Celebrating 30 years of CSAM-SMCA in Vancouver, BC, the conference focused on: Crisis, Controversy & Change. What is the role of education in tackling the overdose crisis?
Three speakers at the education session on Friday offered several potential solutions.
Friday, October 26th: Medical Education in Addictions (CSAM-SMCA Education Committee)
(1:30) Who Learns the Most about Addictions in Hospitals? A Mixed Methods Study.
Jan Klimas (representing a co-author team: Gorfinkel, L., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., and Nadia Fairbairn), summarised the results of a 2-year evaluation of the addiction medicine consult team in the St Paul’s hospital, Vancouver, British Columbia. Learners, such as medical students, completed web surveys before and after their clinical placements with the team. A purposeful sample participated in post-elective interviews. Results of this research study will soon appear in a paper accepted for publication in the Substance Abuse journal.
(1:45) Addiction Medicine Mentorship: Capacity Building Through Relationship Building.
Kate Hardy (Manager) and Sarah Clarke (Sarah Clarke) from the Metaphi mentoring project spoke about the role of primary care providers in the treatment of substance use disorders. The length of the treatment is more important than the intensity. Patients prefer to be treated in primary care. Integrating mental health with physical health services creates better outcomes. Primary care has greater capacity for treatment. But many providers are not willing to take over the care of persons with SUD. Medical mentoring of primary care providers by specialists. There’s no wrong door to access the addictions treatment. Mentorship, such the one provided via Hardy’s and Clarke’s project – metaphi – must be easy and convenient, sufficiently incentivized. Check out the project website www.metaphi.ca.
(2:00) The ABC’s of Addiction Fellowship Programs in Canada.
Melanie Willows (introducing her co-author team: Anees Bahji, Annabel Mead, Nikki Bozinoff, Ron Lim, Lydia Vezina, Ronald Fraser & Kim Corace) and a group of fellowship directors facilitated a session, which was sponsored by the CSAM education committee, about the Canadian fellowships in addiction medicine and offered recommendations for the future of the training programmes in Canada. In addition to the fellowship directors, the talk started with a lived experience of someone who has been accepted to the fellowship but who has not started the fellowship. A recent fellowship alumna concluded the group presentation.
If you enjoyed reading about this year’s CSAM 2018 conference, you can read about the CSAM 2015 here
Will an increasing pressure on prescribers curb the rising opioid overdose rates?
With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.
Mismatch: Why Correlation and Incidence Might Not Match Up
First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?
Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.
Polydrug use and overdose
Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately, we can’t tell how much polydrug use is really leading to addiction or overdose in this context.
Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.
We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.
To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:
Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction
I thank Lauren Gorfinkel for feedback on this post.
If you enjoyed reading this post, you may also like my poem about pain. See link below:
We learn best in places that support our learning and our bio psycho socio spiritual development – from toddlers to elders, reports Jan Klimas from the Canadian Medical Education conference #CCME18.
Starting in Toronto, Justin Hsu and colleagues from University of Toronto described how they improved spaces for communities in teaching ambulatory care, or the so called Medical Education Teaching Clinics (METC). They plan to evaluate METC clinics via audit of referrals to the teaching clinic and the learner satisfaction survey.
Presentation title: Creating unique spaces to support community-based ambulatory care education: the E3 experience.
Presentation authors: Jerry Maniate, Elizabeth Wooster, Douglas Wooster, Justin Hsu
British Columbia quality matters
Jan Klimas’ team from University of British Columbia evaluated hospital as a place of learning about substance use disorders. Who learns most about addictions in hospitals? Using mixed-methods approach, this team showed that medical students get more out of a rotation in hospital than residents or senior learners. Especially in the areas of safe prescribing, screening and withdrawal management. Why is that? Do residents know more or are they more resistant to new learning? For many medical students, hospital could be the first place where they see someone with addiction and that could be why they learn more in this setting.
Presentation title: Who learns most about addiction in the hospitals? A mixed methods study.
