Table of Contents Summary
This study describes pediatric residency program training in adolescent substance use and opioid misuse, correlates training to local overdose rates, and identifies gaps in training.
INTRODUCTION
Nine in 10 adults with a substance use disorder began using substances before age 18.1 Among youth, opioid and polysubstance overdose deaths have increased by 384% and 760%, respectively, since the late 1990s.2 Pediatricians need training in screening, brief intervention, and referral to treatment (SBIRT) for substance use disorders, and in medication treatment for opioid use disorder (OUD)—all recommended as best practice by the American Academy of Pediatrics (AAP).3-5
Pediatric residency training on substance use and opioid misuse is poorly described. The extent to which training relates to regional needs—perhaps most importantly, local overdose death rates—is also insufficiently characterized. We conducted a survey of US pediatric residency programs to assess training in youth substance use and compared findings to regional overdose mortality. We hypothesized that programs located in counties with elevated mortality would be more likely to offer substance use training, but that overall, the percentage offering such training would be low.
METHODS
We developed an online survey on substance use education that was approved and distributed by the Association of Pediatric Program Directors (APPD). The 25-item survey assessed program leadership’s estimated content on substance use and the perceived quality of that training. The survey was distributed by email to pediatric associate program directors (APDs) from all 201 US pediatric residency programs in March 2019. APDs were surveyed per recommendation by the APPD and were given the option of forwarding the survey to a faculty member with more knowledge about the curriculum. Results presented in this manuscript are a from subset of questions from the survey; full survey and results are available online (https://hdl.handle.net/2144/41197).
Opioid overdose mortality for each program’s county was obtained from CDC Wide-ranging Online Data for Epidemiologic Research.6 Counties were classified as having ‘high’ or ‘low’ mortality relative to the national 2018 age-adjusted mean of 14.6 per 100,000.7
Descriptive statistics were used to summarize results, with chi-square analyses to evaluate associations between training and location within ‘high’ vs. ‘low’ overdose counties. The study was considered exempt by the Boston University Medical Campus Institutional Review Board.
RESULTS
Surveys were completed by 120 of 201 programs (60%; Table 1). Ninety-seven programs had county-level overdose data and were included in final analyses. Most programs offered some education on adolescent substance use (n=80, 82.5%); 77 programs required it, and 61 programs offered elective opportunities. Fewer than half provided training inclusive of AAP-recommended SBIRT (n=40, 41.2%; Table 2).
Table 1.
Characteristics of residency programs (n=97).
| Residency Program Characteristicsa | Total n (%)b |
|---|---|
| Size | |
| <30 | 17 (17.5) |
| 30-60 | 42 (43.3) |
| >60 | 38 (39.2) |
| Type | |
| Categorical pediatrics only | 49 (50.5) |
| Combined and other tracks also present | 48 (49.5) |
| Setting | |
| Free-standing and other university-based hospitals | 45 (46.4) |
| Community-based and military | 52 (53.6) |
| Region | |
| Northeast | 33 (34.0) |
| Midwest | 21 (21.6) |
| South | 27 (27.8) |
| West | 16 (16.5) |
| County overdose mortality c | |
| Above median | 59 (60.8) |
| Below median | 38 (39.2) |
Ninety-seven programs had county-level data and were included in final analyses.
Some columns do not add to 100% due to rounding.
Relative to national median overdose death rate of 14.6 deaths per 100,000.
Table 2.
