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When the team of students walked into the exam room, they weren’t sure to expect. They stood on the perimeter of the stark, fluorescently lit room, and introduced themselves to a patient who called herself Sheila Jones.
The students were there to take part in an interprofessional workshop put on by the Warren Alpert Medical School of Brown University. Sheila said she was there because she suffered from extreme back pain.
"It’s really the worst when I wake up," she said. "But throughout the day it goes down to about a four."
"A four?" said Lauren Ortado, a senior studying nursing at the University of Rhode Island. "And what would you say it is in the morning?"
"An eight," Sheila said.
"When you initially got hurt, did they prescribe you anything?" said Taylor DeRocha, a fifth-year student at the University of Rhode Island College of Pharmacy.
"Percocet," Sheila told her.
"And then how long did you use that for. Do you remember?"
"They gave me two refills."
Then, Sheila said she took Tylenol. The students made note of the painkillers she said she took, and continued on with a physical exam. While Tschilis tested her range of motion, Sheila moaned in pain.
The students then took a social history and asked what Sheila did for work and for fun. She said she works as an accountant, and lives alone, but has a close group of friends.
Then students left the exam room to huddle outside in the hallway. Nothing seemed unusual to them. They struggled to come up with a treatment plan. Should they prescribe something else for the pain? Recommend physical therapy?
Then, Ortado realized there was something they forgot to ask.
"I wanted to ask if she had taken anything that wasn’t prescribed to her," she said.
It’s a simple question. But an important one. It can also be uncomfortable to bring up. Figuring out how to go about this is one of the very reasons why Brown has students do this training. But the students were nervous. They went back and forth about who should ask her.
Finally, third-year med student Jason Tsichlis offered to go in. The rest of the students waited in the hall.
"We're wondering have you ever taken any medications that weren’t prescribed to you?" Tsichlis asked.
"That weren’t?" Sheila said.
There was a long pause. Then Sheila told him, "Well, when I ran out my prescriptions that the doctor was giving me, I talked to a friend and she said she had some stuff."
Some "stuff" turned out to be more Percocet. But, when Tsichlis pressed Sheila for more information, he found out that wasn’t the whole truth.
"I stopped buying the percs because it became too expensive, and I decided to get some heroin which was cheaper," Sheila said. "So I've been doing heroin for the past five months."
Tsichlis nodded calmly, and maintained eye contact with Sheila. He used an approach called SBIRT. It stands for Screening, Brief Intervention, and Referral to Treatment. The approach encourages empathy, and working with patients to set realistic, yet optimistic, goals for treatment.
"I know it's not good. That's why I'm basically here because I need to get some sort of control of my pain," Sheila said.
"Well it's really good that you've come here ... and you're in the right place and, we're here to care for you," Tsichlis said.
Sheila isn’t a real patient. She’s a standardized patient, which means the woman portraying her is trained to take on the characteristics of a person with a medical condition. The students knew this going into the exercise, but their job was to give Sheila a diagnosis, and to recommend a treatment plan.
Tsichlis went back into the hallway to regroup with the six other students taking part in the day’s exercise. There were four nursing students, a pharmacy student and a social work graduate student, all of whom are attending colleges across the state of Rhode Island. The interdisciplinary workshop gives students from a variety of backgrounds the chance to work together in order to emphasize that a multifaceted approach is needed to treat opioid use disorder.
Twenty years ago, doctors were taught that pain was the "fifth vital sign," something to be taken as seriously as blood pressure, heart rate, respiratory rate and temperature. As a result, there was a new onus on doctors to prioritize treating pain. Many were taught the solution to treating pain was more prescriptions, often for opioids.
We now know that about a quarter of patients who are prescribed opioids for chronic pain will misuse them. On average, 130 Americans die every day from an opioid overdose. And, it doesn’t stop with prescription pills. In 2016, synthetic opioids, namely fentanyl, passed prescription opioids as the most common drug involved in overdose deaths.