Presentation authors: Jan Klimas, Evan Wood, Walter Cullen, Will Small, Seonaid Nolan, Annabel Mead, Mark McLean, Christophe Fairgrieve, Keith Ahamad, Huiru Dong, Breanne Reel, Lauren Gorfinkel, Nadia Fairbairn
Derek Wilson and colleagues from the same university focused on the quality of health education learning environment (HELES study). HELES survey tool looked at relationship, personal development and program culture as the key parts of the learning environment at the faculty of medicine. For example, the evaluation asked whether the learners have developed a strong sense of community.
Presentation title: Evaluating the Quality of Health Professions Learning Environments: Validation of the Health Education Learning Environment Survey (HELES).
Presentation authors: Derek Wilson, Shayna Rusticus, Derek Wilson, Oscar Casiro, Kevin Eva, Lisa Hazlett, Chris Lovato
Calgary explores and experiences
Maureen Topps and collaborators from University of Calgary, Cumming School of Medicine, asked whether in addition to focusing on the deficiencies and gaps in education, whether we could research the successful activities related to professionalism. The postgraduate education is a key stage in training the next generation of competent and professional clinicians. Professionalism is hard to define and to define it may “limit it,” as Dr Barnhoorn writes in the Academic Medicine journal (2006, Vol. 91, No. 9). But how does the place of learning make for more professional doctors? Slowing down and taking time to plan interactions appears to foster professionalism among other factors such as communication training.
Presentation title: Contexts and Experiences of Postgraduate Residents that support successfully meeting professionalism challenges.
Presentation authors: Janet de Groot, Maureen Topps, Aliya Kassam, Maureen Topps
Nicole Delaloye and colleagues from the same university presented results from her Masters research of the MSc/MD program. Clinicians should be both polite and respective, but not overly submissive. Why do we follow orders? Resuscitation requires wise action, not passive deference. What happens when learners hold back too much and how does the place of learning impact submissiveness? Mechanisms that underly submission in the moment of revival include learner’s mental state, what was going on inside and outside the room, team and motivation.
Presentation title: An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment and the Educational Implications.
Presentation authors: Nicole Delaloye, Elaine Gilfoyle, Rachel Ellaway, Aliya Kassam, Elizabeth Oddone Paolucci
In summary, the best learning places not only support our learning, but also challenge us to learn knew knowledge, adopt the discipline’s values, overcome deference and become successful professionals in our own right.
The opinions and views in this article present the views of the author and not the named persons or the #CCME18 conference organisers.
This study looked at how many, and what types of people who inject drugs (PWID), in the AIDS Care Cohort to evaluate Exposure to Survival Services Study (ACCESS), would be eligible for medical heroin in Vancouver, Canada.
Medical heroin could possibly help people who have treatment resistant opioid use disorder and who live with HIV/AIDS.
How was the study done?
We looked at how many, and what types of PWID in the ACCESS Study would be eligible for medical heroin. Participants had to meet eligibility criteria from clinical trials of medical heroin.
The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. ACCESS participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/)
What did the study find?
478 participants said they injected opioids. 20% met the eligibility criteria for treatment with medical heroin. Those who were homeless, or were involved in the local illicit drug trade, were more likely to be eligible for medical heroin.
20% met the eligibility criteria for treatment with medical heroin and also said they were homeless and dealt drugs.
Why is the medical heroin useful?
Untreated opioid use disorder among people who live with HIV/AIDS can lead to illnesses, overdose, or death. Medical heroin can play an important role in helping people who have treatment resistant opioid use disorders and who live with HIV/AIDS.
Reference: Klimas, J., Dong, H., Fairbairn, N., Socías, E., Barrios, R., Wood, E., Kerr, T., Montaner, J., Milloy, M. (2018) Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addiction Science& Clinical Practice. In Press (https://ascpjournal.biomedcentral.com/track/pdf/10.1186/s13722-017-0104-y?site=ascpjournal.biomedcentral.com)
Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.
Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.
Overdose prevention and management, including naloxone provision, should be a priority for health education.
A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).
Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.
Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.
Few students had direct experience of overdose management although many met patients using opioids.
High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.
Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.
Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students’ Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.