OBSERVATIONS OF A MEDICAL STUDENT
In the busy preoperative area, we—2 medical students—meet our patient prior to her surgery. Along with the resident, we discuss postoperative pain control. The patient reports no allergies to opioids, and when we discuss the analgesic plan, she identifies hydrocodone by brand name, hoping it will also relieve her troublesome back pain. The resident provides the prescription and hurries to the next task. However, we paused to reflect on the exchange. Why did the patient request a narcotic by name? Is it appropriate for her to use this medication for her chronic back pain in addition to her surgical pain? Finally, is the rushed preoperative holding area the best place to have this discussion with the patient?
The United States is in the midst of an opioid epidemic, and solutions require a cultural change surrounding acute pain management. As the physicians of tomorrow, how can medical students help address this critical issue?
Opioid-related morbidity and mortality in the United States is a public health crisis. Given the prevalence of opioid use for acute and chronic pain, this epidemic spans nearly every discipline in medicine. Surgeons, too, play an important role in this problem.1,2 The risks of opioid prescribing for acute pain were previously underappreciated, as many practicing surgeons trained during a time when opioids were marketed as nonaddictive. In turn, opioids are overprescribed postoperatively,1 and patients are at risk of persistent opioid use after surgery.2 For example, when opioid-naive patients receive an opioid prescription after surgery, 6% continue to fill opioids beyond 90 days postoperatively.2 To change clinical practice, we need educational strategies targeting all levels of healthcare delivery and medical training, including medical student education.
OPIOIDS IN MEDICAL EDUCATION
Opioid prescribing and pain management is historically lacking in medical school curricula. Only 29% of United States medical schools in 2010 included opioid prescribing as a required curricular topic.3 In a survey of new surgical interns, most felt underprepared to write opioid prescriptions, citing lack of formal training in medical school.4 In response, educators and lawmakers are beginning to recognize the need for educational programs targeting medical students. For example, in Massachusetts, state government and medical school leadership collaborated to incorporate core competencies for safe opioid prescribing into their curricula.5 Michigan lawmakers have recently proposed legislation to require opioid education in medical school curricula. A focus on medical student education will create a future generation of doctors who practice safe and patient-centered opioid prescribing.
BACK TO THE BASICS: HISTORY TAKING
To accomplish this educational goal, it is critical to focus on a fundamental clinical skill: history taking. Medical students learn the universal template for history taking, which includes a past medical history and medication list. The structure of the history has changed little over the years, yet in a dynamic healthcare landscape, students and physicians must adapt their history-taking accordingly. Histories should include a robust opioid risk assessment when prescribing opioids. Relevant components of such a risk assessment, based on established risk factors for opioid dependence or misuse,6 are presented in Table 1. For example, when prescribing an opioid, past medical history should include a psychiatric and substance use history. This specific aspect of the history is practiced during a psychiatry clerkship, yet often neglected during the surgery clerkship. Current and past medication use is also a key component of the history, as even past opioid use can impact postoperative outcomes. Time constraints may deter these important discussions, but involving medical students in this process, under supervision, can facilitate detailed history-taking and enhance the student's educational experience.
An important tool to quantify a patient's opioid use history is a state's prescription drug monitoring program (PDMP). These registries track a patient's history of controlled substance fills. Though accessible by prescribers at the point of care, PDMPs are under-utilized, especially in acute care settings, with one statewide survey reporting only 26% PDMP registration among surgeons who routinely prescribed opioids.7 In the authors’ experience during medical school clerkships, these tools were rarely discussed or used. All medical students should be aware of the PDMP available in their state, and where allowed, students can help collect PDMP reports preoperatively to inform pain management and opioid prescribing.
Opioid prescribing necessitates informed decision-making. This is often neglected when opioids are prescribed for acute pain. In the vignette above, there was no discussion of risks and benefits with the patient. In the authors’ experience in medical school, we rarely observed communication of the risks and benefits of opioids for acute pain. By comparison, when a short-course of steroids is being prescribed, the authors routinely observed a deliberate risk-benefit discussion. Both steroids and opioids have significant risks, so why should these drugs be handled differently in these instances? Despite the growing body of evidence documenting the risks of opioids, even when used for acute pain, our clinical practice clearly lags behind the science. By involving patients in a discussion of the risks and proper use of opioids, we can put patients back at the center of their pain management while protecting against iatrogenic opioid-induced morbidity and mortality. Including comprehensive education about the risks and benefits of opioids in medical school curricula will help make students better equipped to engage patients in risk-benefit discussions.
Patient education is key to safe opioid prescribing, and involving students in this process is an opportunity to teach critical communication skills. All physicians have a duty to inform their patients about safe pain management. Students, too, can help reinforce this patient education, as they often have additional time to devote to patient encounters. These discussions should explain the rationale behind appropriate prescription size and risks of overprescribing. For example, as many as 72% of all opioid pills remain unused after surgery, and prescribing guidelines are therefore emerging based on actual patient consumption.1,8 Furthermore, most patients report unsafe storage of these leftover opioids,1,9 which can lead to unintended diversion into the community. In fact, 41% of American adults who misuse opioids report obtaining the pills from a friend or relative for free, further highlighting the need for proper disposal.10 Resources are publicly available to facilitate patient education,8 and empowering students to guide patients through such resources can be an effective way to teach safe opioid management while engaging students in the patient encounter. Ideally, such discussions will first take place during the preoperative clinic visit, when more time can be allocated to this important task. On the day of surgery, students can help the surgical team revisit the pain management discussion.
In summary, surgeons have a role in solving the opioid epidemic by prescribing opioids in a responsible and patient-centered manner. A focus on medical student education is critical when designing initiatives to improve opioid prescribing. Educating medical students on safe opioid prescribing, teaching students to take thorough and relevant histories, and engaging students in patient education, is necessary to foster an upcoming generation of safe opioid prescribers.
The authors thank Jennifer Waljee, MD, MPH, MS, Michael Englesbe, MD, Chad Brummett, MD, and Jay Lee, MD for their mentorship and advice on this work.
1. Hill MV, McMahon ML, Stucke RS, et al. Wide variation and excessive dosage of opioid
prescriptions for common general surgical procedures. Ann Surg
2. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid
use after minor and major surgical procedures in us adults. JAMA Surg
3. Mezei L, Murinson BB. Pain education in North American medical schools. J Pain
4. Nooromid MJ, Mansukhani NA, Deschner BW, et al. Surgical interns: preparedness for opioid prescribing
before and after a training intervention. Am J Surg
5. Antman KH, Berman HA, Flotte TR, et al. Developing core competencies for the prevention and management of prescription drug misuse: a medical education
collaboration in Massachusetts. Acad Med
6. Kaye AD, Jones MR, Kaye AM, et al. Prescription opioid
abuse in chronic pain: an updated review of opioid
abuse predictors and strategies to curb opioid
abuse: part 1. Pain physician
7. Irvine JM, Hallvik SE, Hildebran C, et al. Who uses a prescription drug monitoring program and how? Insights from a statewide survey of Oregon clinicians. J Pain
9. Bartels K, Mayes LM, Dingmann C, et al. Opioid
use and storage patterns by patients after hospital discharge following surgery. PLoS One
10. Han B, Compton WM, Blanco C, et al. Prescription opioid
use, misuse, and use disorders in U.S. adults: 2015 national survey on drug use and health. Ann Intern Med