P Clark, G Mamo, J Stout, B McNierney, J Treacy, D DiSandro, H Patrick, D Grana, G Rivera-Colón, T McCarthy, I Kondrat
addiction, curriculum, epidemic, opioid, public health
P Clark, G Mamo, J Stout, B McNierney, J Treacy, D DiSandro, H Patrick, D Grana, G Rivera-Colón, T McCarthy, I Kondrat. Opioid Task Force Phase Four: Undergraduate and Medical School Opioid Certification Curricula. The Internet Journal of Public Health. 2022 Volume 8 Number 1.
The Centers for Disease Control and Prevention (CDC) recently reported that there were over 107,000 deaths from drug overdoses in 2021 in the U.S., a 15% increase from 2020.1 Additionally, since the year 2000, more than one million people have died of a drug overdose, over half of those million deaths occurring in the last seven years.1 Thus, it is clear that the opioid epidemic is far from over and may not have reached its peak impact. Many authorities have cited fentanyl, the synthetic opioid up to 100 times more potent than morphine, as the culprit for the recent rise in deaths, while others point to the over prescription of opioids by physicians in the clinical setting. Whatever the cause, the epidemic is multifaceted with consequences beyond overdose deaths. We believe it is the responsibility of colleges and universities to educate young people, especially those pursuing a career in healthcare, about the epidemic in full. Thus, the following undergraduate and medical school programs aim to encompass all aspects of the epidemic via methods such as training, experiential learning, community service, and academic lectures. Through these, we hope to build a generation of healthcare professionals better equipped to face the crisis effectively.
Addressing a public health crisis as pervasive as the opioid epidemic requires a multifaceted approach. One imperative component of this stratagem includes educating current and prospective medical students about the management and prevention of substance use disorders.2 Proper training of future physicians is essential, as studies have shown a correlation between physician prescribing patterns and the likelihood that their patients will develop a substance use disorder.3,4,5 Lamentably, despite this correlation, individuals entering healthcare professions, and medical students specifically, often do not receive sufficient education on this topic.
Studies have demonstrated that medical schools have produced generations of physicians that are ill-equipped to handle prescribing opioids responsibly. A small study from 2000 examined the errors made by several final-year medical students in a prescribing exercise. It was found that a fundamental cause of prescribing errors was an insufficient scientific and clinical knowledge base. This supports the current trend toward integrating problem-based learning curricula within traditional medical education and emphasizes the importance of a strong foundation in basic science to minimize error.6
Undergraduate Certificate Program
We believe that this issue should be addressed through interventions in both undergraduate education programs and medical school curricula. First, at the undergraduate level, we propose the following three-pronged program that includes training sessions in CPR, naloxone administration, and Mental Health First Aid (MHFA), a 7-part lecture series that covers various topics pertaining to the opioid epidemic, and experiential learning events.
Naloxone is an opioid antagonist that reverses the effects of an opioid overdose by blocking opioid receptors in the central nervous system.7 While the administration of naloxone can quickly restore respiratory function to an individual whose breathing has slowed or stopped as a result of overdose, it does not have a pharmacological effect on the body when no opioids are present in the system.1 Also, the effectiveness of naloxone depends on the amount and type of opioids in the system. If the effects of one dose of naloxone wears off but opioids are still present in the body, the individual may experience the symptoms of an overdose again.1 Additionally, although naloxone has a higher affinity for the opioid receptors than opioids, reversing the effects of an overdose from some stronger opioids, such as fentanyl, may require multiple doses of naloxone.1 The administration of naloxone may also induce withdrawal symptoms in those who are physically dependent on opioids. Although sometimes serious, these symptoms are often not fatal, and the benefits of reversing a potentially fatal overdose far outweigh the risks of withdrawal symptoms or an adverse reaction to the naloxone itself.8
Naloxone may be administered as a nasal spray, such as brand names Narcan or Kloxxado, or injected intramuscularly, subcutaneously, or intravenously.1 The injectable form was approved by the FDA for use in 1971, but naloxone’s intranasal version was approved in 2015 in an effort to increase access, make it easier to use in nonmedical settings, and decrease the risk of infection from contaminated needles.9 Over the last decade, naloxone distribution has increased greatly. The number of naloxone prescriptions administered doubled from 2017 to 2018.10 However, still, only one naloxone prescription is written for every 70 high-dose opioid pain management prescriptions.4 That is why public health leaders, including former CDC Director Robert Redfield, are calling for even more widespread distribution of naloxone. As Redfield declared, “the time is now to ensure all individuals who are prescribed high-dose opioids also receive naloxone as a potential life-saving intervention.”4 Moreover, the CDC calls for states and communities to help encourage the distribution of naloxone at the local level by reducing the stigma surrounding writing and dispensing a naloxone prescription.4
According to the Legislative Analysis and Public Policy Association, as of 2020, all 50 states and the District of Columbia have adopted some sort of naloxone access law(s), most of which beginning in the 2010s.11 While most state laws approve medical professionals, those at risk of overdose, and the families of those at risk to administer naloxone, law varies widely on who beyond those categories are able to administer the drug.5 All states allow an individual to obtain naloxone without a prior prescription in at least some capacity, and 48 states offer legal immunity on some level to laypersons who administer naloxone “in good faith.”5
In Pennsylvania, state law certainly views naloxone access as a public health priority. Pennsylvania Statute Title 35 P.S. Health and Safety § 780-113.8 concerns naloxone access. It grants considerable discretion to laypersons, such as family, friends, first responders, or anyone in a position to assist in preventing an overdose experience, in the administration of naloxone.5 In regards to a layperson’s immunity, the law states:
