Congress and health officials have criticized medical schools for failing to teach doctors about pain management, but medical schools and residency programs are moving quickly to address the issue.
"[I]f you're a veterinarian, you get much more training on how to address pain than if you're a medical student," said director of that National Institute on Drug Abuse (NIDA) in Bethesda, Md., at a Senate hearing last week.
Students in veterinary schools spend five times as many education hours focused on pain management as students in medical schools, she said.
A in The Journal of Pain found that U.S. medical schools allot a median of 9 teaching hours on pain and its management, compared to a median of 19.5 hours in Canada. In the U.S., that's approximately 0.3% of the total curriculum hours.
, dean of the School of Medicine, provost, and executive deputy chancellor of the University of Massachusetts Medical School (UMMS) in Worcester, Mass., spoke about the changes to his school's curriculum at a briefing hosted by the Association of American Medical Colleges here last week.
In September, Flotte met with , , commissioner of the Massachusetts Department of Public Health, and three other medical school deans to discuss the prescription drug crisis.
In Massachusetts, opioid related deaths have more than doubled over the last decade.
Baker told Flotte and the other deans, "Physicians own part of this problem" and challenged them to develop core metrics for opioid abuse prevention.
Six weeks later, Flotte and the other deans presented categorized under three key domains:
- Preventing prescription drug misuse through a more precise understanding of pain and a careful evaluation of alternative options to opioids
- Understanding how to treat substance use disorders in the earliest stage of diagnosis
- Learning to manage substance use disorders as a chronic illness and learning how to save a life following an overdose, using Narcan
At Baker's urging, UMMS then crafted a training module that Flotte described as an "immersive experience." It includes four intense scenarios in which students interview and assess patient actors. The students are evaluated on their interpersonal dialogue with patients and the identification of simulated physical findings.
The trainings also employ mannequin-based simulations for teaching resuscitation after opioid overdose. Finally, students meet with patients in recovery from substance use disorders and engage in reflective writing.
The entire unit will be taught during fourth-year medical students' last week of school, known as the"transition to internship" week. The program will be assessed to identify gaps in training.
UMMS has created a similar module for its second-year medical students and for nurse practitioner students in their final year.
Prevention trending
Michigan State University enhanced its curriculum for Family Medicine residents through a year-long quality improvement project, which includes a half-day seminar on treating chronic pain and the required completion of the Boston University Scope of Pain Education Course.
MSU also developed a systematized approach to pain management that includes:
- Informed consent for opioid treatment
- Mandatory periodic visits for chronic pain
- Use of the during initial screening
- Depression screening at every visit
- Use of the Brief Pain Inventory to track pain and functional impairment
- Mandatory drug screens and automated prescription review
, of the Sparrow/MSU Family Medicine Residency Program, told 乌鸦传媒 that when residents begin their work at Sparrow Family Health Centers in Lansing and Mason, Mich., they typically inherit a panel of patients, some of whom are already on opioids.
The residents' training teaches them to recognize when it's safe to continue opioid treatment versus when you should think about stopping, Odom explained.
The Boston University Scope of Pain Education Course is mandatory for anyone with active staff privileges at the health centers, not just residents.
The course teaches clinicians how to use the Opioid Risk Tool, which touches on personal substance abuse issues, family history of substance abuse, and items related to mental health diagnoses.
The tool lends itself to a dialogue about the risks and potential benefits of prescription painkillers that sometimes segues into the informed consent process -- an agreement between patients and their doctor that includes aspects of safe monitoring.
interim dean of MSU's College of Human Medicine, told 乌鸦传媒 depression screening is particularly important.
"People almost certainly feel more pain when they're depressed. So if you can treat their depression ... they will probably have less pain."
He added, "Also, [depression] is a risk factor for people harming themselves, and opioids have proven to be dangerous in people who have thoughts of hurting themselves as well as people who are not purposely trying to hurt themselves, but taking these medications through addiction or to escape some other part of their life, accidentally do themselves in."
Sousa said it's important for students to also remember that education is more than just science, particularly when working with patients who have substance use problems.
"The relationship part of working with people who are suffering is not easy ... you have to continually remind yourself that you have a general positive regard for somebody, even if they're not behaving in a way that makes it easy to work with them."
The University of Louisville in Kentucky has also strengthened its pain management program.
Its internal medicine residency training program recently instituted a controlled substance guideline, as well as lectures and preclinical conferences focused to help physicians practice "thoughtful prescribing."
Each medical student has a week-long palliative care curriculum, explained associate professor of medicine with U of L and director of the Palliative Medicine Fellowship Program and Palliative Medicine Clerkship.
"During that week they're taught about how to prescribe opioids, how to do a pain assessment and they learn about cancer pain management, in particular through two cases of patients with cancer pain," she said.
Palliative Care fellows rotate through the outpatient palliative care clinic at the Brown Cancer Center in Louisville, where they learn how to use opioid risk assessments, engage in patient prescribing contracts -- agreements that outline the physicians' and patients' expectations -- in "a nonjudgmental therapeutic way," and manage patients on chronic controlled substances.
Challenges remain
As a palliative care physician, Earnshaw said her greatest struggle is in working with patients who have both legitimate pain and addiction issues. While sometimes a prescriber can designate a family member to monitor the use of a medication, not every patient has a support system.
Sometimes providers end prescribing relationships because patients violate their contracts. And it isn't only patients but also family members who are affected.
"In palliative care and then in hospice care, there aren't many opportunities left for mending relationships. It's sad that those are missed opportunities, because we don't have the systems in place to help patients and their families ... I think the big issue that is being poorly addressed is addiction research and treatment and that is where we need to put our efforts," she said.
In a similar vein, Sousa said, "Scientists need access to the data about how patients are using medication and what their outcomes are." One reason the opioid epidemic may have grown so quickly was the inability for people to recognize that drug use was "getting out of control."
"That [data] needs to be available so that more people than just a [drug] company can analyze it, otherwise we put public health at risk."