CLEVELAND — According to the CDC, 44 people die every day from overdoses involving prescription opioids.
One would think that over the last decade, future doctors in medical school would learn about the dangers of substance use disorders (SUD) and the opioid epidemic, but you'd be wrong.
The official curriculum didn't start in Ohio until the fall of 2020.
Before we explain what took so long, we need to look at the history of the opioid epidemic dating back to the 90s.
"Up until the 1990s, physicians had historically been taught to give opiates for chronic pain," said Dr. Ted Parran, Professor at Case Western Reserve University School of Medicine and Co-Medical Director of Rosary Hall, a hospital-based addiction treatment center at St. Vincent Charity Medical Center.
Dr. Parran says CWRU School of Medicine was one of only a handful of medical schools in the nation that began teaching substance use disorders to medical students back in the 90s.
It’s easy to blame doctors for the epidemic. They overprescribed opioids for several reasons:
- They didn’t want patients to suffer in pain. They’re used to prescribing 30 or 60 pills when five or ten would have been adequate.
- They wanted good patient satisfaction reports. Some received money from pharmaceutical companies for prescribing their meds.
- They had little, if any, understanding of substance use disorders.
- And in the case of Oxycontin, made by Purdue pharmaceuticals, they were flat out lied to about its risks by an unscrupulous marketing campaign that caused an avalanche of lawsuits against the company and billions in settlements.
Around the same time Oxycontin was FDA approved, the American Pain Society introduced pain as the “5th vital sign” and doctors were told to treat pain just like they would high blood pressure.
Then there were the criminal doctors. The “pill mill” pain pill peddlers, who had a license to prescribe, but only accepted cash for narcotic pain meds for anyone who had the money to buy, for any reason, no questions asked.
Dr. Parran says there have been four opiate epidemics in the United States since the Civil War.
They tended to hit the East and West Coasts and urban areas. But this one, was different. For the first time ever, it hit the entire nation.
"This opiate epidemic hit Appalachia, it hit small-town Ohio, it hit southern Ohio, it hit suburbs and it hit rural areas. There had never been an opiate epidemic in the history of the U.S. to hit those parts of the country," Dr. Parran said.
According to the U.S. Department of Health and Human Services, since 1999, 760,000 Americans died from a drug overdose. Two out of three involved an opioid and the majority started with a prescription given by a doctor.
All because of a shift in thinking 25 years ago.
"That resulted in at least a 400% increase in opiate prescribing in America," Dr. Parran says.
He adds that back then, the U.S. prescribed nearly 500% more narcotics than any other industrialized nation.
In Ohio, the peak of opioid prescribing hit around 2012. By then, the opioid epidemic was already catastrophic.
Ohio eventually became ground zero, leading the nation in overdose deaths.
By the time doctors started realizing the problem and cut back prescriptions by 40%, street drugs like heroin and fentanyl took over.
Narcotic pain medicines, such as Oxycontin and Percocet, were too expensive on the street to buy, so drug dealers offered heroin as a cheaper option.
When drug users stopped using, they’d become “dope sick” which is akin to having the flu, but 20 times worse. If they managed to get clean but then go back and use, they would overdose and often die.
By 2017, overdose deaths in Ohio were beginning to decline. Then the COVID-19 pandemic hit.
Disruptions in treatment, social isolation and economic stress were damaging to those battling substance use disorders.
According to the Ohio Department of Health, 2020 became the highest year for overdose deaths in the state with 5,017. 81 percent of those deaths involved fentanyl.
Despite all of this, the majority of medical students weren’t learning about the opioid epidemic and substance use disorders (SUD) in school.
It’s not that the issues weren’t important. Medical students do not have the ability to write prescriptions. Once they move on to a residency program at a hospital, that’s when prescribing practices were typically learned.
But the opioid epidemic taught us that early intervention and education is critical.
In 2016, the American Academy of Medical Colleges began encouraging schools to begin curriculum that covered the subject. That same year, Ohio awarded a state grant to the Northeast Ohio Medical University (NEOMED) to develop curriculum for the state’s seven medical schools.
Stacey Gardner-Buckshaw, Ph.D., M.P.A., NEOMED assistant professor and Director of Community Engagement in the Department of Family and Community Medicine, wrote the grant.
The Ohio Mental Health grant allowed them to develop 36 teaching modules that encompasses 70 hours of content.
"There's not time for 70 hours of content in the medical student curriculum so understanding that students have a residency they will also be lifetime learners as physicians," she said.
The curriculum became available in the fall of 2020 and each Ohio Medical School can choose sections to use.