Person, law enforcement agency, fire department or fire company acting in good faith and with reasonable care who administers naloxone to another person whom the person believes to be suffering an opioid-related drug overdose: (1) is immune from criminal prosecution, sanction under any professional licensing statute, and civil liability for such act; (2) is not subject to professional review for such act; and (3) is not liable for any civil damages for acts or omissions resulting from such act. Receipt of training and instructional materials and the prompt seeking of additional medical assistance create a rebuttable presumption that the person acted with reasonable care in administering naloxone.5
The statute does require the Pennsylvania Department of Health to develop training to educate individuals on opioid overdoses, administering naloxone, and seeking further medical attention.5
The driving force behind the push for naloxone to be distributed to the public is the drug’s potential to be used as a harm reduction technique. Harm reduction is an approach focused on minimizing the negative results that go hand-in-hand with drug abuse. Harm reduction techniques have both a medical and ethical impact on the individual and society as a whole. Harm reduction techniques accept the individuals as they are, while also tailoring that person’s treatment to fit his or her needs.12 Furthermore, there are certain principles that are quintessential to an understanding of harm reduction, as listed by the Harm Reduction Coalition:
- Accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
- Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
- Establishes quality of individual and community life and well-being–not necessarily cessation of all drug use–as the criteria for successful interventions and policies.
- Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.
- Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
- Affirms drug users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.
- Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
- Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.13
Naloxone’s ability to reverse the effects of a heroin overdose gives it the potential to be used as a harm reduction agent in and of itself as it will save lives. Furthermore, many individuals who die from opiate overdoses did not receive necessary medical treatment in time to save them; allowing more lay people access to naloxone can then save many preventable deaths. If we as a society value human life as sacred, we must find a way to prevent these deaths. Distributing naloxone to trained personnel as a harm reduction agent could present a way to solve this problem and save thousands of lives.
Community-based programs, such as the one run by the Center for Addiction Recovery and Education at Saint Joseph’s University, have trained police officers, firefighters, and other first responders in naloxone administration and education. Our goal is to extend that education to undergraduate students, specifically those interested in healthcare careers. The purpose of bringing this program to the undergraduate level is threefold. First, we aim to better prepare those going into medical professions for their future careers. A major aspect of the rise of the opioid epidemic since the year 2000 has been the physician-patient relationship. According to the AMA Journal of Ethics, the over prescription of opioids by physicians without regard for their addictiveness over the previous two decades has resulted in this alarming situation in which the country finds itself.14 Preparing individuals at such an early stage in their overall careers can help create future physicians who are better equipped to handle pain management and thus eliminate one of the modes through which this epidemic was created. Second, public knowledge of the epidemic is generally low, specifically now as the COVID-19 pandemic has taken over the media outlets. Training students in this program can expand undergraduates’ knowledge of the situation and hence public knowledge overall. Lastly, equipping undergraduates with Naloxone training allows them to be first responders on their campuses and in their communities.
Death from an opioid overdose rarely occurs immediately, and in the majority of cases, overdoses are witnessed by a family member, peer, or someone whose job brings them into contact with opioid users.15 If an overdose occurs in a setting without immediate access to naloxone, cardiopulmonary resuscitation (CPR) and rescue breathing can be vital life-sustaining interventions used to combat the depressed respiration brought on by opioid use. Since an opioid overdose can essentially happen anywhere at any time, it is crucial for laypeople to be familiar with such maneuvers. This is especially important for pre-health students and those who intend to work with vulnerable populations in any capacity. Proper CPR training is therefore an integral skill for those who would attain their opioid certification.
It has been found that short video self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can function as an effective alternative to instructor-led basic life support courses.16 Having interested students partake in such a program would be an efficient strategy to equip more members of the school community with the skills necessary to further reduce the harm that may be caused by opioid use and abuse.
Mental Health First Aid (MHFA) is a skills-based training course focused on mental health and substance-use issues. This program is designed to improve understanding of mental health and substance use and provide an “action plan” that teaches people to safely and responsibly identify and address these issues. Just as increasing the number of CPR trained individuals in a population promotes a safer environment, equipping individuals with the tools to recognize and respond to mental health and substance use crisis can do the same.
Beyond general MHFA, there are also courses specifically tailored to the issues unique to opioids. By completing MHFA’s Opioid Response Supplement, students can be efficiently trained to recognize the signs and symptoms of an opioid overdose, learn how exactly to respond to an overdose, and understand the context and statistics for opioid use and abuse.17 This comprehensive program should serve as a solid foundation upon which one can further explore these topics throughout the rest of their journey to become certified through the Opioid Certification Program.