Adolescent substance use education at residency programs.
| Total n (%) | High overdose countya |
Low overdose countya |
p-value | |
|---|---|---|---|---|
| Education about adolescent substance use | ||||
| Any | 80 (82.5) | 52 (88.1) | 28 (73.7) | .07 |
| Screening | 77 (79.4) | 51 (86.4) | 26 (68.4) | .03 |
| Brief intervention | 61 (62.9) | 39 (66.1) | 22 (57.9) | .41 |
| Treatment | 41 (42.3) | 28 (47.5) | 13 (34.2) | .20 |
| All | 40 (41.2) | 27 (45.8) | 13 (34.2) | .26 |
| Education about opioid use disorder (OUD) | ||||
| Any | 67 (69.1) | 47 (79.7) | 20 (52.6) | .005 |
| Epidemiology | 46 (47.4) | 33 (55.9) | 13 (34.2) | .04 |
| Screening | 57 (58.8) | 40 (67.8) | 17 (44.7) | .02 |
| Medication for OUD | 30 (30.9) | 23 (39.0) | 7 (18.4) | .03 |
| Fentanyl | 22 (22.7) | 14 (23.7) | 8 (21.1) | .76 |
| Treating overdose | 48 (49.0) | 37 (61.7) | 11 (29.0) | .001 |
| Naloxone prescribing | 20 (20.6) | 15 (25.4) | 5 (13.2) | .15 |
| All | 9 (9.3) | 6 (10.2) | 3 (7.9) | .71 |
| Buprenorphine waiver course | ||||
| Offered | 22 (22.5) | 16 (26.7) | 6 (15.8) | .21 |
| Any resident completed | 15 (15.5) | 13 (22.0) | 2 (5.3) | .03 |
Counties classified relative to the national 2018 age-adjusted mean overdose death rate of 14.6 per 100,000.
Programs in high overdose counties were more likely to have education on opioids (including about substance-exposed neonates) as a part of their standard residency curriculum than those in low overdose counties (79.7% vs 52.6%, p=.005; Table 2). Few programs offered a buprenorphine waiver course (n=22, 22.5%), though programs in high overdose counties were more likely to have any residents complete this optional training (22.0% vs 5.3%, p=.03).
Overall, 97.5% of programs reported that training about opioid misuse was “important” or “very important,” though just 12.5% rated their overall education on opioid misuse as “good” or “very good.” The main barriers to providing education about adolescent opioid misuse included insufficient faculty expertise (62.8%), curricular time (50.4%), and available content (47.9%). Only 3.3% of programs identified lack of interest as a barrier. All (100%) respondents reported interest in a shared, web-based curriculum on adolescent opioid misuse and related topics.
DISCUSSION
Although most U.S. pediatric residency programs provide education about adolescent substance use, gaps remain, particularly with respect to opioid misuse. Programs in counties with a high opioid overdose burden had more training on OUD, but overall rates of training inclusive of treatment were low. Two AAP-recommended interventions, SBIRT and medications for OUD, were infrequently covered.4,5 Few programs offer education about how to prescribe naloxone, a life-saving intervention for opioid overdose, despite high regional overdose mortality and widespread availability of such training.
This study had limitations. The survey collected self-reported data, which may be subject to social desirability bias, and some respondents may have been unaware of the full extent of the training offered.
Given that substance use disorders often have their onset in adolescence and that opioid-related mortality among youth is rising, addressing gaps in training for pediatricians should be a priority.
Acknowledgements
Research supported by the Adolescent Fellow Immersion Training in Addiction Medicine 2020, Boston University School of Medicine (funded by NIH/NIDA R25DA013582).
Funding/Support:
Allen: HRSA/MCHB LEAH training grant T71MC00009. Hadland: NIH/NIDA K23DA045085, L40DA042434, and R25DA013582-19S1, Thrasher Research Early Career Award. Bagley: NIH/NIDA 1K23DA044324 and R25DA013582-19S1.
Role of Funder/Sponsor:
The NIH and HRSA had no role in the design and conduct of the study.
Abbreviations:
- AAP
American Academy of Pediatrics
- APD
Associate Program Director
- APPD
Association of Pediatric Program Directors
- OUD
Opioid Use Disorder
- SBIRT
Screening, Brief Intervention, Referral to Treatment
Footnotes
Conflict of Interest Disclosures: The authors have no conflicts of interest to disclose.
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