"The curriculum in its entirety is not start to finish, it's done in a series of modules that each medical school could pick and choose to use as part of another course as it fits into the course," Dr. Gardner-Buckshaw said.
Dr. Parran says the only way to combat the epidemic is through education on all sides.
"In the first couple years of med school, they should learn about substance use disorder in general and in the last couple years of med school about the basic principles of safe prescribing of addictive drugs," he said.
This new shift in thinking may help future doctors save even more lives.
"The goal is to have the right balance of content to insure that students have what they need to be good doctors practicing in this area," Dr. Gardner-Buckshaw said.
Ohio's seven medical schools all have access to the course work developed at NEOMED, but every school teaches it in a different way. And in the last decade, it's likely many incoming medical students were very aware of the opioid epidemic. Including some with personal connections.
Both CWRU School of Medicine and NEOMED students now have extensive training on SUD and the opioid epidemic. The following is medical school class overviews from Ohio University and The Ohio State University:
Ohio University Heritage College of Osteopathic Medicine just graduated the first class to be trained in the college’s new Pathways to Health and Wellness Curriculum which includes the following instruction related to substance abuse and opioids:
Year 1: Students are introduced to the topic of substance abuse.
Year 2: Addiction (assessment, diagnosis, and treatment), the opioid epidemic, and the association between childhood trauma and adult addiction. Includes a hands-on interprofessional overdose simulation lab which includes Narcan administration. The students are presented with an ecstasy and an opioid overdose case.
Year 3: Physician use/abuse. In the psychiatry course, students learn alcohol, opiate, cannabis and stimulant use disorders from a clinical intervention perspective. In the ER course, acute overdoses are covered.
Year 4: Students have the option of taking an addiction medicine elective
At The Ohio State University College of Medicine, addiction and substance use treatment is a core component of the Lead Serve Inspire curriculum.
Content is introduced in the pre-clerkship phase of the curriculum (Part 1) in the second year where students learn the historical perspectives and epidemiology of opioid use disorder, the pharmacology and neurobiology, clinical manifestations and diagnostic implications of substance use disorders, the approach to the patient, and treatment modalities.
During Part 2 (M3/third year), these concepts are reinforced in the clinical environment where students review the clinical manifestations and treatment strategies for substance use disorders, withdrawal, and addiction including medication assisted treatment. This includes differentiating among substance use, misuse, and dependance and review of prescribing guidelines.
During Part 3 (M4/fourth year), students learn advanced approaches to the care of patients with chronic pain and the need for palliative care and they reinforce practices for safe prescribing. Students have the opportunity to rotate on an addiction psychiatry elective if desired.
At Northeast Ohio Medical University (NEOMED)
Since academic year 2020, NEOMED’s College of Medicine has taken the bold step to implement formal training in use of medications to treat opioid use disorder for all physician graduates.
Each of the past three years of implementation of this curriculum has resulted in refinements in its delivery with the aim to ensure that graduates are well prepared for residency programs where these newly minted physicians are on the frontline in providing care to so many.
The College of Medicine’s Opioid Use Disorder curriculum starts from the first year of medical school and culminates in the fourth year’s Clinical Epilogue and Capstone course situated just before graduation. The first year focuses on understanding the patient perspective, with a patient panel, including physicians in recovery, and group activities to prompt thoughtful reflections on the human cost of this disorder.
Through the foundational science coursework in the first two years, students learn the biophysical, behavioral and social sciences that shape the current understanding of this public health crisis. Just prior to the third year, when students began their clinical rotations among health care teams across Northeast Ohio, students are introduced to pain management and medications for treatment of opioid use disorders.
They also complete the formal training required to prescribe these medications during a focused clerkship (clinical course) in psychiatry alongside further detailed coursework on the neurobiology of addiction, evidence-based behavioral and pharmacological treatments of addiction, and other important topics that inform and help students master the skills needed to accurately diagnose and treat these disorders.
Three fourth-year experiences round out the curriculum when different aspects of caring for individuals and communities impacted by opioid use disorder are revisited as a part of the required Social Determinants of Health course, an elective for those who seek further focused clinical experience in treatment and management of addiction, and then the capstone course which focuses on social justice aspects of this public health crisis.
NEOMED’s College of Pharmacy also provides curriculum on opioid use disorder. Instruction includes the underlying pathophysiology of the disorder, screening for opioid use disorder, medication treatment for opioid use disorder and harm reduction strategies (such as naloxone). The College also discusses opioid use disorder treatment during pregnancy.