2. Academic (Lecture Series)
The opioid epidemic is multi-faceted with no single factor or direct cause to pinpoint. Our purpose for the lecture series is to try to cover the main contributors to the epidemic, primarily from individuals with direct experience in the respective fields. The following sections and lectures are our proposed seven lectures that best encompass the epidemic.
A. Mental Health and Opioids
Mental health in general has become a more prevalent focus in the United States and in the world, as celebrities, politicians, sports figures, and others have brought the topic to the forefront of the media and healthcare. Various studies have illustrated the strong connection between mental health issues and opioid use. The order of onset of psychiatric disorders and substance-use disorders is not always clear. Sometimes, psychiatric disorders can occur as a result of substance abuse, for instance due to withdrawal or only while using a certain drug.18 However, other research suggests that the prevalence of adolescent substance use disorders and psychiatric disorders is strong and that youth drug use may predict later mental disorders and vice versa.19
Thus, it is important to have such a lecture in an undergraduate program for a few reasons. First, the students are young adults themselves, and being educated in this topic allows them to not only become aware of any issues they are dealing with internally but also, they may be able to be a resource for peers who they may observe struggling with mental health or substance use issues. Second, as aspiring healthcare professionals, students of this program should be exposed to the connection between mental health and substance use issues, as an awareness early on may help them become better advocates and resources for their patients in the future. Some research suggests that early diagnosis of a mental health disorder may help reduce comorbidities in the future.18 Thus, creating a generation of pre-health students more aware of this connection could eventually help reduce the prevalence of such comorbidities.
B. Treatment of Opioid Abuse/Overdose: Perspectives of Medical Residents
Another aspect of the epidemic is the medical treatment of opioid users. In recent years, healthcare providers in general have been slammed with the accusation that overprescription of opioids has been the cause of the epidemic we see today. Overall, there is no doubt that overprescription is certainly a factor. For reference, in 2015, about 240 million opioid prescriptions were dispensed, nearly one for every adult in the US.20 Physician training appears to play a major role, as opioid prescribing has been found to be negatively correlated with medical school ranking, suggesting that a lack of proper preparation can lead to this issue.19
However, this may only be one side of the medical coin in this epidemic. Another study of almost 15,000 patients in Oregon found that drastically reducing the opioid dosage of a patient in pain greatly increased the risk of suicide in those patients compared to others whose dosages were stable or increased.21 Additionally, another study of over 100,000 patients found that abruptly decreasing the dosage of opioids of a patient increased risk of overdose by 28% and risk of mental health crisis by 78%.22 Thus, not only is over prescription an issue, but the treatment of patients after the initial prescription is also a problem. Thus, hearing from a medical resident fresh out of medical school and on the front line of healthcare about how prepared he or she feels to treat a substance abuse or pain patient can be interesting for aspiring healthcare professionals.
C. Pharmacology of Opioids
Given that the proposed program mainly targets pre-health students, many of whom are natural science majors, we propose a lecture about the pharmacology of opioids that covers modes of administration and mechanisms of action as well as clinical manifestations of opioids and their side effects. It should be noted that these topics are rather complex and way beyond the scope of undergraduate knowledge. However, if explained in a clear enough way, we believe that understanding the aforementioned aspects of the pharmacology of opioids will allow for a more complete understanding of why opioids do what they do. Additionally, this lecture can be given by pharmacy students, which would allow them to improve upon explaining complex topics in a simpler way. This is a vital skill to have as a healthcare professional communicating directly with patients in an effort to gain informed consent from them.
A. Opioid Survivor: Experiences of Individuals in Recovery
Given that there is no teacher quite like experience, a lecture given by an individual who has suffered from a substance abuse disorder, has been through rehab, and is committed to now making a change in the world of substance abuse treatment would be an excellent perspective to have in the program. There would be no real agenda or outline for this lecture other than for the lecturer to speak genuinely about his or her own experience and what he or she sees is needed in the world of addiction treatment. As the epidemic rages on and we search for ways to save lives, hearing from people with real experiences may be the best route towards finding a solution.
B. Opioids and the Law: Perspectives of Law Enforcement
Often thought about from the perspective of arresting drug traffickers and removing drugs from the public, law enforcement is intimately connected in other ways to the epidemic. In fact, U.S. Immigration and Customs Enforcement (ICE) recognizes that they cannot arrest their way out of the crisis.23 Instead, better treatment, rehabilitation, and prevention tactics must be put in place. The role of police, then, becomes of paramount importance given their trifold duty in relation to the crisis. First, they are the emergency response team when a suspected overdose is reported, so they must be equipped with naloxone as well as the ability to determine symptoms of an overdose. Second, they have a responsibility towards public safety and preventing harm to the community. Third, they have their aforementioned duty as law enforcement to prevent criminal activity. Due to the role they play in all aspects of this crisis, police oftentimes can be the primary point of entry of a drug user toward his or her road to recovery. Thus, hearing the experiences of a law enforcement professional about how he or she has dealt with such occurrences in the past as well as about the stigma surrounding individuals suffering from addiction can help students more fully grasp the realities of the epidemic.
