Developing Core Competencies for the Prevention and Management of Prescription Drug Misuse: A Medical Education Collaboration in Massachusetts

Abstract

Drug overdose has become the leading cause of injury death in the United States. More than half of those deaths involve prescription drugs, specifically opioids. A key component of addressing this national epidemic is improving prescriber practices.

A review of the curricula at the four medical schools in Massachusetts revealed that, although they taught components of addiction medicine, no uniform standard existed to ensure that all students were taught prevention and management strategies for prescription drug misuse. To fill this gap, the governor and the secretary of health and human services invited the deans of the state’s four medical schools to convene to develop a common educational strategy for teaching safe and effective opioid-prescribing practices. With leadership from the Department of Public Health and Massachusetts Medical Society, the deans formed the Medical Education Working Group in 2015. This group reviewed the relevant literature and current standards for treating substance use disorders and defined 10 core competencies for the prevention and management of prescription drug misuse.

The medical schools have incorporated these competencies into their curricula and have committed to assessing students’ competence in these areas. The members of the Medical Education Working Group have agreed to continue to work together on key next steps, including connecting these competencies to those for residents, equipping interprofessional teams to address prescription drug misuse, and developing materials in pain management and opioid misuse for practicing physicians. This first-in-the-nation partnership has yielded cross-institutional competencies that aim to address a public health emergency in real time.

According to the Centers for Disease Control and Prevention, drug overdose was the leading cause of injury death in the United States in 2013.¹ Of the 43,982 drug overdose deaths, 22,767 (52%) involved prescription drugs. Of these, 16,235 (71%) involved opioids and 6,973 (31%) involved benzodiazepines (these data overlap as some deaths involved both).² Together, these data indicate that the United States is facing a national opioid epidemic.

In Massachusetts, an estimated 1,526 residents died of a drug overdose in 2015. The number of unintended opioid-related deaths has risen sharply since 2013 and has exceeded the number of motor-vehicle-related deaths since 2005 (see Figures 1 and 2). A recent survey of Massachusetts residents found that 50% of respondents felt that painkillers are prescribed too often or in larger doses than necessary; 47% felt that getting painkillers from those who save them is too easy. Only 36% of respondents who had been prescribed an opioid were informed of the addiction potential by their prescriber either before or while they were taking the medication.³ In 2014, 4.4 million prescriptions for Schedule 2 or Schedule 3 opioids were written for Massachusetts residents, resulting in the dispensation of 240 million pills or tablets.⁴ Together, these data point to the need to explore prescriber education as a component of any strategy to address the current opioid epidemic.

Figure 1: Number of opioid-related deaths (unintentional/undetermined) in Massachusetts, 2000–2015. Reprinted with permission from the Massachusetts Department of Public Health.

About the Medical Education Working Group

As part of a multifaceted strategy to stem the tide of preventable deaths due to prescription drug misuse, Charlie Baker, the governor of Massachusetts, and Marylou Sudders, the secretary of health and human services for Massachusetts, invited the deans of the state’s four medical schools (Boston University School of Medicine [K.H.A.], Harvard Medical School [J.F.], Tufts University School of Medicine [H.A.B.], and the University of Massachusetts Medical School [T.R.F.]) to convene to develop a common educational strategy for teaching safe and effective opioid-prescribing practices, based on the recommendations from the Governor’s Opioid Working Group.⁵

Over the two-month time period, from October through December 2015, the resulting Medical Education Working Group, which was made up of the four deans and their faculty, as well as leaders from the Massachusetts Department of Public Health (M.B.) and the Massachusetts Medical Society (D.M.D.), met for a series of four meetings to review the relevant literature on addiction medicine and prescription drug misuse, including more than 25 peer-reviewed journal articles, as well as current medical school practices in this area. The working group also evaluated the existing curriculum at each of the four Massachusetts medical schools and found that although they all taught various components of addiction medicine and prescription drug misuse throughout the four-year curriculum, no uniform standardized mechanism existed to ensure that all students were taught prevention and management strategies for prescription drug misuse.

Outcomes of the Medical Education Working Group

To address this gap in the curriculum, the Medical Education Working Group, in collaboration with senior faculty educators, defined 10 core competencies for the prevention and management of prescription drug misuse that all graduating medical students must demonstrate (see List 1). They focused on the following themes that emerged from their literature review and from national and local standards for treating substance use disorders—an emphasis on evidence-based safe prescribing practices, the importance of screening and using the prescription drug monitoring system, understanding the potential treatment options for pain and substance use disorders, and the need for patient-centered interviewing skills. The core competencies are meant to enhance medical student training in primary, secondary, and tertiary prevention strategies for prescription drug misuse and to provide students with a strong foundation in prevention, identifying substance use disorders, and referring patients to appropriate treatment. These competencies are designed to serve as a vital bridge between undergraduate medical education and residency training.

