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An Asynchronous Curriculum to Address Substance Use Disorder Training Needs for Medical and Surgical Residents

Truncali, Andrea MD, MPH; Silva, Kristen MD; Stickney, Isaac MEd, CGS; Johnson, Marin MS; Holt, Christina T. MD, MSc

Author Information
Journal of Public Health Management and Practice: May/June 2021 - Volume 27 - Issue - p S168-S173
doi: 10.1097/PHH.0000000000001305

Abstract

Unhealthy substance use (SU), which includes the spectrum of high-risk use to severe use disorders, has broad population health impact. The prevalence of use disorders alone is 1 in 7 in the United States, and people with substance use disorder (SUD) are overrepresented in medical settings.1,2 Furthermore, receipt of medical care poses the risk of exposure to reinforcing substances and the threat of subsequent chronic use.3 Attending to SU risk and disorder stands to prevent major accidents, development of use disorders, SU-related health sequelae, death, and community impact.2,4–6 Despite this, systems and providers are notoriously underprepared to address SU risk or disorder.2,7 As with any chronic medical condition, all providers must understand their role, carry a basic set of skills and knowledge about unhealthy SU, and limit related harm from medical encounters. The need for training across specialties is especially true with SU since many patients with unhealthy use present only to acute care settings and because motivation to address the SU problem can vary on the basis of phase of illness and circumstances of the health care encounter.

Developing SU skills in medical training has been a challenge. Residents in teaching hospitals bear a large burden in managing SU sequelae and often lack knowledge and support to address the psychosocial and medical aspects of this condition.1 There is no designated position in undergraduate medical education to develop core skills, and medical faculty who guide students and residents have variable competency in the field.2,7,8 In the setting of medical systems with fledgling capacity to treat SUD as well as unconscious bias, a “hidden curriculum” of stigma and clinical inertia toward SU is perpetuated.2,9,10

We developed and delivered an addiction medicine curriculum to provide a defined, consistent set of broadly applicable core knowledge and skills for residents across specialties in a tertiary care center.

Methods

Graduate medical education leadership and the designated institutional officer agreed to provide protected educational time for SU training at first-year orientation. Three 1-hour online Web modules were developed by preventive medicine and addiction medicine faculty. These modules covered (1) Unhealthy SU Screening, Detection, and Intervention; (2) Implicit Bias and Communication; and (3) Safer Prescribing in Acute Pain (Table 1). The module is publicly accessible at https://mmc.instructure.com/courses/448. Modules used a mix of narrated content, video demonstrations and patient interviews, audio podcast, multiple-choice questions, and reflective writing to engage learners. The modules were hosted on the institution's learning management software (Canvas) and were designed to be completed in sequence. Although learners could click through some of the content, they were required to correctly complete embedded questions in order to advance (see Supplemental Digital Content Figure 1, available at https://links.lww.com/JPHMP/A750, to view sample content). All incoming residents were assigned to independently complete the modules and given protected time during orientation in which to do so. The due date for completion was immediately prior to a 2-hour live skills session involving 4 faculty members, including 2 addiction medicine providers (one of whom completed a Public Health and General Preventive Medicine residency) and 2 Addiction Medicine fellows.

TABLE 1 - Description of Substance Use Disorder Curriculum as Delivered to First-Year Medical and Surgical Residents
Online Module 1: Identifying and Intervening with Unhealthy Substance Use
Goal: Increase learners' ability and willingness to identify and intervene upon patients who have unhealthy SU
Objectives Competencies Format
  1. Distinguish high-risk SU from SUDs

  2. Recognize screening tools as a means of asking about SU problems

  3. Describe the goal of brief intervention

  4. Identify role in referring or prescribing medication for alcohol and OUDs

Identification and intervention with the broad spectrum of unhealthy SU
Introduce the following: screening tools, screening vs detection, high-risk SU use vs SU disorder, steps of brief intervention, motivational interviewing introduction, treatment options, concept of reachable moments, role of all providers in recommending and motivating treatment and medication as standard for alcohol and OUDs
Narrated slides
Videotaped interactions
Online Module 2: Caring for People With SUD
Goal: Improve providers' ability to communicate effectively when caring for people with SUD through enhanced understanding of implicit bias
Objectives Competencies Format
  1. Describe firsthand perspectives about living with SUD