C. Drug Scheduling: Classification of Drugs
Drug scheduling refers to the way in which the U.S. Drug Enforcement Agency (DEA) classifies drugs relative to each other based on dependency and abuse potential. Scheduling can also reveal a bit about the potential medical uses for a given drug. For instance, marijuana is a Schedule I drug, meaning that it has no accepted medical use and has a high potential for abuse. A lecture about the five classifications of drugs and its implications medically, ethically, and socially can help students understand the regulations behind certain opioids and other drugs and how that affects their prescription and a person’s treatment.
A. The Ethics of Safe Injection Sites
Today, there are almost 200 “overdose prevention centers” in operation worldwide across 14 countries. These sites are designed to help persons who inject drugs (PWIDs) safely self-administer their own drugs under the supervision of medical staff. Additionally, there are other services offered, such as fentanyl testing strips, naloxone, wound care, mental health services, blood testing, and rehabilitation counseling. New York City opened the first U.S. site in December 2021, and given its success, there is a greater push legally and politically to establish more sites nationwide. However, there is significant pushback against such a movement, mainly due to the idea that these sites appear to help PWIDs continue to use illicit drugs. However, many in the medical and public health realms recognize the potential benefits of these sites for society at large: reducing overdoses, saving money by preventing diseases, reducing risks of contracting blood-borne diseases such as HIV, increasing entry into treatment, and decreasing the amount of people using illicit drugs. Therefore, understanding the ethical rationale for such sites, namely the harm reduction theory, will allow students of this program to have an informed opinion about this potentially lifesaving intervention.
Needle Exchange Program Visit: Prevention Point Philadelphia
Needle exchange programs (NEPs), also referred to as syringe service programs (SSPs) and/or syringe exchange programs (SEPs), are programs specifically designed to provide communities with adequate access to sterile needles and syringes, promote the safe disposal of used needles and syringes, as well as provide individuals with information and resources such as: rehabilitation programs, treatment opportunities, overdose prevention, naloxone usage, wound care, vaccinations, mental health services, etc.24 The first NEPs emerged in Europe in the early 1980s, in the hopes of ceasing the transmission of Hepatitis B and HIV.25 NEPs became popularized in the United States in the 1990s.24 Today, according to the Centers for Disease Control (CDC), there are roughly 350 NEPs in over 42 states.24,26 In the 1990s, the Government Accountability Office (GAO), the CDC, and the National Academy of Sciences conducted several federally funded studies, “...all reached similar conclusions that NEPs work in reducing HIV’s spread among IV drug users, their partners and children, and that they do not encourage increased drug use”.24 Subsequently, a study conducted in Seattle, found that drug users who enter community-based programs such as NEPs are five times more likely to enter rehabilitation than those who do not.27 NEPs are also the leading factor in the reduction of infections.23 “Non-sterile injections can lead to transmission of HIV, viral hepatitis, bacterial, and fungal infections and other complications.”23 Despite this scientific evidence, the United States continues to be the only country to have a federal funding ban, established by Congress in 1989, on NEPs.24 NEPs are invaluable because these programs expose adicts to valuable resources aimed at getting them clean, decreasing the number of overdoses nationwide, and significantly reducing the spread of easily transmissible viruses such as HIV/AIDS.23
There are currently around 20 NEPs across Pennsylvania.28 Prevention Point Philadelphia (PPP), is a nonprofit public health syringe service organization located in Kensington, PA. PPP was founded in 1991.29 The nonprofit aims to “promote health, empowerment, and safety for communities affected by drug use and poverty.” 28 PPP, “promotes harm reduction through mobile medical care, sterile syringe exchange, transitional housing, referrals to social services, and comprehensive prevention case management services.”28 Prevention Point’s workers and volunteers are avid advocates for social justice within their struggling opioid encompassed community. Syringe exchange programs such as Prevention Point have significantly reduced the spread of viruses such as HIV, Hepatitis C, etc.28
This program will include a visit to Prevention Point in Philadelphia. Through this, we hope to allow students to apply the theoretical aspects of the lecture series into a practical, firsthand experience of these sites to increase understanding of the interventions in place to combat all aspects of the epidemic.
