About Twenty years ago, doctors were taught that pain was the “fifth vital sign,” and something to be taken as seriously as blood pressure, heart rate, respiratory rate and temperature. As a result, there was a new duty for doctors to prioritize treating pain and many of them were taught the solution to treating pain was more prescriptions, often for opioids. We now know that about a quarter of patients who are prescribed opioids for chronic pain will misuse them. On average, 130 Americans die every day from an opioid overdose.
This epidemic has made many realize that addiction can begin in the doctor’s office so many med schools are rethinking the way they train the next generation of doctors. Four medical schools are taking on this new approach: The University of Massachusetts Medical School, the Warren Alpert School of Medicine at Brown University, the University of Michigan School of Medicine and the Uniformed Services University of the Health Sciences.
Training around use and misuse of opioids begins in the first year of med school, and students spend 30 hours of the curriculum learning about topics related to opioids and substance use. In addition to taking part in workshops, every med student receives training to prescribe buprenorphine. The medication, when combined with the opioid-reversal drug naloxone, is branded as Suboxone. It reduces the craving for opioids, as well as the chance of a fatal overdose. But federal regulations prevent clinicians from prescribing Suboxone without a waiver. Rules for obtaining the waivers vary from state to state.
“After graduating from medical school, a doctor could now prescribe pain medication,” said Dr. Sarita Warrier, an associate dean of medical education at the school. “They can prescribe Oxycodone, they can prescribe morphine. It seems almost unfair that they can’t prescribe a medication that’s used to treat some of the consequences of prescribing opioids. So being able to include buprenorphine training within our medical school curriculum became very important to us.”
Paul Wallace, a recent graduate of the medical school, is now going to focus on addiction psychiatry during his residency at University of California, San Francisco. Even though he’s pursuing a specialization in addiction medicine, he told On Point he thinks the certification is valuable for every student. “Unfortunately, my generation of physicians who are now close to midcareer are the ones who are on the frontlines with patients who are suffering from opioid use disorder, so we’re playing the catch-up game.” Dr. Paul George, Brown University “It helps dispel the notion that treating opioid use disorder is purely the domain of addiction specialists or primary care doctors when truly all different types of physicians are going to encounter patients with opioid use disorder, whether it be an emergency physician who seeing a patient after an overdose or an obstetrician who’s working with a pregnant patient with opioid use disorder,” he said.
All medical students, and all graduate nursing students, take part in what the school calls its “OSTI” program, which stands for Opioid Safe Prescribing Training Immersion. This education begins in the first year for medical students, and includes work with standardized patients, and panels where students can hear from patients and their family members, to name a few.
When Dr. Michael Englesbe was a surgery resident about three decades ago, he said he received no specific education about prescribing opioids.
“So the way surgeons learn [is], your first day as a resident, you ask the person sitting next to you how many pills do you get for this procedure,” he said. “That number continued to get more and more over the past decade or two, and surgeons were kind of running for more and more opioids.” “What we learned is, we as nurses and doctors do a poor job of talking to patients about their pain and how we can best care for it,” said Dr. Englesbe, professor of surgery at the University of Michigan Medical School. “This has expanded to a point where this small template of trying to align the pills to their pain has been exported across every procedure in the state of Michigan.”
The university estimates that the introduction of the new curriculum has prevented more than 40,000 excess pills from entering the community. Senior medical students at the university learn a technique that’s called “battlefield acupuncture.” Needles are put in up to five different points in a patient’s outer ears and fall out on their own after a few days. Dr. Arnyce Pock, associate dean for curriculum at the university, said patients have seen results in as little as a few minutes.
“In our clinic we’ll have patients coming in with say eight or nine out of 10 severe back pain,” she said. “We’ll put these needles in their ears, one at a time. And it’s not uncommon that five or 10 minutes later the patient walks out of the clinic either completely pain free or with her pain dramatically reduced from where they came in just with this alone.””Pain has an emotional quality to it. People will feel pain and it will manifest in other ways. So I think having this broader picture is important.” Jason Tsichlis, Brown University medical student
The technique was named “battlefield acupuncture” because, even in a disaster zone, the ears are accessible. But Pock says the technique isn’t limited to people who have been in combat. Between 2014 and 2016, 2,700 physicians, nurses and physical therapists were trained in the technique as part of a collaboration between the Department of Defense and the Department of Veterans Affairs. Now, she says the technique is being used extensively throughout the Washington, D.C., area.
“The beauty is even if the technique doesn’t work 100 percent, [meaning] it doesn’t bring someone’s pain all the way down to a zero, and even if they need some additional medication, chances are they’ll need far less medicine than they might have had they not had this technique,” Pock said. All of this training is just the beginning. But it’s making a difference for students. And, while that broader picture is critical to informing how practitioners approach treatment, the rest of the health care system needs to catch up, said Dr. Kelly Clark, the immediate past president of the American Society of Addiction Medicine.
“The structure that we have now of having treated addiction like a social or a moral problem with social approaches only versus where we need to be with a whole continuum of care, is really the same issue we have with pain management,” she said. “We have not built it in, [and in] some cases have dismantled a multidisciplinary infrastructure that is so needed.”
Dr. Englesbe, from Michigan, said that there’s always room to grow the curriculum. The changes put in place are a good start, ones he hopes will inform students for years to come. “Now, what we give students in the curriculum is more than just knowledge,” he said, “it’s agency to create change.”
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