Calling their curriculum deficient, students at Harvard Medical School are teaching themselves how to treat opioid addiction — joining the ranks of critics who say medical schools across the country aren’t doing enough to prepare doctors for a deadly crisis.
This spring, students at Harvard have organized their own trainings on how to use new medication to treat opioid addiction. And they’ve launched a campaign to raise awareness about how to buy and use naloxone, the overdose-reversal drug.
The efforts take place amid a surge in deaths from opioid overdoses, which killed an estimated 28,000 people in the United States in 2014. At least half of those deaths involved a drug prescribed by a doctor.
“We are over 10 years into this epidemic, and I don’t think we’ve seen a robust enough response from the medical community,” said Michael Botticelli, head of the White House Office of National Drug Control Policy, in a recent interview. “Law enforcement has taken much more innovative action … than the medical community has.”
The nation has seen “no huge change in prescribing behavior” around addictive opioid painkillers, Botticelli said, partly because “there is little to no education within medical education curriculums around addiction and safe prescribing.” Meanwhile, he said, the number of people who die of overdoses in each state is closely linked to how widely doctors are prescribing opioids.
The White House in March asked medical schools to sign a pledge to require students to learn new federal guidelines for safe opioid prescribing before they graduate. Of the nation’s 170-plus medical schools, 61 signed on.
Harvard Med and others refused.
“We don’t agree with the idea of taking pledges with what to put in our curriculum,” Dean Dr. Jeffrey Flier said in an interview last week. If Harvard started doing that, “I don’t see what would limit the number of groups going through, telling us what to put in our curriculum,” he said, “which would be the death of higher education.”
Harvard and other medical schools say they are already teaching safe prescribing methods, and are enhancing their curriculums to keep up with the epidemic.
“Virtually all medical schools are covering both substance abuse and pain management in both preclinical coursework as well as in the clinic,” said Tannaz Rasouli, senior director of public policy and strategic outreach for the Association of American Medical Colleges, citing a survey done by the accrediting body for medical schools.
In the face of criticism that medical schools aren’t doing enough, the association has been sharing examples of new efforts to equip students, residents, and physicians to confront the opioid crisis.
At Case Western Reserve University School of Medicine, for instance, Dr. Ted Parran Jr. has been teaching a remedial course for over 20 years to doctors who get in trouble with their medical boards for overprescribing painkillers. Now the school is offering a version of that course to medical students and residents, he said.
Massachusetts is high on the association’s list of good examples. Last November, Governor Charlie Baker worked with all four medical schools in the state to come up with a list of 10 skills essential to safe opioid prescribing and addiction treatment, and to incorporate them into their curriculums. The schools have been trading notes on what they’re already doing and how they can improve.
They have made some changes already: Just last week, graduating medical and nurse practitioner students at the University of Massachusetts took a new, required, four-hour opioid course, featuring clinical scenarios with trained actors. Among other changes, Boston University plans to add naloxone training to first-year students’ basic life support class. Tufts, which already requires students to take an addiction medicine course, has started to weave some of the 10 skills into required clinical experiences for third-year students.
Harvard Med plans to increase the emphasis on pain treatment and substance use disorder in two required preclinical courses, as well as infuse those subjects throughout the curriculum by September, said Dr. Todd Griswold, director of medical student education in psychiatry.
“By and large, medical schools have not done a good job in educating students about all of the complicated issues related to substance use, substance use disorder, and addictions,” he said.
Meanwhile, some students feel the school is moving too slowly.
Since Harvard Med’s basic life support course did not cover naloxone, students from the Center for Primary Care launched their own training, teaching second-year students how to use the life-saving drug. And they spread out to local pharmacies to test whether pharmacists would sell naloxone (also known as Narcan) over the counter.
In some cases, said student Siva Sundaram, “We were the first people to ask. Pharmacists didn’t know what to do.” In other cases, pharmacies had just two doses of the drug, so they wanted to save them for people who were at risk of overdose. Students who bought Narcan posted photos of themselves on a Facebook group called White Coats for Recovery.
In addition, fourth-year Harvard Med student John Weems organized an eight-hour training for medical students on how to use buprenorphine to treat opioid addiction.
Weems, Sundaram, and students from the state’s three other medical schools are part of the Student Coalition on Addiction, which is working to identify gaps in curriculums and recommend improvements.
Besides training in specific skills, students say there needs to be a broader change, so that medical staff see addiction as a chronic disease, not a moral shortcoming.
“There’s a cultural problem to address, a stigma about addiction,” said Katrina Ciraldo, who just graduated from BU’s medical school. “The doctors who are teaching us medicine have not gotten this education” about safe prescribing and addiction treatment.
For Ciraldo, the topic hits home: During her first year of medical school, her best friend from childhood died of a heroin overdose.
“She had all of these interactions with the health care system before she died,” Ciraldo said, but nobody noticed the signs of addiction, such as injection marks all over her arm.
There were “missed opportunities,” Ciraldo said. “We could do so much better.”