AA/NA Meeting Visit
AA meetings were created in the late 1930s, as a program for struggling individuals searching for help in finding sobriety through attending a support group.30 The 12-step program was later developed in an effort to provide better guidelines for addicts to adhere to on their journey to sobriety. The first step was focused on “...accepting one’s inability to control drinking; the last, [was] helping others sustain sobriety by becoming a sponsor of a new member. The AA model — open to all and free — has spread around the globe, and AA now boasts over 2 million members in 180 nations and more than 118,000 groups.”29
The evaluation of nearly 35 studies, which included over 10,000 willing participants, concluded that AA and NA meetings have been found to be more effective than psychotherapy in achieving abstinence from drugs and alcohol.29 Individuals who abuse drugs and/or alcohol have chronic mental health conditions.31 The 12-step program is focused on treating members’ addiction as a disease.30
The main goal of visiting and sitting in on AA and NA meetings is to ensure that students and other participants are familiarized with the various approaches, such as the 12-step program, which will ensure they are well informed on how to aid struggling individuals and where to refer them for further care and guidance.33
Visit to Addiction Treatment and Recovery Center: Eagleville Hospital
Visiting a treatment and recovery center can be a fruitful experience for undergraduates in this program, particularly because the theme of the program stresses the interdisciplinary nature of the opioid epidemic. Treatment and recovery centers such as Eagleville Hospital take a biopsychosocial approach to care for their patients, as they address biological, psychological, and social/environmental factors to a person’s current condition. Being able to go to the site and hear from nurses, social workers, counselors, and psychiatrists can help students fully grasp what a solution to the epidemic looks like. As with all of the experiential aspects of this program, this visit will allow students to apply theoretical aspects learned in the lectures to the practical experience in the hospital and treatment centers.
Medical Marijuana Dispensary Visit
Cannabis has a long history of being used for recreational purposes, but in recent years there is growing support for its use in the medical arena.34 Because cannabis is considered an illegal substance on a federal level and has not been as extensively researched as other well established drugs, the implications of utilizing marijuana medicinally are complex not only from a clinical perspective but also from a legal and even ethical perspective as well.33 One of its proposed uses is as a replacement therapy for individuals addicted to opioids. Visiting a distribution center, or dispensary, can help students understand the highly regulated process of obtaining medical marijuana and also help reduce the stigma surrounding the use of medical marijuana for those struggling with addiction.
Methadone Clinic Visit
Suboxone and Methadone are a pair of synthetic opioids used to combat opioid addiction and dependence. While they are both used to accomplish the same goal, their individual mechanisms of action and effectiveness differ in several key ways.
Methadone is a synthetic opioid agonist that suppresses withdrawal symptoms and drug cravings by acting on opioid receptors in the brain. Other opioids like heroin and OxyContin interact with the same receptors, however, methadone activates them more slowly and at prescribed doses does not induce the characteristic state of euphoria associated with such narcotics.35 Introduced to the public in 1947, methadone has since been a staple of opioid addiction treatment. Specifically, methadone maintenance therapy (MMT) has become common practice among physicians tasked with treating opioid dependence.36 This treatment regimen involves the long-term administration of methadone as an alternative to whatever opioid an individual was originally dependent on. The drug is typically administered orally in around 100 milliliters of liquid that cannot be injected. When a proper dosage is achieved, methadone will suppress opioid withdrawal symptoms, reduce opioid cravings, and reduce the euphoric effects of other opioids all without inducing any other form of intoxication. As a long acting opioid, methadone can remain in the body much longer than other opioids and only needs to be dispensed once a day to remain effective. Additionally, methadone tolerance develops slowly, allowing patients to remain on MMT indefinitely.37 The aim of MMT is to enhance the quality of life for patients by improving their physical and mental wellbeing, reducing instances of relapse, and reducing risky behaviors that facilitate the spread of infection. In fact, studies have found MMT to be responsible for a sizable reduction in heroin and opiate addiction and risk-taking behaviors.38
Despite its success in treating addiction, the side effects of methadone raise their own concerns. Afterall, methadone is an opiate, meaning patients will remain physically dependent on opioids during their treatment. Like other opiates, methadone can induce decreased respiratory function and addiction when used long-term, requiring close monitoring of patients through regular clinic visits and drug screenings to ensure optimal outcomes. Additionally, methadone’s long-acting characteristics allow it to build up relatively quickly in the body if one takes more than prescribed. The drug’s analgesic effects typically last up to 8 hours while its half-life can last up to 59 hours. While this long half-life benefits those recovering from opiate addiction, those suffering from chronic pain may put themselves at risk of an overdose by inadvertently exceeding their prescription in an effort to alleviate their discomfort.39 The long half-life of methadone inside the body also means withdrawal symptoms last much longer than would occur during withdrawal off another opiate.
