Schools train doctors to battle opioid crisis
Twenty years ago doctors began treating pain more aggressively and started prescribing narcotics at much higher doses than ever before, said Dr. Jason Beaman.
“They did not recognize a problem was coming,” said Dr. Elisa Crouse.
It came with a vengeance, and today it’s up to people like Crouse — at the University of Oklahoma College of Medicine — and Beaman — at the Oklahoma State University College of Osteopathic Medicine — to help train doctors to handle the opioid epidemic.
“We’re having to adapt daily because we’re in the middle of a public health crisis,” said Beaman, chairman of the department of psychiatry and behavioral science.
“This is our generation’s plague, and — not only as physicians, but as educators of physicians — we’re having to adapt very quickly to how we teach our students, and then how we are delivering the health care to treat the addiction.”
Medical schools must do more than teach physicians what is appropriate when it comes to prescribing pain medication, said Crouse, associate dean for graduate medical education. They also must teach what resources are available for patients who overuse, and how to talk to patients about “what you’re willing and able to do for them to prevent overuse,” she said.
As doctors see more and more new patients who already have an addiction, the old rules of prescribing no longer apply.
“Opioids are a good drug in certain circumstances, and we need to be able to have some of those medications,” Crouse said. “Physicians want to help their patients and want to provide the things their patients need ... but we need to monitor better.”
There are systems in place that allow doctors to safely prescribe pain medication, Beaman said. In addition to guidelines and recommendations for proper use, state law is designed to prevent the diversion of painkillers to the street.
“They have a very large street value. And I would say in Oklahoma, all those pills are coming from Oklahoma doctors,” Beaman said. “I have been bamboozled by an 80-year-old grandmother who was getting the pain medicine and giving it to her grandson to sell.”
Some physicians have overcompensated and established a policy never to prescribe pain medicine, “and that’s not what we want either,” he said.
Medical schools are telling doctors they must look for red flags like patients demanding pain medication, coming in early for refills and using multiple pharmacies.
In the classroom
Addiction medicine once was centered in psychiatry, but medical schools have changed.
“Addiction is not just about psychiatry anymore,” Crouse said. “It never was, but it was largely focused in psychiatry. And now that we’ve discovered how expansive the problem is, we need to have training programs that are more broad reaching.”
All Oklahoma medical school students — whether they will become radiologists, surgeons or pediatricians — are trained in addiction medicine.
“We give them an early foundation, and then what they get in a residency is definitely more advanced,” said Dr. Chris Candler, senior associate dean for academic affairs at OU’s College of Medicine.
“It’s not just opiates. We also teach about alcohol. That’s another huge, huge issue, “Candler said. “We cover the whole spectrum — nicotine, ecstasy, cocaine, marijuana, amphetamines. We try to hit on every type of drug of abuse their patients may come in with. They’re taught how to diagnose and treat or manage each of those.”
Students learn about drug use through all stages of life, and about recovery programs, legal aspects of controlled substances and physician addiction, he said. And if they want more, they can take an elective course on addiction medicine.
At OSU’s College of Osteopathic Medicine, all medical students take a class devoted totally to addiction medicine and do a rotation in a Tulsa addiction hospital “where they get to see it firsthand,” Beaman said.
When graduates become residents, they are targeted with lectures across all specialties, and the psychiatrists work in the 12 & 12 addiction recovery center, he said.
In the community
While all doctors need to know about drug addiction, Beaman and Crouse say it is critically important for primary care physicians who are on the front lines of health care.
“They are the ones who really need to be able to recognize the signs and symptoms,” Crouse said.
“The best thing we can do for Oklahoma is to get primary care physicians to start aggressively treating addiction,” Beaman said. “They are the boots on the ground.”
Rural family medicine clinics are among the places where heavy prescribing is an issue, he said.
“There are just a few doctors that are doing it unscrupulously,” Beaman said. “Most doctors who are prescribing pain medicine genuinely believe that they are doing what is best for their patients. They’re doing what they’ve been taught.”
So in addition to training up-and-coming doctors, there is a need to train established doctors across the state to change their practices, he said.
“We’re in the middle of that switch right now,” Beaman said.
New guidelines include no longer prescribing opioids for back pain — the most common reason they are prescribed — and limiting narcotics to no more than three days “because we know your chances of getting addicted dramatically increase after three days,” Beaman said.
The OSU Center for Health Sciences uses a teams of specialists to train primary care providers in rural areas how to treat addiction through weekly tele-education consulting conferences.
Doctors can present a patient’s case to the expert panel and get instructions on how to treat that patient.
“What we find, is after they participate for a year, they don’t need to come anymore because they know what we’re going to say before we say it,” Beaman said. “Now they know how to treat addiction, and we’ve created an addiction specialist in that small town.”
In the future
OSU-CHS is establishing an addiction medicine fellowship to train physicians in most specialties to become board-certified in the treatment of addictive disorders, along with their specialty, Beaman said.
The OU Health Sciences Center expects to implement in the next two years an addiction medicine program that doctors can enter from any specialty to focus on their fields of medicine, Crouse said.
She envisions a multidiscipline approach “because the care of a patient who has overuse or addiction needs must involve physicians, social workers, psychologists, nurses and pharmacists.”
Integrating behavioral health and social issues with primary care is critical to the future of addiction care, said Gary Raskob, dean of the OU College of Public Health and chairman of the Oklahoma City County Health Department Board of Health.
A patient is much more likely to get the help needed if the experts are all in one location, Raskob said.
“We have to think of this from a multi-factor approach,” he said. “We can address a lot with education, but we also have policy tools.”
The statewide database where doctors must enter certain medications they have prescribed was “a big step to stop the doctor shopping” by patients who are addicted, Raskob said.
“Addiction is a lifelong illness and you always have to be on guard,” Beaman said. “But with appropriate medication and other support we can prevent the horrible damage that addiction causes both in our families, our finances, our jobs and also with death.”