Students learn to treat pain, with and without opioids

As the opioid epidemic claims even more lives, medical schools are rethinking how they teach students to manage patients’ pain. The result? A better understanding of the nature of pain, addiction, and substance use disorder.
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Kyle Freischlag, a fourth-year medical student at Duke University Medical School, was on rounds when he walked into the hospital room of an elderly man recovering from surgery. The man was unconscious and having trouble breathing. Freischlag saw that the patient had just resumed taking his regular medications, which included oxycontin for chronic pain. “He was on a fairly high dose and that was stacked on what he received in the OR,” Freischlag says.

Fortunately, Freischlag had recently participated in a simulation involving a medical manikin in the throes of an opioid overdose and realized what was happening. He grabbed a nurse, called the attending physician, and within minutes the patient was resuscitated with naloxone. “It clicked because of that simulation,” he says. “In that moment I was able to recognize the problem and know what to do.”    

Such experiences are becoming more commonplace at medical schools across the country as institutions ramp up their curricula to confront the nation’s opioid epidemic. The efforts can’t come soon enough. In 2016, drug overdoses, mostly opiates, claimed the lives of over 50,000 people — more than guns or car accidents. According to data from the U.S. Department of Health and Human Services, nearly a third of the population — about 97.5 million people — use prescription pain relievers.

“This problem is so important that it needs to be addressed in a standardized way with a set curriculum.”

Nancy W. Knudsen, MD
Duke University Medical School

“When I was in medical school, I received much more training on the use of antibiotics than I did on use or prescription of opioids,” says Martin M. Klapheke, MD, assistant dean for medical education and psychiatry residency program director at the University of Central Florida College of Medicine. “A strong foundation of scientific evidence for pain management had not yet evolved. Over the years, we slowly began to learn more, including the downside of prescribing opioids.”

In 2016, a Centers for Disease Control and Prevention (CDC) review found insufficient evidence to prescribe opioids for the long-term treatment of pain and issued new prescribing guidelines. By then, medical schools had already begun to change their curricula around pain management. According to a 2018 AAMC survey, 87% of medical schools offer training in four broad areas related to the opioid crisis: the nature of pain; pain assessment; pain management and the treatment of overdose; and the context of pain and substance use disorder. “As the opioid epidemic continues unabated, it’s critical that our students become competent in pain management and proper opioid prescribing,” says Lisa Howley, PhD, senior director of strategic initiatives and partnerships in medical education at the AAMC. “Fortunately, we have noticed that many schools have adapted their curricula to address areas related to the nature, assessment and management of pain and the prevention, recognition and treatment of substance use disorders.”

All 102 medical schools responding to the AAMC survey have taken steps to address the opioid crisis in their curricula, from lectures on addiction to role-playing with standardized patients seeking pain medication. While it may take years to determine how effective the curricular changes have been, students like Freischlag say they feel more confident that they’ll be able to handle issues that are likely to crop up. “It’s helping me to take a little bit of the next step,” he says.

Statewide collaborations

When deaths from accidental overdose in Massachusetts more than doubled between 2012 and 2015, the state’s medical colleges, including the University of Massachusetts Medical School, developed 10 core competencies for avoiding and managing prescription drug misuse and began tweaking their curricula.

“Within three months, we had a new curriculum to fit where we thought our needs and gaps were,” says Melissa Fischer, MD, professor of medicine, associate dean for undergraduate medical education, and director of the Interprofessional Center for Experiential Learning and Simulation (iCELS) at the school.

The school now has an “Opioid Conscious Curriculum” that spans all four years. For one component of the new curriculum, a group of faculty and students across a variety of disciplines came up with a series of standardized patient cases surrounding opioid use in a variety of contexts.

“The goal was to give our students the opportunity to learn and practice talking with patients who were at different risk of substance use disorder, or who just needed pain treatment and did not have a risk for substance use disorder, as one core experiential component,” Fischer says. “The cases not only are created by an interprofessional team, but our students go through it as an interprofessional team.”

Students also meet with panels of people who are in recovery and families of people who have had substance use disorders to hear from them about their experiences with the health care system and the impact on their lives.

Massachusetts’ other medical schools — Boston University School of Medicine, Harvard Medical School, and Tufts University School of Medicine — have also enriched their curricula around pain and substance use disorders, and as a collaborative, the schools have provided a model for other states. Last year, all 10 medical schools in Florida joined forces to brainstorm ways to get future doctors up to speed on opioids.