Because addiction can begin in the doctor’s office, many med schools are rethinking the way they train the next generation of doctors. The Association of American Medical Colleges recently honored four colleges for their innovative work on this front: the University of Massachusetts Medical School, the Warren Alpert School of Medicine at Brown University, the University of Michigan School of Medicine and the Uniformed Services University of the Health Sciences.
On Point spoke to professors and students at the schools to learn more about how they’re approaching pain today. Here’s what we found:
Warren Alpert Medical School Of Brown University
Training around use and misuse of opioids begins in the first year of med school, and students spend 30 hours of the curriculum learning about topics related to opioids and substance use.
When Dr. Paul George, associate dean for medical education at the school, was attending Brown’s med school in the mid-2000s, he doesn’t remember pain being a major focus.
"I probably had a lecture or two on pain and chronic pain,” he said. “Unfortunately, my generation of physicians who are now close to midcareer are the ones who are on the frontlines with patients who are suffering from opioid use disorder, so we're playing the catch-up game, and we have to learn sort of on the go about treating pain. I'm sort of sad that we at get this kind of education when we were in med school but glad that our students are."
In addition to taking part in workshops like the one described above, every med student receives training to prescribe buprenorphine.
The medication, when combined with the opioid-reversal drug naloxone, is branded as Suboxone. It reduces the craving for opioids, as well as the chance of a fatal overdose. But federal regulations prevent clinicians from prescribing Suboxone without a waiver. Rules for obtaining the waivers vary from state to state. All of Brown’s medical students receive training to get the waiver, but they can only prescribe the medication in the second year of their residencies if they practice in Rhode Island because there is currently no reciprocity between states.
"After graduating from medical school, a doctor could could now prescribe pain medication," said Dr. Sarita Warrier, an associate dean of medical education at the school. "They can prescribe Oxycodone, they can prescribe morphine. It seems almost unfair that they can't prescribe a medication that's used to treat some of the consequences of prescribing opioids. So being able to include buprenorphine training within our medical school curriculum became very important to us."
Paul Wallace, a recent graduate of the medical school, is now going to focus on addiction psychiatry during his residency at University of California, San Francisco. Even though he’s pursuing a specialization in addiction medicine, he told On Point he thinks the certification is valuable for every student.
"Unfortunately, my generation of physicians who are now close to midcareer are the ones who are on the frontlines with patients who are suffering from opioid use disorder, so we're playing the catch-up game."Dr. Paul George, Brown University
"It helps dispel the notion that treating opioid use disorder is purely the domain of addiction specialists or primary care doctors when truly all different types of physicians are going to encounter patients with opioid use disorder, whether it be an emergency physician who seeing a patient after an overdose or an obstetrician who's working with a pregnant patient with opioid use disorder," he said.
The University Of Massachusetts Medical School
All medical students, and all graduate nursing students, take part in what the school calls its "OSTI" program, which stands for Opioid Safe Prescribing Training Immersion. This education begins in the first year for medical students, and includes work with standardized patients, and panels where students can hear from patients and their family members, to name a few.
Dr. Melissa Fischer, professor of medicine and associate dean for undergraduate education at the University of Massachusetts Medical School, said the program was developed after Massachusetts Gov. Charlie Baker put out a call to medical schools to address the opioid crisis in 2015. The university revamped its curriculum in order to give students more learning opportunities that simulate encounters they’ll have with patients.
"[These encounters] allow students to practice skills and address the bias of the health care system and individual bias," she said. "And change the way that we're thinking about this disease, and approach the issue of pain treatment from a public health perspective."
"I think in our curriculum now we are more deliberate about [telling patients], 'You're going to have pain if you had surgery ... let me tell you about it and what to expect.'"Jill Terrien, University of Massachusetts Medical School
And, unlike in the past, when doctors were likely to reach for the prescription pad to try to eliminate pain, the school is now teaching students to be up front with patients about the realities of pain.