Methadone has been shown to be a reliable treatment for opioid addiction, but to achieve the desired outcome of MMT, methadone dosage routines must be followed precisely. Patients undergoing such therapy must be fully bought in on the process and willing to follow through with drastic lifestyle changes.40
Suboxone offers an alternative to traditional MMT. Unlike methadone, suboxone was specifically designed to help combat opioid addiction. Suboxone is composed of buprenorphine, a partial opioid agonist, and naloxone, a opioid receptor antagonist that blocks the effects of opioids. Being a partial opioid agonist, buprenorphine has an upper limit to its opioid effects as only so many opioid receptors can be activated. This feature of buprenorphine greatly reduces the potential for overdose or respiratory depression. Naloxone can be used on its own to reverse the effects of an opioid overdose, but is also added to buprenorphine to discourage misuse of the drug and block the effects of other opioids. The combination of buprenorphine and naloxone provides the user with relief from withdrawal symptoms while also keeping the body from experiencing any euphoria, thus decreasing suboxone’s potential to be abused.41
Intended as a safer alternative to other opioid pain medications, buprenorphine was first developed in the 1970s and approved for use as a painkiller in 1985. Buprenorphine was eventually recognized as a safe and accessible alternative to methadone in treating opioid addiction. In time, pharmaceutical research prompted the decision to combine buprenorphine with naloxone to further reduce the drug's potential for abuse. In 2002, suboxone was approved by the FDA to treat opioid addiction.42
In medication-assisted treatment (MAT), suboxone is used as part of a comprehensive treatment plan including behavioral interventions and peer-support groups. This is similar to what can be expected from MMT, however, MAT with suboxone is often more accessible for many patients. While the ceiling effect of suboxone makes it safer, it could also mean that the drug is less effective in combating opioid addiction in some circumstances. More specifically, it has been found that suboxone fails to surpass methadone in retaining people in treatment if prescribed in a flexible dose regimen or at a fixed low dose. However, the two drugs perform comparably at larger fixed doses.43 Additionally, suboxone’s weaker efficacy means it would be best administered to those with mild to moderate dependence, while methadone can be used with all levels of dependence.44
Despite their differences, both methadone and suboxone serve as effective treatments for opioid dependence when proper precautions are adhered to.
Completion of this program will require students to attend all three training sessions, at least four out of the seven lectures, and at least two out of the five experiential events. We propose this format because this program is being implemented at a non-credit certification. This first implementation will serve as a pilot program, after which we will reassess to determine what more is needed to make this program as successful and sustainable as possible.
Medical School Certification
To address this at the level of medical education, we propose that medical schools should adopt the following curriculum model. To demonstrate a proper mastery of the subject matter, students will be required to complete assignments, lessons, and objectives in four separate disciplines over the course of medical school. These requirements will be supplemental to the conventional course load and can be completed at any time prior to graduation. The four proposed disciplines include experiential learning, community service, scholarly research, and clerkships. The expectations and merits of each of these components will be explored more thoroughly in subsequent sections of this paper. Implementing a comprehensive curriculum for medical students will potentially reduce rates of inappropriate prescribing habits and increase substance abuse disorder management competency.
Upon fulfilling all four components of the curriculum, students will receive a certificate of mastery in addiction medicine that will be placed in their curriculum vitae. In addition, they will receive a corresponding letter of recommendation outlining the rigorous extracurricular workload they undertook during their pursuit of becoming better physicians. These accolades will serve as recompense for each student's sustained efforts and will provide a unique opportunity to stand distinguished from peers when applying to residency programs.
With the copious amount of information that medical students must process throughout their medical education, it is paramount for students to fully understand and to make connections to the material they are learning. This in-depth understanding facilitates development of critical thinking skills. Without such skills, physicians are prone to making cognitive errors that ultimately impact the quality of care provided to the patient.45 To promote a holistic understanding of material, medical students should be exposed to a curriculum focused on experiential learning. This form of learning “begins with experience, followed by reflection, discussion, and analysis, re-experience and evaluation, and ends with the construction of internalized meaning and value.”46
Based on this theory of experiential learning, students will be required to participate in 30 hours of shadowing with an addiction medicine physician or pain management specialist throughout their four years of medical school. According to a study sponsored by the National Institute on Drug Abuse, 49 percent of the opioid doses and 27 percent of the total number of opioid prescriptions between 2003 to 2017 were from the top 1 percent of healthcare providers of opioids.47 Opioid dosage in the study referred to a specific cumulative amount, as dosage can vary with each individual opioid prescription. The study notes that these prescribers consisted of family medicine, physical or pain medicine and rehabilitation, anesthesiology, and internal medicine physicians.47 In particular, physical or pain medicine and rehabilitation specialists and anesthesiologists were highly overrepresented as they each consisted of 14 percent of the top opioid prescribers, despite each specialty accounting for only 1 percent of all providers.47 Targeting medical students interested in these specialties under the guidance of responsible physicians will allow them to directly learn safe opioid prescribing patterns in practice.
In addition to physician shadowing, students will be required to participate in 30 hours of shadowing a medical care provider at a MAT (Medication-Assisted Treatment) clinic or a safe injection site. A MAT clinic is “a specialized clinic aimed at effectively treating Opioid Use Disorder (OUD) utilizing medications such as buprenorphine/naloxone (Suboxone).”48 At MAT clinics, students will be able to learn about prescription medications to reduce opioid cravings and withdrawal symptoms, prescription opioid tapering, and prescription medications that assist in recovery from alcohol and nicotine use.49 On the other hand, a safe infection site is a “medically-supervised facility for the use of intravenous drugs [that provides] a hygienic and secure environment where IV drug users can inject safely.”49 Students will be able to observe medical care providers trained in overdose prevention, and observe how providers delicately handle the challenge of connecting people who inject drugs (PWID) with addiction and social services.
