Better medical education: One solution to the opioid crisis

published on August 7, 2017 by Jan Klimas in The Conversation

We are in the middle of an overdose crisis in Canada and around the world. Opioid overdose is a complex problem, but opioid addiction can be managed with effective interventions. Nonetheless, many evidence-based interventions are underused, and inadequate medical education is contributing to the problem.

Specialized addiction medicine fellowships for doctors can offer a new and effective way to fight addiction. A recently launched addiction medicine fellowship — at the University of British Columbia (UBC) and St. Paul’s Hospital in Vancouver — promises to change how addiction is taught in medical schools and beyond.

Historically, treatment of addiction has been in the hands of psychiatrists. Most health authorities have not trained doctors in addiction medicine. But training more doctors more efficiently can help to improve diagnosis and treatment of substance use disorders. It can also help reduce the public health epidemics that can result from improper prescribing of opioid analgesics – an ongoing problem in North America.

As a postdoctoral fellow at the University of British Columbia and researcher at the British Columbia Centre on Substance Use, I recently began to study how to improve addiction medicine education for doctors. This research includes a review of best practices that will help inform an international consultation of experts developing standards for teaching doctors in addiction medicine worldwide.

New treatments, old training

Over the past few decades, addiction science has advanced in leaps and bounds. We have found innovative ways to treat addiction, especially if it’s diagnosed early and treated promptly. However, most interventions are underused. Early diagnosis and treatment by medical professionals fail mainly due to a lack of skills and knowledge in addiction medicine. The result is myriad public health problems that stem from untreated addiction and untrained doctors.

Not long ago, for example, medical doctors in several provinces were told by representatives of pharmaceutical companies that OxyContin was not addictive — a lie that caused a mess to be cleaned up over the next decade.

All of this could be prevented with better training and better use of the interventions that we already have. Among them is buprenorphine/naloxone (also known as Suboxone), which is used to treat addiction to opioids. The new opioid treatment guidelines now recommend it as the first line of treatment for opioid addiction. In the past, it was not covered by provincial medical plans and only a handful of physicians could prescribe it. They needed to have their methadone licences first. New regulations and new guidelines removed these barriers so that more people can access it and other drugs needed to treat opioid addiction.

Global shifts

The situation of addiction training in Europe and elsewhere has changed, but not so dramatically. The Dutch created one of the most complete programs in Europe — a whole masters degree in addiction medicine. It also shaped the Indonesian national training program. But both the Dutch and the Indonesian models have been inspired by the Canadian models of addiction training.

Norway has started a full medical speciality in addiction medicine that is supported by the government. In the U.K., St George’s medical school at the University of London led a project that studied teaching in 19 cities and resulted in national guidelines for medical schools. On the other side of the globe, Australia offers three years of supervised training in addiction medicine, with regular assessment and a focus on harm reduction and evidence- based interventions.

Few of these programs provide teaching that is necessary for skilled addiction specialists. Better programs should include training in detoxification protocols, inpatient consultation, residential treatment, youth addiction, mental health problems and chronic pain management as well as long-term treatment based in the community.

A new model for addiction education

In this respect, new training programs to address these problems have emerged around the globe, including in Canada. The fellowship at UBC and St Paul’s Hospital teaches addiction science to eight physicians over 12 months of specialized training. They come from family medicine, internal medicine and other disciplines and thus expand the skilled addiction treatment workforce to a community of front-line workers who see people with substance use disorders frequently.

From the very beginning, the American Addiction Medicine Foundation accredited the fellowship, and trainees are supported to sit the foundation’s exams. They receive not only training in clinical skills, but also research skills via intensive work with mentors. They have lots of access to public research articles, participate in academic half-days, conferences and journal clubs. They are trained on how to talk to journalists, how to influence public opinion and how to advocate on patients’ behalf – becoming true leaders in the field.

In recent years, the number of applicants for the fellowship have increased and challenged the program’s capacity to train the next generation of addiction doctors. To respond to this urgent need, and to save more lives of people who overdose, new training pathways have been built around the fellowship program. Nurses and social workers are now trained — two from each profession annually.

Another U.S.-funded fellowship program of dedicated research training in Canada teaches science skills to four physicians on a part-time basis every year. These clinician scientists are an important piece in the overdose management puzzle because they deliver the care, know their patients well and can prescribe effective medications.

A new, free online diploma in addiction medicine was also launched in May. Anyone can access it and study just one or all the educational modules on various topics of addiction medicine. In addition, the Provincial Opioid Addiction Treatment Support program has been moved online to reach a wider audience of prescribers as the program became part of the new British Columbia Centre’s on Substance Use portfolio.

With these recent developments, the potential to improve the system of addiction care and prevent people from dying due to overdose has reached unprecedented levels. Lives will be saved.

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