"I think in our curriculum now we are more deliberate about [telling patients], 'You're going to have pain if you had surgery ... let me tell you about it and what to expect,' " said Jill Terrien, an associate professor of nursing and medicine at the University of Massachusetts Medical School’s Graduate School of Nursing.
The University Of Michigan School Of Medicine
When Dr. Michael Englesbe was a surgery resident about three decades ago, he said he received no specific education about prescribing opioids.
“So the way surgeons learn [is], your first day as as a resident, you ask the person sitting next to you how many pills do you get for this procedure,” he said. “That number continued to get more and more over the past decade or two, and surgeons were kind of running for more and more opioids.”
In 2016, a med student at the university followed up with patients who had their gallbladders removed to find out how many pain pills the patients took after their operations. The patients had generally been prescribed 45 pills. But the average patient only took six. The student’s work led to a change in the number of pills prescribed after these procedures, as well as a change in the curriculum at the university.
“What we learned is, we as nurses and doctors do a poor job of talking to patients about their pain and how we can best care for it,” said Dr. Englesbe, professor of surgery at the University of Michigan Medical School. “This has expanded to a point where this small template of trying to align the pills to their pain has been exported across every procedure in the state of Michigan.”
The university estimates that the introduction of the new curriculum has prevented more than 40,000 excess pills from entering the community.
The Uniformed Services University Of The Health Sciences
Senior medical students at the university learn a technique that’s called "battlefield acupuncture." Needles are put in up to five different points in a patient’s outer ears, and fall out on their own after a few days. Dr. Arnyce Pock, associate dean for curriculum at the university, said patients have seen results in as little as a few minutes.
"In our clinic we'll have patients coming in with say eight or nine out of 10 severe back pain," she said. "We'll put these needles in their ears, one at a time. And it's not uncommon that five or 10 minutes later the patient walks out of the clinic either completely pain free or with her pain dramatically reduced from where they came in just with this alone."
"Pain has an emotional quality to it. People will feel pain and it will manifest in other ways. So I think having this broader picture is important."Jason Tsichlis, Brown University medical student
The technique was named "battlefield acupuncture" because, even in a disaster zone, the ears are accessible. But Pock says the technique isn’t limited to people who have been in combat. Between 2014 and 2016, 2,700 physicians, nurses and physical therapists were trained in the technique as part of a collaboration between the Department of Defense and the Department of Veterans Affairs. Now, she says the technique is being used extensively throughout the Washington, D.C., area.
"The beauty is even if the technique doesn't work 100%, [meaning] it doesn't bring someone's pain all the way down to a zero, and even if they need some additional medication, chances are they'll need far less medicine than they might have had they not had this technique," Pock said.
'Agency To Create Change'
All of this training is just the beginning. But it’s making a difference for students. Tsichlis, the Brown med student, says the interdisciplinary education he’s received will inform how he thinks about pain throughout his career.
"It's really easy to dissociate yourself from the pain somebody feels when they're in a hospital and you go back and you talk to the care team," he said. "It can be very easy to not feel that pain that they're feeling. Pain has an emotional quality to it. People will feel pain and it will manifest in other ways. So I think having this broader picture is important."
And, while that broader picture is critical to informing how practitioners approach treatment, the rest of the health care system needs to catch up, said Dr. Kelly Clark, the immediate past president of the American Society of Addiction Medicine.
“The structure that we have now of of having treated addiction like a social or a moral problem with social approaches only versus where we need to be with a whole continuum of care, is really the same issue we have with pain management,” she said. “ We have not built it in, [and in] some cases have dismantled a multidisciplinary infrastructure that is so needed.”
Dr. Englesbe, from Michigan, said that there’s always room to grow the curriculum. The changes put in place are a good start, ones he hopes will inform students for years to come.
“Now, what we give students in the curriculum is more than just knowledge,” he said, “it’s agency to create change.”
Correction: A previous version of this story incorrectly identified the Association of American Medical Colleges. The story has been updated. We regret the error.
This article was originally published on May 28, 2019.
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