing in diverse roles and settings possess the ability and knowledge to effectively manage pain, responsibly prescribe opioid analgesics, educate patients about harm reduction techniques, and treat opioid use disorder. Clinicians knowledgeable about pain management and substance use disorder can also be leaders in the development and implementation of policy addressing these interrelated public health crises.

Healthcare professional curricula at undergraduate and graduate levels currently lack the content needed to adequately prepare future clinicians to intervene at the clinical and policy levels with regards to opioid use disorder and pain (Mezei & Murinson, 2011; Smothers et al., 2018; Watt-Watson et al., 2009). A survey of six prelicensure health professional programs in five US states found that 1% of nursing curriculum hours were focused on pain, significantly less than in medical/pharmacy programs (2%), dental (6%), and physician assistant (PA) (17%) programs (Doorenbos et al., 2013). Curricula on substance use disorders are also limited (Finnell et al., 2018; Knopf-Amelung et al., 2018; Smothers et al., 2018) Nurses are the largest healthcare workforce, which places them in an ideal position to screen for unmanaged pain and substance use disorders, as well as to advocate for patient needs (Knopf-Amelung et al., 2018; Nash et al., 2017; Oermann, 2018; Savage et al., 2014). Ensuring that undergraduate nursing students receive education focused on substance use disorders helps to reduce stigmatizing attitudes and increase competence and confidence in managing patients with these diseases (Koetting & Freed, 2017; Lewis & Jarvis, 2019; Mahmoud et al., 2018; Nash et al., 2017). Graduate nursing and medical education is similarly lacking in substance use disorder content; nurse practitioner and medical students receive as little as 3 hours of classroom-based education and scant clinical substance use disorder education (Campbell-Heider et al., 2009; The National Center on Addiction and Substance Abuse at Columbia University, 2012).

Recent efforts to address the dearth of opioid-related content in health professional curricula include a program developed by the Arizona Department of Health Services and faculty from Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP), Doctor of Dental Medicine (DMD), Doctor of Podiatric Medicine (DPM), and Doctor of Naturopathic Medicine (ND) programs in the state (Arizona Department of Health Services, 2018). This content is free of charge, and schools may incorporate it into their curriculum as appropriate. Unfortunately, details about the content of this program are unclear, as is how and when schools are integrating the curriculum into their courses and whether it includes public health and policy modules. Faculty implementing such curricula should write about and disseminate their experiences to guide other educators in the design of innovative courses (Smothers et al., 2018).

The detrimental effect of this lack of training is apparent in the healthcare community’s response to the opioid and overdose crises. While access to medications for opioid use disorder (MOUD) is necessary in the effort to decrease opioid relapse and overdose, individuals desiring MOUD face barriers. For example, less than 10% of patients requiring specialty substance use disorder treatment in the past year were able to access that treatment (Substance Abuse and Mental Health Services Administration, 2019). In the case of buprenorphine, this is in part due to a lack of willing and certified prescribers (Fiscella et al., 2018). Any physician, NP, or PA is now able to prescribe buprenorphine in the US with an “X-waiver,” but a lack of education and concerns about the safety of buprenorphine may discourage potential prescribers (Tong et al., 2018; Wakeman & Barnett, 2018). It is also possible that biases and fears about the patient population in general contribute to an unwillingness to provide comprehensive care for individuals with substance use disorders (Provenzano, 2018). Patients seeking chronic pain treatment also face barriers as clinician fears about opioid prescribing and lack of education about comprehensive pain management approaches, as well as policies and opioid control efforts such as pharmacy limits on dispensing have led to decreased access (Demidenko et al., 2017; Dowell et al., 2019; Rothstein, 2017).

Future clinicians and health policy makers should thus receive comprehensive training in two vital areas: pain and substance use disorders. Curricula must include the safe and responsible management of pain with opioids as well as other pharmacological and nonpharmacological approaches, screening and treatment for opioid and other substance use disorders, harm reduction techniques for patients who use substances, treatment of pain in individuals who suffer both substance use disorder and chronic pain (and other special populations including elderly and pregnant patients), and content related to pain and substance use policy, including the War on Drugs and opioid control efforts. Bolstering education in these areas will produce professionals willing and able to fill the clinician void and to intervene at a policy level.

Opioids: From Receptors to Epidemic

As a group of educators at a top-ranked US nursing school, we felt that it was imperative to address this gap in our curriculum. We designed and taught an innovative transdisciplinary elective course titled “Opioids: From Receptors to Epidemic.” The purpose of this course is to provide undergraduate nursing and non-nursing majors with a foundation in opioid pharmacology as it relates to both pain management and opioid use disorders, and a broad understanding of the policy and public health consequences associated with the opioid crisis.

A primary goal of the course is to recruit undergraduate students representing future clinicians (nursing and premed students), policy makers, social workers, and scientists. Because the treatment of both substance use disorders and pain are best provided by interdisciplinary teams, this course was designed for a diverse group of students, with a secondary goal of providing a shared multidisciplinary learning environment. There are six main course objectives: (1) describe the anatomy and physiology of pain and the differences between acute and chronic pain and how they are treated; (2) explain opioid pharmacology (agonists, antagonists, and mixed agonist/antagonists) and how these medications are used to treat pain; (3) describe the neurobiology of opioid use disorders; (4) compare different treatment options currently used to treat opioid use disorders, including for pregnant women and neonatal abstinence syndrome; and (5) explain the historical foundations and current political climate surrounding the opioid overdose crisis as well as the societal impact of the opioid overdose crisis.

