In this post, SLC member Siva Sundaram, representing the Advocacy Subcommittee, shares what his team has been doing to address the opioid epidemic ravaging Massachusetts. Despite increasing attention to the crisis in the media and the Governor’s office, there are few instructors with the knowledge and experience available to provide skills-based training for health professions students. Despite these challenges, Siva lays out what each of us can do as students—today—to make a difference.
In January 2016, the Center for Primary Care Student Leadership Committee (SLC) hosted a training by Dr. Joji Suzuki, an expert in addiction psychiatry from Brigham and Women’s Hospital, entitled “Treating Opioid Addiction: Tools for the Wards.” The training fell on a typical cold and blustery night in Boston, at a time when most students were unwinding from another busy day or (more likely) studying for the next round of exams. Nevertheless, Dr. Suzuki’s training drew more than 70 students representing four schools from across Boston: Harvard Medical School, Boston University School of Medicine, and Tufts University School of Medicine, as well as the MGH Institute of Health Professions. What does such broad interest and large turnout tell us about what today’s students want from their health professions education?
Few issues in Massachusetts have as high a profile today as the opioid epidemic. Media outlets cover opioid-related news daily. Legislators in the State House have been working for months to pass new laws to address the crisis. The medical and dental schools in Massachusetts have even answered Governor Baker’s call by committing to improve education around pain management and opioid prescription. However, the size of Dr. Suzuki’s audience that January evening suggests that all of these well-intentioned plans and discussions have not yet met the specific needs of students who will soon be on the frontlines of the fight against opioid addiction and overdose.
Much of the public conversation in Massachusetts around addressing the opioid crisis has thus far focused on prevention, specifically by reforming prescription practices to cut down on the supply of opioid painkillers. Prevention is undoubtedly crucial—but as future healthcare professionals, we are acutely aware that preventive measures will not help us care for individuals who are already struggling with substance use disorders. We want and need new skills. Yet effective training in these skills can be hard to come by (see a previous post by another SLC member, Helen Jack, also calling for more skills-based training). We see that many of those entrusted with teaching us clinical skills were themselves trained in a different era, when medical education around addiction often did not extend beyond recognizing “drug-seeking behavior” in patients. Addiction has long been seen in American society primarily as a moral failing and less so as a chronic illness deserving of medical treatment; medical training at large has often reflected these assumptions.
Now, however, attitudes and beliefs surrounding addiction in our country are changing. More and more public figures (including the federal government’s drug czar) are acknowledging that the “War on Drugs,” which has sought to criminalize addiction in order to fight drug abuse, has failed. President Obama recently called for more than $1 billion in funding for the expansion of treatment programs. Of particular note, Obama’s plan emphasizes medication-assisted treatment (MAT), a combination of behavioral therapy and medication that has been demonstrated to be more effective than abstinence-based treatment alone at limiting illicit opioid use, preventing overdoses, and keeping people in long-term recovery. (To learn more about MAT, take a look at this fact sheet that our SLC team put together.)
Yet change in practice has been neither rapid nor consistent across the country. In February, the SLC’s Advocacy Subcommittee hosted a screening of the popular HBO documentary “Heroin: Cape Cod, USA,” which depicts the ravages of the opioid epidemic in Massachusetts. Not once was medication-assisted treatment mentioned as an alternative to the demoralizing cycle of detox, “clean” living, relapse, and death by overdose that afflicted the documentary’s subjects time and again. Instead, we watched parents lament the moral failures of their children and heroin users chastise themselves for their lack of willpower. The stigma of addiction remains a formidable foe, even in areas where addiction has become a commonplace fact of life.
Even within the world of medicine, inadequacies are rampant. Significant barriers continue to impede the availability of medication-assisted treatments with drugs like buprenorphine. Although such treatment models work very well in office-based, primary care settings (as providers like Boston Medical Center have convincingly demonstrated), prescribing buprenorphine requires physicians to undergo an 8-hour training session and apply for a waiver, after which they are able to prescribe only to a limited number of patients. Precious few physicians within Harvard Medical School (HMS)-affiliated hospitals and clinics provide medication-assisted treatment, a scarcity we have discovered as we have looked for role models to teach us compassionate, evidence-based treatment of opioid use disorder.
The time is ripe for us, as students, to advocate for understanding and treating addiction as what it is: a chronic illness. The SLC Advocacy Subcommittee, in partnership with the Student Coalition on Addiction, an advocacy group spanning all four Massachusetts medical schools, is working to do what is in our power as current students and as the future generation of health care providers.
First, we are educating ourselves. Where gaps in our regular curriculum exist, we are asking our course directors to remedy them. In the meantime, we are creating learning opportunities outside of the classroom by turning to experts like Dr. Suzuki and diving into the expansive research literature ourselves. Even more concretely, fourth-year HMS student John Weems, co-chair of the SLC Advocacy Subcommittee, recently organized what we believe is the first-ever buprenorphine training for medical students to demonstrate the viability of a new model for increasing the supply of medication-assisted treatment providers.
Next, we are bringing our peers into the fold. Beyond events where students can learn information and skills, we are facilitating direct action. For example, at HMS, we are organizing our classmates to purchase naloxone (the opioid overdose-reversal drug, also known as Narcan) from local pharmacies. Doing so will allow us to respond to an overdose ourselves, to gather information about naloxone availability across pharmacies that will help improve access for community members, and to teach our patients how to acquire and use naloxone. To help build awareness and fight stigma (including within the medical community), we are posting pictures of our purchases on Facebook under the page White Coats for Recovery.
In the next phase, our team is using the knowledge and skills we have acquired with the help of people like Dr. Alex Walley at Boston Medical Center to train others in opioid overdose response and naloxone administration. As of now, this training is not yet approved as an official component of the curriculum at HMS. Nevertheless, as evidence of the student demand for skills-based training, 97.5% of the second-year class at HMS (195 individuals) voluntarily participated in our optional training offered after their Basic Life Support training in preparation for clinical clerkships. Moreover, as we have discovered, our medical student peers are not alone in wanting to be prepared to save lives by preventing overdose deaths. We have begun training providers and staff at HMS-affiliated primary care clinics, including the Windsor Street Health Center and the Zinberg HIV Clinic in Cambridge, and we are actively seeking more opportunities to do so. (You can find the materials we prepared for use in our trainings here.)
Ultimately, our goal is to create a culture of students prepared to “teach up”: to draw on evidence-based knowledge and practical skills in advocating for better care for their opioid-dependent patients as clerkship students, residents, and beyond. We must be able to hold our educators and authority figures to a high standard, both so that we are truly learning high-quality medicine and so that the profession that we are entering remains one we are proud to represent.
We know that we are one of many constituencies that must come together to mount an effective response as powerful and complex as the opioid crisis itself. We are ready to do our part.