In addition to shadowing experiences, students will be required to have 10 hours of training with standardized patients portraying different scenarios of asking for painkillers. According to the AAMC, nearly all U.S. medical schools utilize “standardized patients (SPs), also known as simulated patients or simulated participants. Educators coach these lay people to portray patients in realistic situations as a means to help medical students learn how to grapple with sensitive issues.”50 Through having the opportunity to practice interacting with patients and dealing with practical scenarios, students will be able to not only develop their prescribing skills, but also hone their ability to show empathy and connect with the patient on a personal level. SP scenarios should involve patients who actually need painkillers, such as those in sickle cell crisis, as well as other scenarios involving drug-seeking patients. The American Academy of Family Physicians Foundation (AAFP) has developed a systematic approach to dealing with drug-seeking patients: involving the entire medical team, recognizing suspicious behavior, obtaining a thorough history of present illness, looking for consistency in the exam, conducting appropriate tests, prescribing non-pharmacological treatment, and proceeding cautiously.51 By experiencing diverse scenarios involving drug-seeking patients, students will be able to recognize the signs of someone who is seeking drugs and how to appropriately deal with these patients. Furthermore, to assess the effectiveness of shadowing, SP encounters will be performed before, during, and after the completion of shadowing requirements. The student encounters will be recorded and assessed using a SP encounter rubric, and students will have the opportunity to get valuable formative oral feedback from SPs. Feedback directly from SPs offers a unique and rare perspective for future clinicians before their clinical exposure.52 Since PWID tend to be marginalized, it is important for medical students as future physicians to ensure equal and quality care to all their patients, despite their unique backgrounds.
Alongside traditional coursework covered throughout medical school, an integral part of a holistic education is community service, particularly in underserved communities. Service-learning courses are incorporated at medical schools throughout the country. An associate provost from Rush Medical College in Chicago, IL, states that the service-learning course offered at Rush allows medical students valuable learning opportunities outside of the classroom, and “provid[es] exposure to populations they may not encounter during their clinical placement.”53 The opportunity to incorporate didactic coursework on substance use disorders and the opioid epidemic into real-world scenarios through community service will provide medical students with a deeper understanding of these topics. As a result, they will be able to provide better care to their future patient populations.
In particular, students would benefit from volunteering through Syringe Service Programs (SSPs). The CDC states that SSPs serve multiple purposes including helping to prevent transmission of blood-borne infections, substance use, and support public safety.4 Medical students who volunteer at such sites would gain valuable experience through aiding in syringe services, overdose prevention, and wound care. Additionally, interaction with specific patient populations outside of the classroom has been shown to improve medical students’ understanding of the needs of that population.54
A study on the effects of service learning in medical education was conducted with first-year medical students on taking blood pressure.55 Through their didactic work, the medical students were taught effective physician-patient communication skills and how to properly take and understand blood pressure readings. The students performed their service-learning course at a community health clinic and after completion of the course, nearly 75% of the students felt that they were prepared to practice in a community similar to that of their project site. According to a pre- and post-test, the students also demonstrated an increase in understanding of the health-related needs of their specific patient populations, the barriers to healthcare that their patients face, and how to communicate effectively with a diverse patient set.
A program similar to this could provide medical students with indispensable experiences and information on the opioid epidemic far beyond what is learned in the classroom by incorporating real-world experiences that will enhance patient care upon graduation. If medical students were to complete a minimum of 25 hours in a SSP in conjunction with their didactic coursework on pain management and safe opioid prescribing, they would be properly equipped to combat the opioid epidemic.
The benefits of pursuing research projects include development of critical thinking skills, exploration of areas of interest, and the building upon rudimentary knowledge base. Graduate research allows for students to become exposed to and to respond appropriately to problems in the real world.2 Using the information learned in a classroom and implementing that knowledge in an active way through research strengthens a student’s learning and idea of career goals.56 Students who are more involved in reading literature, asking questions, and collecting data, analysis, and presenting their research are more likely to develop impactful skills than students who perform simple or insignificant tasks.57
This graduate-level research or scholarly work can occur within or outside of the classroom. In the proposed curriculum, students will create or participate in a form of scholarly work focusing on the opioid epidemic, which can be accomplished through several different avenues. For example, students can create a Quality Improvement (QI) project on their individual medical school’s opioid curriculum. This type of project is data-driven to analyze and test change58. In healthcare, QI projects can be used to improve clinical care or to develop new healthcare programs or initiatives. Alternatively, students may propose an original research project of their interest involving the opioid epidemic and submit it to a faculty member for approval to ensure it adequately focuses on the topic. Additional options for scholarly work include case reports, attendance of national conferences, or a poster presentation.
All scholarly work projects that students pursue must be approved by and be under direct supervision of a faculty member. Working with a mentor will ensure that the student’s topic of choice pertains to the opioid epidemic and ultimately confirms the student has demonstrated proficiency in the topic. After a student’s project is deemed suitable, it must be admitted for acceptance in a peer review, and later submitted for publication. Research projects are to be completed by the final year of medical school.