  2. Identify an implicit bias in oneself that impacts care of patients with SUD

  3. Use a new communication skill for challenging SUD-related interactions

Address provider attitudes and communication regarding care of patients with SUD by exploring concepts of implicit bias and self-awareness Narrated slides
Videotaped standardized patient cases including 3 different possible patient reactions to new OUD diagnosis and OUD in pregnancy
Online Module 3: Safer Prescribing for Acute Pain
Goal: Develop an opioid-sparing, risk-mitigating approach to the treatment of acute pain in adult patients.
Objectives Competencies Format
  1. Recognize the impact of hospital opioid exposure on chronic opioid use

  2. Describe key elements of an effective opioid-sparing acute pain regimen

  3. Identify major risks of NSAID therapy

  4. List 3 features of safer opioid prescribing in the hospital

  5. List 3 steps when discharging a patient with opioids

  6. Prescribe naloxone for overdose rescue

Identify the risk of opioid prescribing for acute pain in adults and provides learners with the knowledge to develop an opioid-sparing and risk-mitigating approach to acute pain management
Assessment of pain, how to effectively prescribe nonopioids and decide on need for opioids
Risk mitigation strategies and tools including use of prescription monitoring programs, setting patient expectations and overdose education with naloxone prescription
Narrated slides
Podcast from Core IM
Q+A to engage the learners
Live Session (via Zoom)
Goal: Enhance knowledge, attitudes, and skills needed for uptake of practices covered in the modules
Objectives Competencies Format
  1. Identify communication strategies to address common patient responses when offered naloxone prescription

  2. Identify resources for prescribing naloxone depending on insurance status

  3. Conduct a brief intervention regarding a patient's high-risk alcohol use

  4. Refer patients for specialty SUD treatment within the local health care system

Practice of key skills and added information about local resources
Two role-plays including (1) Offering naloxone to a newly inherited patient taking opioids for chronic pain and (2) Assessment and intervention with a patient admitted for a motor vehicle accident with high-risk alcohol use vs alcohol use disorder
A combination of interactive teaching strategies: poll everywhere, word clouds, breakout room/smaller group discussions and role-play
Abbreviations: NSAID, nonsteroidal anti-inflammatory drug; OUD, opioid use disorder; SU, substance use; SUD, substance use disorder.

Because of COVID-19, the live session was converted from an in-person session to a virtually delivered live session and was conducted through Zoom videoconferencing (V5.0). It combined a brief large group didactic with breakout sessions for role-play and small group discussion. To promote active engagement, we used the Vevox app to poll the audience with multiple-choice questions and develop a word cloud and utilized a group chat in the last half of the 2-hour session.

Pre/posttesting (see Supplemental Digital Content Figure 2, available at https://links.lww.com/JPHMP/A751) was performed to evaluate learners' knowledge, attitudes, and confidence. Testing was developed by our group to target intended outcomes, with some of the attitudes questions based on others' SUD attitudes surveys.11,12 Attitudes and confidence were measured on a 4-point Likert scale. The Maine Medical Center Institutional Review Board deemed the evaluation exempt from human subjects' research requirements on June 15, 2020, case number 1615908-1.

Results

Curriculum completion was 100.0% (68/68). Users spent an average of 282 minutes logged onto the 3 modules. Results of pre/posttesting are displayed in Table 2. Knowledge increased from a mean ± standard deviation composite score of 3.13 ± 1.06 (52.2% correct) on the pretest to 4.97 ± 0.98 (82.8% correct) on the posttest (+30.6% correct, P < .001 using the paired-samples t test). Among individual questions, the most significant knowledge changes were found for effectiveness of acute pain regimens (ie, using 3 medications to treat acute pain, +24.0% correct, P < .001 using the χ2 test with continuity correction) and relative efficacy of medications (nonsteroidal anti-inflammatory drugs vs opioids) for acute pain (+45.6% correct, P < .001 using Fisherʼs exact test), as well as the impact of prescribing medication for alcohol use disorder (+22.0% correct, P < .001 using Fisher's exact test).