Other institutions are also moving the needle on the opioid crisis. In 2015, the Warren Alpert Medical School of Brown University created a curriculum that would fulfill the requirements of the state’s Drug Addiction Treatment Act waiver, which is required to prescribe and dispense buprenorphine, a medication-assisted treatment for opioid use disorder. The state’s public health department and state licensing boards partnered with the school.

“Other states are looking at this in order to increase the number of providers who are eligible to provide medication-assisted treatment,” says Paul George, MD, assistant dean of medical education at Alpert Medical School and director of its Primary Care-Population Medicine Program.

New curricular approaches

Duke is one of the many schools making room for more education around opioids — among other substance use disorders — in a crowded medical school curriculum. “This problem is so important that it needs to be addressed in a standardized way with a set curriculum,” says Nancy W. Knudsen, MD, assistant dean for learning environment and professor of anesthesiology at Duke.

The four-week brain and behaviors course in the first year of training has been beefed up to include more content on addiction, she says. And information on pain and related topics appears in several second-year clerkships, including surgery, where three days are dedicated to pain management.  

In the psychiatry rotation, students take a formal course on substance use disorders alongside students in the pharmacy, physician assistant, nursing, and social work programs, which focuses on empathy, behavior change counseling, and the screening and treatment of addiction. The course includes role-playing, case-based learning, and group discussions and requires students to attend a 12-step meeting and write about their experience.

“Working at the Healing Place has helped me to see that these are people who want to be happy. They are sick and they want to feel better. Working with these people has given me a greater sense of responsibility as a future physician.”

Riley Crandall
Fourth-year medical student
University of Louisville School of Medicine

The acute care rotation in the fourth year puts students through several simulations using manikins in dire medical situations, including the opiate overdose scenario, challenging students to act quickly. “You’re reacting to what’s going on in front of you,” says Freischlag. “To me, it’s a great way to learn and to have things stick.”

An enhanced approach

While Case Western Reserve University School of Medicine already had a robust curriculum on addiction, it too is enhancing its approach in response to the current epidemic. The school has emphasized drug use and related issues since 1998, but recently added content on addictive diseases to second-year requirements and a workshop addressing pain in people with substance use disorders for students in the third year.

A unique feature of the curriculum is an evening seminar series on prescribing. Offered to undergraduate medical students for the past five years, the series grew out of a remedial course for prescribers who have been identified by their licensure agencies as high prescribers. “It covers all the basic skills that people need to comfortably and appropriately prescribe controlled drugs in clinical practice — how to figure out when not to prescribe, and how to be able to say no without destroying the doctor-patient relationship,” says Ted Parran, MD, the Isabel and Carter Wang professor and chair in medical education.

Says Jana Jaffe, a third-year student at the school, “I’m learning there’s a very careful balance to make sure patients are not in pain but to not give too much so that they don't become addicted and have further issues with that.”

Applying lessons learned

At the University of Louisville School of Medicine in Kentucky, students learn about pain management and addiction through all four years of school, starting in the first year when students get training in difficult conversations, such as asking a patient about their use of pain pills. 

“Then we walk students through a series of cases that apply the CDC prescribing guidelines in a compare and contrast way for a patient with chronic pain who's not a palliative care patient versus a patient with advanced cancer who is a palliative care patient with chronic pain,” says Amy Holthouser, MD, associate dean for medical education and associate professor of medicine and pediatrics at the university.

But it is at the student-run medical clinic at the Healing Place, a residential drug and alcohol treatment facility in the city, where students are able to see the ravages of opioid addiction first-hand and apply the lessons they are learning in the classroom. The future doctors take medical histories, perform physical exams, and just listen to patients’ stories.

Megan Mercer, now a fourth-year medical student, recalls one patient in particular — a grandmother who was fighting her addiction to opioids. “She’d lost her husband, her house, just about everything you can imagine,” says Mercer. “But she was finally in the phase of recovery where she was looking forward to reuniting with her family. It helped to humanize addiction and recognize that these people are working very hard to beat their illness.”  

Adds fourth-year student Riley Crandall: “Working at the Healing Place has helped me to see that these are people who want to be happy. They are sick and they want to feel better. Working with these people has given me a greater sense of responsibility as a future physician.”