Was addiction and substance use disorder previously part of the medical school curriculum?
If it was, it was sporadic across programs and schools.
When I started medical school about 20 years ago, I recall getting virtually no education on these topics. I remember on a psychiatry rotation, one of the post-call psychiatry residents had an interest in addiction and gave a five-minute spiel about the medications to treat opioid use disorder on his way out the door to go home and get some sleep. That was about it.
My thought at the time was, "I wonder why we don't get more of this."
What has led to the change?
The opioid epidemic has been the primary driver.
Tragically, we’ve had substance use disorders that have impacted people for decades that were either easier to ignore by society at large or met with overzealous enforcement.
Over the last two decades, that has obviously changed in many respects. Opioid overdoses and concomitant stimulant overdoses are now leading drivers of mortality, especially among young people. Many of our students know someone in their lives who has struggled with substance use. It’s a complex social, economic, and political conversation at a large scale.
What is the overall philosophy in teaching new students about addiction today?
The major shift in educational philosophy has been to acknowledge the reality of substance use disorders as a multifaceted issue that is neither a moral failing, nor a purely genetic constellation of factors that drive drug use.
Instead, substance use disorders are really complex and require some nuanced solutions and approaches to help people out. What we're trying to do is equip our learners with the skills, knowledge, and philosophies that are most evidence-based to try to improve the health of the people we’re seeing.
There are decades worth of evidence to build from. We know that "just say no" doesn’t work. We know that chastising doesn’t work. We know that abstinence-based approaches also don’t work. So, it's all about finding ways to counsel people who use drugs to do so safely in a way that promotes their safety and health, as well as the safety and health of those around them.
What does the addiction curriculum look like at CU Anschutz?
I've worked on addiction education with nursing, physician assistants, medical students, fellows, and residents. I'll focus mostly on our medical students since that's my primary swim lane.
For our first-year medical students, we cover a lot of background: biological basis for addiction, risk factors, neural pathways involved in problematic drug use, as well as the medications and standard treatments for commonly-encountered substance use disorders.
We then take a step back for a broader perspective in a health and society course. My friend and colleague Alexis Ritvo, MD, MPH, and I put together a half-day session that includes a lecture on the relationship between substance use disorders, the economy, and how insurance coverage affects treatment options for substance use disorders and other psychiatric disorders.
Then we do a two-hour, small-group session where we look at elements of how our culture interacts with people struggling with drug use. This includes case-based reviews, examining stigma and harm reduction, as well as the interaction with the criminal justice system. As part of that, we cover drug courts – which is a program where people with drug offenses don't necessarily go to jail, but rather are entered into a court-supervised treatment. The clinic that I work with, ARTS (Addiction Research and Treatment Services) in the Department of Psychiatry, works closely with several local governments in their drug courts.
We also bring the students to a one-hour large group session where I interview a couple of patients who volunteer to talk about their experiences with addiction, drugs, and the healthcare system. The patient panel always gets rave reviews. Students really like hearing from real-life patients who can speak to their journeys and see that addiction isn’t a dead end – people can and do get better.
In their second year, we have offered a session on harm reduction where we bring in local experts who work for local governments or non-profits to talk about principles of harm reduction and why harm reduction matters. Then in their fourth year, medical students get an intensive series of specialty-specific sessions on pain management, opioid management, and the opportunity to practice encounters with standardized patients portraying clinical situations involving drug-related concerns.
What is harm reduction and preventive medicine?
My dad was a physician and had a funny saying: “These humans are frisky creatures.” Harm reduction is a philosophy that acknowledges his saying in a way – people are going to do things that have the potential to cause them or those around them harm. Harm reduction aims to mitigate these harms, and is a core component of the philosophies that we bring to bear on campus in our educational programs and in our clinical programs.
Rather than telling people not to do something like use drugs – which we know doesn’t really work – harm reduction acknowledges drug use is going to happen and by providing counsel to patients on how to mitigate common problems arising from drug use, we promote their health.
Harm reduction in the space of drug use includes things around how to use drugs safely. Syringe access programs to reduce infections associated with injection drug use are one example – the data shows they save money and improve outcomes.
Harm reduction occurs outside of addiction medicine. For example, seat belts are harm reduction – driving in a car has risks, and wearing a seat belt mitigates some of that risk.
Preventive medicine is population health, and for this population, includes harm reduction at scale. It includes advocacy work toward enacting policies that are more helpful for affected people. For example, here in Colorado, we advocated for increasing the maximum daily dose of buprenorphine, a drug used to treat opioid use disorder, that Medicaid will pay for without a prior authorization because the old benchmark was medically insufficient in the era of ultra-potent fentanyl in our illicit drug supply. That law just went into effect this year, and we're hopeful that that will continue to help.
Are there clinical aspects to the addiction curriculum?
Yes, in their fourth year of medical school, all students complete a course called “Transition to Residency.” Within that course, we have developed specialty-specific content for soon-to-be interns covering case-based discussions around opioids. So for example, the cases for people going into internal medicine are different from the cases for people going into pediatrics, though the themes are similar. We wanted to make the content as realistic and useful as possible, so we worked with chief residents, faculty, and content experts to design the sessions for maximal applicability to the real world.
Through our Center for Advancing Professional Excellence, we simulate challenging conversations between our learners and standardized patients, who are actors trained to portray patients in a clinical setting. Students get to dive right in and practice having challenging talks with patients about opioids, and then receive near real-time feedback from peers, instructors, and the standardized patients themselves after the encounter. The student ratings for this series has been overwhelmingly positive.
We really try to bring in these multimodal approaches to reaching our students to help them understand the nuance and complicated picture of addiction – and how to start thinking about improving the current system.
How is stigma covered – both with students and faculty?
For students, I think there’s a baseline generational change. In general, they’ve grown up with a more expansive and empathetic view of the topic – due to personal experiences and the scale of the opioid epidemic. But the patient panels we do are really humanizing on the topic as well. Students can ask questions of people who look just like them and break apart notions of how TV dramas portray people using drugs – typically manipulative and combative. Instead, they are actually people just living their lives.
For faculty, it can be a bit of a tougher nut to crack. There might be some older-school versus some newer-school approaches and sentiment among faculty members depending on how they were trained, their experiences, their upbringing, and their education. CU faculty are overwhelmingly empathetic and receptive to our efforts in this space, though there will typically be a few outliers here and there.
With stigma and substance use disorder – and addiction in general – we try to take the long view. Old perspectives are baked into the system. But if we can move things forward a bit at a time, then future generations will have things easier with more compassionate care. That’s what drives us as teachers and healthcare providers.
Photo credit: Shimaa Basha, MPH, director of the CAPE.
