Amid opioid crisis, med schools boost addiction training

Nationally, opioid ODs accounted for 42,000 deaths in ’16.

During SAN FRANCISCO — the three years that Dr. Hannah Snyder worked at San Francisco General Hospital part of her residency

— training to become a primary care doctor she noticed a

— troubling pattern.

Patients were coming in with skin abscesses and heart valve infections over and over again. Both are common medical complications from long-term use of heroin, when injected with needles that are not sterile.

“We’ll give them antibiotics and send them on their way, but that doesn’t get to the root of the problem,” Snyder said.

The experience prompted Snyder, once she completed training in 2017, to begin a year-long fellowship in addiction medicine. The School of Medicine at the University of California at San Francisco started the program last year, partially in response to the growing need to treat opioid addiction in California and beyond. It is the first such fellowship in the University of California schools of medicine.

The program, funded by the city and county of San Francisco, is designed to give doctors like Snyder extensive training in addiction medicine at the beginning of their careers. It is part of a broader shift by medical schools around the country to adapt to the opioid crisis by better incorporating addiction medicine — historically a field within psychiatry — into overall medical training.

“I started learning about treating addiction and realizing we had highly effective medications to treat addiction,” said Snyder, one of two doctors scheduled to complete the fellowship this month. “I got really excited about that because there’s a way to prevent people from having those complications in the first place.”

As part of the training, Snyder works at Ward 93, a methadone clinic at San Francisco General Hospital, where she meets with patients to discuss treatment options and reviews results of medical tests to monitor whether, among other things, higher doses of methadone are causing heart damage.

Snyder also is working with hospitals across the United States to create new protocols for treating patients with opioid-use disorder, using San Francisco General and Oakland’s Highland Hospital as models. That primarily means getting patients started on buprenorphine or methadone — two longterm prescription medications for opioid-use disorder — when they come to the hospital after overdosing or having severe withdrawal symptoms. Many public health officials and addiction experts have advocated this approach in recent years as the number of deaths from opioid overdoses continues to climb.

Nationally, opioid overdoses accounted for 42,000 deaths in 2016, more than any other year on record, according to federal health data. In California, the number of people dying from opioid overdoses — both prescription and illegal drugs — has held relatively steady, between 1,900 and 2,000 people each year, for the past five years. But the number of deaths from fentanyl, an illegally produced opioid that is many times more powerful than prescription pills and heroin, is skyrocketing. In 2017, a record 746 Californians died after overdosing on fentanyl — more than triple the year before, and nine times what it was in 2013.

The medical profession acknowledges that it played a role in creating the opioid epidemic. Many doctors began prescribing painkillers liberally, starting in the 1980s, believing the drugs were safe. Once they recognized the dangers and began curbing prescriptions, many patients turned instead to illicit opioids like heroin.

Today, the medical community is grappling with the consequences.

Since 2011, the Addiction Medicine Foundation has accredited 52 U.S. addiction medicine fellowships — including 12 in 2017, more than any other year.

Fellows like Snyder are doctors who have completed their standard three- to sixyear residency training for a medical specialty and are pursuing optional training in a sub-specialty. The American Board of Medical Specialties recognized addiction medicine as a sub-specialty in 2016.

“It’s the dawning awareness within the medical community that addiction in general is a growing problem in our patient population,” said Dr. Anna Lembke, a psychiatrist at Stanford School of Medicine who is overseeing efforts to add addiction medicine courses to the curriculum. “The opioid epidemic has put it front and center in a way that gives people permission to focus on it. Suddenly there are research dollars available to study it, and federal grants. It has momentum it never had before.”

At Stanford, part of the push is coming from students. Alexander Ball, a fifth-year medical student, worked with Lembke to create lectures for first- and second-year students on pain and addiction. Stanford incorporated the lectures into the curriculum this school year, and Ball is working with faculty members to add more for next year. The courses focus on safe opioid-prescribing practices, how to administer buprenorphine and other medication, and a counseling technique known as motivational interviewing to help patients with substance-use disorder to set goals.