Educators Address Gap in Addiction, Pain Training

Psychiatric educators are mobilizing to train medical students and psychiatry residents to confront the nation’s opioid epidemic.

The Association of Directors of Medical School Education in Psychiatry (ADMSEP) and the American Association of Directors of Psychiatric Residency Training (AADPRT) have launched initiatives around educating trainees about pain management and addiction, while a growing number of medical schools have developed their own training efforts, often in collaboration with community agencies and governing bodies in communities heavily hit by the opioid epidemic.

A common theme is an emphasis on integration of care across disciplines and systems of care. “Collaboration is key,” said Martin Klapheke, M.D., a professor of psychiatry and assistant dean of medical education at the University of Central Florida (UCF) College of Medicine. “No one discipline owns this problem.

“At UCF, this problem was on our radar even before the CDC guidelines were released [in 2016],” Klapheke told Psychiatric News. “We started to review our curriculum to see where we might need to strengthen it around pain management and addiction. We concentrate on pharmacologic and nonpharmacologic strategies for pain management throughout the four years of medical school. But we really focus on it in the clerkship years—we have beefed up our didactics and initiated ‘flipped classrooms’ where our students do independent study on pain management and then return to class to do case applications.”

UCF is not alone. Klapheke said the nine-member Council of Florida Medical School Deans Pain Management Group, of which he is a member, is collaborating to share didactics and best educational practices and to develop a model curriculum. “Here in Florida, we have been hit very hard by the epidemic,” he said. “All nine medical schools are committed to developing a common language for how to teach our students about this problem.”

At ADMSEP’s 2017 annual meeting, Lisa Fore-Arcand, Ed.D., education coordinator and co-director of the addiction medicine curriculum at Eastern Virginia Medical School (EVMS), and Senthil Kumar Rajasekaran, M.D., associate dean for academic affairs there, led a plenary session on medical student education in addiction.

Since 1994 EVMS has had an integrated addiction medicine curriculum until last year when they introduced a new systems-based curriculum—in which learning is organized around body systems—and wove in addiction training emphasizing integration of care across specialties.

“We wanted to move our curriculum closer toward a true integration with other disciplines,” Fore-Arcand told Psychiatric News. “Addiction training is threaded throughout the four years of training and across all the clinical rotations. It’s important that when we designed this curriculum, we wanted our students to understand that addiction is not the ownership of psychiatry or any other discipline.”

The EVMS curriculum emphasizes the disease model of addiction to help students understand the relapsing and remitting nature of addiction. “Traditionally addiction has been viewed as a not-very-glamorous discipline in part because it seems like patients don’t get better,” she said. “But we really emphasize that addiction is a disease, not a choice.”

An innovative strategy for “threading” addiction education throughout the curriculum at EVMS is the use of “virtual families”—prototypical families in which one family member’s addiction is seen in context with the conditions and disorders experienced by other family members and the surrounding community.

“The virtual family naturally lends itself to discussion about social and behavioral issues as part of the case discussion,” Rajasekaran told Psychiatric News. EVMS received an Accelerating Change in Education grant from the AMA for this curricular model.

Another critical element of the curriculum is a requirement that students attend meetings of Narcotics Anonymous and Alcoholics Anonymous.

“The students are expected to go to two NA or AA meetings a year and write a reflective essay about the experience,” she said. “Hopefully, when they talk to patients, they will be able to explain what attendance at a meeting is like. Our students learn a lot from hearing the stories that people in recovery tell, and they learn that this can happen to anyone—lawyers and college professors. It can be an eye-opener.”

What Is Optimal Addictions Training?

In a May 31 president’s blog, AADPRT President Sandra DeJong, M.D., reflected on a grim phenomenon: addicts were overdosing in the public bathrooms of cafes and shops including relatively upscale neighborhoods.

“Commuting to my office in Cambridge, Mass., this spring, I listened with some shock to a National Public Radio story about a new problem in the neighborhood where I work: the cafes of Inman Square were struggling to cope with the rate of overdose deaths in their restrooms. … [T]he owner of [a local coffeehouse] where our residents and faculty regularly purchase their lattes and espressos reported he had mounted a sharps box and is training baristas in naloxone use.”

Under DeJong’s leadership, AADPRT established the Presidential Task Force on Addictions with the following charge:

• To ascertain what training programs need in order to implement expert recommendations on addictions training and identify ways to meet those needs.

• To use these data to develop a strategic plan for improving addictions training, including a developmental approach that will help trainees acquire milestone-based competencies related to assessment and treatment of addiction.

• To provide a clearinghouse for existing educational resources and a platform for disseminating them.

• To develop educational modules that turn content into dynamic, interactive adult-learning sessions.

• To offer “train the trainer” sessions at the AADPRT annual meeting.

DeJong has made the issue a theme of her presidential year. “I had been concerned about the state of addictions training in psychiatry, and how it seemed to be lagging behind the burgeoning need for treatment in this area given the public health crisis in our country,” she told Psychiatric News.

“In the summer of 2016, I pulled together an advisory board of representatives from the various allied organizations, including addictions experts and representatives from training and education, many of whom were already doing work in this area,” she said. “I felt our first task was to try to define what optimal addictions training in psychiatry might look like. The task force has begun its work by developing a survey of general psychiatry training directors to find out what they are doing in their programs and what resources they would need to have in place to meet what the experts are saying would be optimal.”

The survey is being piloted now, and DeJong said the task force anticipates distributing it to AADPRT training directors in September. “Those results will guide us in developing a strategic plan for addictions training, identifying what resources need to be made available to programs across the country, and providing a platform for dissemination through websites and other technologies and annual meetings.”

DeJong said she believes that the Accreditation Council on Graduate Medical Education’s requirements in addictions training may need to be revised, but in the meantime programs across the country cannot be expected to do more until better resources are available.

Addiction services are lacking in many parts of the country, so it is hard to find clinical sites where residents can get addictions training. “Programs without addictions fellowships may not have addictions experts on their faculty,” DeJong said. “And the current generation of training directors and faculty may themselves not have received much training in addictions, so we need to train the trainers for residents and fellows to receive the training they need.” ■