Medical School Clerkships
In addition to the previously discussed shadowing, volunteer, and research experiences, further immersive experience is necessary to prepare medical students for the realities of prescribing opioids once they enter residency. Medical schools do not teach dosages and prescription strengths of all drugs since these topics are not tested on Step/Level 1 and 2 of medical boards. This information is not acquired until the first year of residency, in which interns are responsible for writing orders. As a result, medical students that graduate and enter residency are usually unprepared in prescribing the correct doses of opioids and writing for the correct number of pills since they have had little to no training in this in medical school. One solution to this challenge is to implement a clerkship rotation during the third or fourth year of medical school, in which students can spend four weeks focusing solely on this topic. A course such as this during medical school clerkships would be very useful to prepare students for the intern year. They will already be familiar and comfortable with prescribing narcotics and are less likely to make mistakes. This formal instruction will in turn lead to more informed physicians, leading to less over-prescription of opioids in the long term.
Currently, several online courses exist, for physicians and other medical staff, regarding opioid education and prescription to obtain Continuing Medical Education (CME) credit59. Various medical associations also offer the option for physicians to become board certified in addiction medicine. These include The American Board of Preventive Medicine, The American Osteopathic Association, The American Board of Psychiatry and Neurology, and The International Society of Addiction Medicine. Several pathways also exist for non-physicians to become certified addiction medicine specialists, including The Addictions Nursing Certification Board and The National Certification Commission for Addiction Professionals.60
While individual medical schools may offer their own local clerkships focusing on this topic, there is presently no widely available clerkship for third- and fourth-year medical students about this specific subject. This presents another barrier for future prescribers of opioids to obtain this information before entering residency. Several clerkships that do currently exist include Addiction Medicine, Pain and Addiction, Medical Toxicology, and Clinical Pharmacology. However, no courses specifically focus purely on the opioid epidemic and drug prescribing currently. Topics that may be addressed in this course include the history of the opioid epidemic, physician overprescribing, opioid misuse and overdose, the ethics of prescribing painkillers (including the identification of drug seeking behavior versus a pain crisis), strategies for improvement, and how to administer naloxone.61
Due to the COVID-19 pandemic, several medical school clerkships have been canceled or are accepting limited numbers of students. As a result, there has been a recent increase in virtual clerkship offerings. Therefore, a virtual opioid education elective would be most appropriate as it would be accessible to any medical student in the country, in both allopathic and osteopathic schools. In the virtual format, it would be beneficial to have interactive, live-stream daily lectures, discussions, or meetings to ensure students’ participation.
A small 2021 study described how the COVID-19 pandemic has affected medical student education. After implementing a virtual two-week elective on radiation oncology, it was found that overall knowledge in this field was significantly improved after taking the course. Reasons for this may include exposure to telehealth, which is becoming increasingly prevalent in the U.S., and more individual attention with residents.62 Virtual electives such as this will serve as educational resources for students facing roadblocks during the pandemic, such as in-person rotation cancellations.
The ability for this clerkship to be optional also allows students who are genuinely interested to enroll. This course would be particularly useful to students who are interested in pursuing Family Medicine, Internal Medicine, Sports Medicine, Orthopedic Surgery, Psychiatry, and Addiction Medicine, among others. Additionally, this course would be required for the medical school opioid curriculum but would also be available for all other students.
The University of Massachusetts Medical School currently offers a four-year “Opioid Conscious Curriculum” which includes the use of standardized patient cases, opportunities to interact with patients with substance use histories and facing addiction, and interdisciplinary learning. Programs such as this were implemented in the state of Massachusetts after the number of deaths from accidental overdoses doubled between 2012 and 2015. Longitudinal curriculums such as this should be adopted by more medical schools throughout the country.63
Implementing multifaceted curricula to educate both undergraduate and medical students about the management and prevention of substance use disorders is crucial to improving physician prescribing patterns of opioids and the overall state of the epidemic. By utilizing the proposed approaches, students at both levels will build a strong foundation in basic science while also gaining hands-on experience in various fields.
The undergraduate certification program attempts to introduce students to the many factors incorporated into the current epidemic and expose them to current interventions being utilized to help alleviate further harm. Given the relatively limited knowledge base of undergraduate students in these fields, we believe our proposed program includes the correct balance between introduction to and education on these issues.
Through experiential learning, students will observe responsible prescribing patterns of analgesics and be able to apply what they have learned during their standardized patient sessions. Engagement in community service provides in-depth understanding of individuals with substance use disorders and their specific needs, thus improving and enhancing care of these patients. The scholarly research discipline will promote students’ critical thinking skills, compelling them to identify issues and determine means of improvement. This will not only enhance their own knowledge of the opioid epidemic but also opens the opportunity to improve the education of their peers should they choose to work on QI projects. Finally, a virtual clerkship for medical students will provide them with the necessary knowledge to practice safe prescribing habits once they become residents. Upon graduating, those who participate in this curriculum will be well-equipped to manage cases of substance use disorders and practice responsible prescription of opioids, both of which are imperative in combating the opioid epidemic.
There is no single solution that can be used to completely eliminate the opioid epidemic. However, we believe that educating future healthcare professionals will be an effective and efficient way to improve the lives of those suffering through the epidemic and help save future lives.