Most Doctors Are Ill-Equipped to Deal

Most Doctors Are Ill-Equipped to affect the Opioid Epidemic. Few Medical Schools Teach Addiction.

BOSTON — To the medical students, the patient was a conundrum. According to his chart, he had residual pain from a leg injury sustained while performing on a train track.

Now he wanted an opioid stronger than the Percocet he’d been prescribed.

So why did his urine test positive for 2 other drugs — cocaine and hydromorphone, a powerful opioid that doctors had not ordered?

It was up to Clark Yin, 29, to work out what was really happening with Chris McQ, 58 — as seven other third-year medical students and two instructors watched.

“How are you getting to have a conversation around the patient’s positive tox screen results?” asked Dr. Lidya H. Wlasiuk, who teaches addiction awareness and interventions here at Boston University School of Drugs.

Mr. Yin threw up his hands. “I haven't any idea,” he admitted.

Chris McQ may be a fictional case study created by Dr. Wlasiuk, delivered to life for this class by Ric Mauré, a keyboard player who also works as a uniform patient — trained to represent a true patient, to assist medical students to practice diagnostic and communication skills.

The assignment today: grappling with the fragile art and science of managing a chronic pain patient who could be tipping into a substance use disorder.

How can a doctor convert a patient who fears being judged? the way to determine whether the patient’s demand for opioids may be a response to dependence or pain?

Addressing these quandaries might sound fundamental in medical training — such patients appear in only about every field, from general medicine to orthopedics to cardiology.

the necessity for front-line intervention is dire: medical care providers like Dr.

Wlasiuk, who practices family practice during a Boston community clinic, routinely encounters these patients but often lacks the expertise to stop, diagnose and treat addiction.

According to the Centers for Disease Control and Prevention, addiction — whether to tobacco, alcohol, or other drugs — may be a disease that contributes to 632,000 deaths in The United States annually.

But comprehensive addiction training is rare in American medical education.

A report by the National Center on Addiction and drug abuse at Columbia University called out “The failure of the medical community at every level — in the school of medicine, residency training, continuing education and in practice” to adequately address addiction.

Dr. Timothy Brennan, who directs an addiction medicine fellowship at Sinai Health System, said that combating the crisis with this provider manpower is “like trying to fight war II with only the Coast Guard.”

Now, a decade-long push by doctors, medical students, and patients to legitimize addiction medicine is leading to blips of change around the country.

a couple of students have begun to concentrate on the nascent field, which concentrates on the prevention and treatment of addictions and therefore the effect of addictive substances on other medical conditions.

In June, the House of Representatives authorized a bill to reimburse education costs for providers who add areas particularly afflicted by addiction.

There are only 52 addiction medicine fellowships (addiction psychiatry may be a separate discipline), minuscule compared to other subspecialties.

In August, the primary dozen finally received gold-standard board certification status from the Accreditation Council for Graduate Medical Education (by contrast, there are a minimum of 235 accredited programs in sports medicine).

While most medical schools now offer some education about opioids, only about 15 of 180 American programs teach addiction including alcohol, tobacco, and other drugs, according to Dr. Kevin Kunz, executive vice chairman of the Addiction Medicine Foundation, which presses for the professionalization of the subspecialty.

And, therefore, the content in all schools varies, he noted, starting from one pharmacology lecture to many weeks during a third-year clinical rotation, usually in psychiatry or family practice.

Programs rarely go deeper. But Boston University braids addiction training into all four years.

This 75-minute session to show B.U. students the nuances of assessing a pain patient are already unusual.

What also distinguishes it's the presence of an addiction medicine fellow, Dr. Bradley M. Buchheit of Boston center.

“What isn’t present in his tox screen?” Dr. Buchheit prompted students. Fidgety silence.“What we’ve prescribed him — Percocet,” Dr. Buchheit told them.

“So we've to work out where that Percocet has been going.”And suddenly the medical maze surrounding Mr. McQ became even more complex.

Asking about cocaine use When you are a twenty-something medico, fists clenching nervously within the pockets of your white medical coat, learning to urge gruff, grizzled Chris McQ to disclose uncomfortable truths aren't readily gleaned from a textbook. Mr. McQ is crusty and defensive.

As students resorted to an equivalent chirpy rejoinder — “Awesome!”— he tried not to flinch. the person just wanted pain meds.

In each small-group session, a student had a quarter-hour to assess Mr. McQ and make a plan. Mr. McQ once had a cocaine problem. His girlfriend was taking hydromorphone, known as Dilaudid, for back pain.

Was he in danger of misusing opioids? “Ask him about his pain first,” Dr. Wlasiuk told the scholars. “Language matters. Avoid saying, ‘I found this out.’Instead, say, ‘This was in your urine screen.’

you would like to stay that conversation going, not shut it down. The students had learned about “motivational interviewing,” a way that encourages patients to articulate health goals.

As medicine moves far away from doctor-knows-best paternalism, students are being schooled in engaging the patient with a joint-decisionmaking, team approach.