TABLE 2 - Knowledge, Attitudes, and Confidence Before and After Substance Use Disorder Curriculum
Pretest (N = 68) Posttest (N = 68) P
Knowledge (frequency of correct answer), n (%)
Medications for alcohol use disorder 52 (76.5) 67 (98.5) <.001a
Medications for opioid use disorder 51 (75.0) 59 (86.8) .13b
Goals of brief intervention for high-risk alcohol use 53/67c (79.1) 56 (82.4) .80b
Risk of short-term opioid prescription for acute pain 24 (35.3) 27 (39.7) .72b
Using 3 medications to treat acute pain 45/67c (67.2) 62 (91.2) <.001b
Relative efficacy of medications for acute pain 37 (54.4) 68 (100.0) <.001a
Total knowledge score, mean correct ± SD (n = 67) 3.13 ± 1.06 4.97 ± 0.98 <.001d
Attitudes
Little I can do to help SUD .26a
Strongly disagree 44 (64.7) 52 (76.5)
Somewhat disagree 23 (33.8) 15 (22.1)
Somewhat agree 1 (1.5) 1 (1.5)
Strongly agree 0 (0.0) 0 (0.0)
SUD is a chronic medical problem .82a
Strongly disagree
Somewhat disagree 1 (1.5) 0 (0.0)
Somewhat agree 11 (16.2) 10 (14.7)
Strongly agree 56 (82.4) 58 (85.3)
Can't be helped if many relapses .55a
Strongly disagree 49 (72.1) 46 (67.6)
Somewhat disagree 19 (27.9) 20 (29.4)
Somewhat agree 9 (0.0) 2 (2.9)
Strongly agree 0 (0.0) 0 (0.0)
Part of my job to address SU .10a
Strongly disagree 0 (0.0) 1 (1.5)
Somewhat disagree 0 (0.0) 0 (0.0)
Somewhat agree 15 (22.1) 7 (10.3)
Strongly agree 53 (77.9) 60 (88.2)
Specialist referral is the only way to treat SUD .10a
Strongly disagree 34 (50.0) 42 (61.8)
Somewhat disagree 31 (45.6) 25 (36.8)
Somewhat agree 3 (4.4) 0 (0.0)
Strongly agree 0 (0.0) 1 (1.5)
Total attitudes score, (max = 20); mean ± SD (n = 68) 18.4 ± 1.5 18.7 ± 1.5 .068d
Attitude domains, median [interquartile range]
Treatment optimism/understanding (max = 12) 11 [10.2-12] 12 [11-12] .45e
Provider role (max = 8) 5 [5-6] 5 [5-6] .027e
Confidence (frequency), n (%)
Asking about use of alcohol and drugs .11a
Not at all confident 0 (0.0) 0 (0.0)
Not very confident 2 (2.9) 0 (0.0)
Somewhat confident 37 (54.4) 29 (42.6)
Very confident 29 (42.6) 39 (57.4)
Assessing need for opioid medication in acute pain <.001a
Not at all confident 6 (8.8) 0 (0.0)
Not very confident 37 (54.4) 7 (10.3)
Somewhat confident 25 (36.8) 55 (80.9)
Very confident 0 (0.0) 6 (8.8)
Educating and prescribing naloxone to prevent overdose <.001a
Not at all confident 9 (13.2) 0 (0.0)
Not very confident 35 (51.5) 2 (2.9)
Somewhat confident 17 (25.0) 31 (45.6)
Very confident 7 (10.3) 35 (51.5)
Safely treating acute pain with opioids <.001a
Not at all confident 14 (20.6) 2 (2.9)
Not very confident 40 (58.8) 9 (13.2)
Somewhat confident 14 (20.6) 56 (82.4)
Very confident 0 (0.0) 1 (1.5)
Total confidence score (max score = 16); mean ± SD (n = 68) 10.0 ± 1.7 12.9 ± 1.4 <.001d
Abbreviations: SD, standard deviation; SU, substance use; SUD, substance use disorder.
aFisher's exact test.
bChi-square test with continuity correction.
cOne data point missing and removed from the denominator.
dPaired-samples t test.
eWilcoxon test.

Attitudes were positive at baseline with a mean ± standard deviation composite score of 18.4 ± 1.5 (18.4/20; 92%) and did not significantly change at posttest with a score of 18.7 ± 1.5 (18.7/20; 93.5%) (+1.5%, P = .07 by the paired-samples t test). When the data were divided into 2 domains (treatment optimism and provider role), no change was seen in the already optimistic attitudes toward treatment (+0.1% median, P = .45 using Wilcoxonʼs test). Although the median score for the provider domain was the same pre- and posttests, there was a significant positive change in attitudes about the provider's role ownership (+0.0%, P = .027 by Wilcoxonʼs test); this is explained by 20 learners having positive differences and 6 having negative differences (with no change in the other 42). Thus, while the median for this domain did not change, there was a significant change in a subgroup of learners who had more negative attitudes at baseline with regard to provider role.