Opioid receptor pharmacology, including central and peripheral sites of action as well as cellular and molecular neuroadaptations to opioids, are discussed in relation to substance use disorders, physical dependence, tolerance, hyperalgesia, and withdrawal. Genetic and pharmacogenomic effects on opioid efficacy are also presented. Opioid use disorder and the actions of opioids on pain systems are reviewed, with an emphasis on their preclinical and clinical expression. The effects of regulatory, pharmaceutical, and criminal justice forces on opioid prescription in the United States are considered vis-à-vis pain management and opioid use disorders. Finally, the causes and consequences of the current opioid and overdose crises are reviewed, as are federal, healthcare, and community efforts to address it. We welcome guest lecturers from a variety of backgrounds, including nursing, medicine, psychology, public health, and law. In Table 1, we outline briefly the topics covered in the course in the hope that educators at other universities will consider our syllabus as a guide when designing similar opportunities for their students. In the Appendix, we provide a list of example readings that educators may choose to assign in their courses.

Table 1.

Weekly Class Topics

Weekly Topics	Content Details
Neuroanatomy and physiology of pain	• From nociceptors to ascending and descending pain pathways
Acute vs. chronic pain	• Chronification of pain
	• Central sensitization
	• Gate-control theory
Pain treatment disparities	• Racial, ethnic, age, and gender
Nonopioid pain treatment modalities	• Efficacy of nonopioid analgesics in treating nociceptive and inflammatory pain versus neuropathic and functional pain
Biopsychosocial model of pain	• Interdisciplinary pain clinics
	• Cognitive behavioral therapy
	• Mindfulness
Opioid pharmacology	• Agonists, antagonists, mixed agonist/antagonist drugs
	• New directions: biased agonists
Neuroscience of opioid use disorders	• Drug reinforcement
	• Development of compulsive drug-taking
	• Withdrawal phenotypes
	• Craving-induced relapse
Animal Models of Addiction	• Modern behavioral neuroscience approaches to understanding opioid use disorder
Clinical presentation of opioid use disorder	• Medical and psychiatric comorbidity
Treatment for opioid use disorders	• Medication for opioid use disorder (MOUD)
	• Psychosocial interventions
	• Harm reduction approaches
Neonatal abstinence syndrome	• Treatment of pregnant women
	• Treatment of neonate
History of the current opioid overdose crisis	• Pharmaceutical industry involvement
	• Impacts of US foreign policy on drug manufacturing and supply from Mexico
	• “Pill mills” and prescribing practices
	• Introduction of increasingly potent opioids
Opioids and the law	• Federal and state regulations
	• US “War on Drugs” approach
	• Decriminalization and legalization
Policy responses to the opioid crisis	• Prescription Drug Monitoring Programs (PDMPs)
	• Pennsylvania- and Philadelphia-specific approaches: local syringe exchange services, city-sponsored harm reduction efforts, housing-first initiatives
	• Safe-consumption sites

The class runs for a full 14-week semester, and meets for 90-minute sessions twice weekly. The first meeting of each week is a didactic lecture presented by course faculty or a guest speaker. The second meeting involves student-led presentations corresponding with topics presented in the previous lecture, such that students are able to take a deeper dive into topics they are intrigued by. This format offers the opportunity for students to practice oral presentations and stimulate class discussion. Students are evaluated with weekly quizzes based on assigned readings, an in-class short-answer midterm exam, weekly student-led presentations, and a take-home short essay final exam. Final exam short essay questions are focused on hypothesis-driven behavioral pharmacology experiments, policy issues related to the opioid crisis, and identification of important areas needing further research, such as new treatment modalities. This final exam format provides an opportunity for students to think critically and defend their thoughts in scholarly written format.

Per course evaluations, students rated the overall quality of the course a 3.83 on a 0–4 scale the first year it was taught and a 3.88 the second year. According to one of the students, “this was a really interesting and valuable course…it focuses on the prevalence of addiction and chronic pain, and connects it to the current opioid crisis. I think every student, especially pre-health, should take this course.” Another student stated “I learned so much about opioids, pain, and the epidemic we are currently facing. I think the course is very topical and relevant. I was blown away by the number of speakers that came to speak who are leaders in their practice…gave me an entirely new perspective on the crisis we are currently facing as well as better ways to engage with people suffering...this class is incredibly applicable to many sectors including nursing and policy-making.”

Conclusion

According to Facing Addiction in America: The Surgeon General’s Spotlight on Opioids, “the existing health care workforce is already understaffed and often lacks the necessary training and education to address substance use disorders” (U.S. Department of Health and Human Services HHS & Office of the Surgeon General, 2018 p 9). We believe that courses such as this one are a vital step in addressing the current opioid and overdose crises, and it is our hope that students leave this course with a basic understanding of pain and opioid use disorders and the complex ways in which both impact therapeutic approaches and society. As stated by one of our students, the class provided “a great environment that brought together future clinicians from different fields to learn about important topics that we will be faced with.” Future plans include expanding the course to graduate students from nursing and other disciplines.