List 1

Core Competencies for the Prevention and Management of Prescription Drug Misuse

In the appropriate setting, using recommended and evidence-based methodologies, the graduating medical student should be able to demonstrate the ability and/or knowledge to independently:

Primary prevention domain: Preventing prescription drug misuse (screening, evaluation, and prevention)

• 1. Evaluate a patient’s pain using age, gender, and culturally appropriate evidence-based methodologies.
• 2. Evaluate a patient’s risk for substance use disorders by using age, gender, and culturally appropriate evidence-based communication skills and assessment methodologies, supplemented by relevant available patient information, including but not limited to health records, prescription dispensing records (e.g., the Prescription Drug Monitoring Program), drug urine screenings, and screenings for commonly co-occurring psychiatric disorders (especially depression, anxiety disorders, and posttraumatic stress disorder).
• 3. Identify and describe potential pharmacological and nonpharmacological treatment options, including opioid and nonopioid pharmacological treatments for acute and chronic pain management, along with patient communication and education regarding the risks and benefits associated with each of these available treatment options.

Secondary prevention domain: Treating patients at risk for substance use disorders (engaging patients in safe, informed, and patient-centered treatment planning)

• 4. Describe substance use disorder treatment options, including medication-assisted treatment, as well as demonstrate the ability to appropriately refer patients to addiction medicine specialists and treatment programs for both relapse prevention and co-occurring psychiatric disorders.
• 5. Prepare evidence-based and patient-centered pain management and substance use disorder treatment plans for patients with acute and chronic pain with special attention to safe prescribing and recognizing patients displaying signs of aberrant prescription use behaviors.
• 6. Demonstrate the foundational skills in patient-centered counseling and behavior change in the context of a patient encounter, consistent with evidence-based techniques.

Tertiary prevention domain: Managing substance use disorders as chronic diseases (eliminating stigma and building awareness of social determinants)

• 7. Recognize the risk factors for, and signs of, opioid overdose and demonstrate the correct use of naloxone rescue.
• 8. Recognize substance use disorders as a chronic disease by effectively applying a chronic disease model in the ongoing assessment and management of the patient.
• 9. Recognize their own and societal stigmatization and biases against individuals with substance use disorders and associated evidence-based medication-assisted treatment.
• 10. Identify and incorporate relevant data regarding social determinants of health into treatment planning for substance use disorders.

Each medical school in Massachusetts has incorporated these competencies into their curriculum and plans to develop assessments to evaluate students’ competence in these areas. These assessments will include patient- and standardized patient-based examinations, as well as technology-enhanced simulations. For example, at the University of Massachusetts Medical School, third- and fourth-year medical students now complete the Opioid Safe Prescribing and Training Immersion performance assessment. This assessment incorporates all 10 core competencies and includes four standardized patient simulations. All four medical schools have agreed to perform an annual review of their curriculum and the corresponding assessments to ensure that the competencies are being appropriately addressed.

Critical Next Steps

Given the acuity of the current opioid epidemic and its connection to prescription drug misuse, the Medical Education Working Group felt that immediately incorporating these core competencies into each medical school’s curriculum was critical. The group also agreed to continue to work together on key next steps. The group recognized that the practical application of the skills learned in undergraduate medical education continues during graduate medical education training. Medical schools and hospitals sponsoring graduate medical education also have begun to develop core competencies for residents, especially those in primary care, that address a wide variety of clinical needs, such as safe prescribing for acute short-term opioid use and the management of long-term opioid prescriptions for the treatment of chronic nonmalignant pain. Integrating the core competencies for the prevention and management of prescription drug misuse with any related competencies for residents is critical to ensuring that medical students are required to maintain and expand these skills as they enter residency training. Furthermore, the group recognized the need to expand interprofessional education opportunities designed to better equip collaborative teams for primary, secondary, and tertiary prevention of opioid use disorders. As other practitioners, including nurses, pharmacists, dentists, and mental health providers, among others, also contribute to the provision of care, they too must demonstrate competence in this area. Finally, the group recognized the need for continuing medical education materials for current prescribers. Many such tools have been developed in Massachusetts, including the Boston University Safe and Competent Opioid Prescribing Education program (www.scopeofpain.com), which is used by more than 30,000 prescribers nationally. In addition, the Massachusetts Medical Society now offers their current continuing medical education programs in pain management and opioid misuse (www.massmed.org/Patient-Care/Health-Topics/Opioids/Prescriber-Education) free of charge through their Web site. Making these tools and others like them available to all prescribers will help to ensure that practicing physicians have access to the materials they need to practice safe and effective prescribing.

In conclusion, this collaboration represents the power of bringing together public health professionals and medical educators to respond to public health emergencies in real time. Our first-in-the-nation partnership has developed cross-institutional core competencies for the prevention and management of prescription drug misuse that will reach all medical students in the Commonwealth of Massachusetts. As a result, Massachusetts’s medical students will be better prepared with the skills and foundational knowledge needed to be part of the solution to the current opioid epidemic. This national opioid epidemic has required us to rethink our educational goals for all future physicians, and we urge other medical schools to incorporate these competencies into their curricula as an important step to address this epidemic.

Figure 2: Number of unintentional opioid-related overdose deaths compared with number of motor-vehicle-related injury deaths in Massachusetts, 2000–2013. Reprinted with permission from the Massachusetts Department of Public Health.

Acknowledgments: The authors wish to thank the members of the Governor’s Medical Education Working Group on Prescription Drug Misuse.