Learners showed increased confidence in key skills with mean ± standard deviation composite scores of 10.0 ± 1.7 pretest versus 12.9 ± 1.4 posttest (+2.9, P < .001 using the paired-samples t test). This change was driven by increased confidence in treating acute pain (educate and prescribe naloxone for overdose response: 35.3% somewhat/very confident pretest to 97.1% posttest, P < .001 for overall change in response distribution using Fisherʼs exact test; assess need for opioids in acute pain: 36.8% somewhat/very confident pretest to 89.7% posttest, P < .001 for overall change in response distribution using Fisherʼs exact test; and safely treat acute pain with opioids: 20.6% somewhat/very confident pretest to 83.9% posttest, P < .001 for overall change in response distribution using Fisherʼs exact test).

Several observations stood out from the live sessions, conducted after completion of the Web modules. Learners had attained a relatively firm grasp of core knowledge in safer prescribing for acute pain, but there remained the opportunity to address their sense of confidence in conversations about high-risk profiles and behaviors (eg, suggesting the risk of overdose and need for naloxone; suggesting the car accident was related to alcohol use), due to concern that they might make patients feel “badly” or “insulted.” Word cloud results from learners' feelings toward this population of patients are included in Supplemental Digital Content Figure 3 (available at https://links.lww.com/JPHMP/A752). It is also noted that 5 to 6 faculty members and fellows who reviewed this content during or prior to the sessions provided feedback that the online content provided information that was new to them and relevant to patient care.

Discussion and Conclusion

The training curriculum described aimed to impart knowledge and skills common to most specialties in the prevention and treatment of SU problems. Participation in this group of first-year residents was high as evidenced by completion, log-on time, pre/posttesting, and performance in the live session. Only 1 learner of 68 appeared to advance rapidly through the online material, at a speed that would suggest nonengagement. The intervention was highly effective in enhancing knowledge and confidence, especially in the area of more safely addressing opioid prescribing for acute pain. Attitudes started out with high scores and showed minimal change, though measurement was perhaps limited by ceiling effect and/or social desirability. Results suggest, however, that more providers understood and acknowledged their individual role in addressing SU problems through this educational intervention. This experience demonstrated the value of training residents across specialties at the beginning of residency, especially in circumstances where there is inconsistent practice on the ground and where learners are spread across departments. It also highlights the need for high-level institutional support in order to deliver a cross-disciplinary curriculum in residency programs.

Next steps will be to evaluate the curricular impact on practice, include senior residents, teaching faculty, and community providers, and identify systems needs to support adoption of the recommended practices. Given the role that all health care providers can play in SU prevention and treatment, along with their potential for doing harm, all teaching hospitals should consider implementation of this or a similar curriculum for this stage of learner.

Implications for Policy & Practice

  • All medical providers have a role in preventing and addressing unhealthy SU; however, there is a curricular gap in medical education and residency training with a fragmented system perpetuating that gap.
  • Asynchronous, structured learning experiences are a convenient way to provide a consistent set of core knowledge and skills, especially where on-site practice is still variable and expertise varies across departments.
  • Recognition and backing from educational leaders are essential in reaching a broad set of learners, especially those who are most subject to the “hidden curriculum.”
  • The online portion of this curriculum may be useful beyond residency programs, with uptake incentivized through provision of continuing education credit.

References

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2. National Center on Addiction and Substance Abuse, Columbia University. Addiction medicine: closing the gap between science and practice. https://drugfree.org/wp-content/uploads/drupal/Addiction-medicine-closing-the-gap-between-science-and-practice_1.pdf. Published 2012. Accessed July 2020.
3. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW, Binswanger IA. Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Internal Med. 2016;31(5):478–485.
4. Kaner EF, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2(2):CD004148.
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8. Wood E, Samet JH, Volkow ND. Physician education in addiction medicine. JAMA. 2013;310(16):1673–1674.
9. Kane JC, Elafros MA, Murray SM, et al. A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Med. 2019;17(1):17.
10. Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The hidden curricula of medical education: a scoping review. Acad Med. 2018;93(4):648–656.
11. Barone EJ, Huggett KN, Lofgreen AS. Investigation of studentsʼ attitudes about patients with substance use disorders before and after completing an online curricular module. Ann Behav Sci Med Educ. 2011;17(1):10–13.
12. Yale School of Medicine. Brief Substance Abuse Attitude Survey. Screening, brief intervention and referral to treatment. https://medicine.yale.edu/sbirt/curriculum/modules/medicine/brief_substance_abuse_attitude_survey_100733_284_13474_v1.pdf. Accessed October 26, 2020.
Keywords:

acute pain management; medical education; online learning; stigma; substance use disorder

Supplemental Digital Content

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