Education of New Physicians

I read an interesting study in the May/June issue of the Journal of Addiction Medicine. This article, by Shuey et al, described Internal Medicine residents’ knowledge and attitudes towards treatment of opioid use disorder with buprenorphine.

This study reports on results of survey questionnaires sent to Internal Medicine residents in Florida residency programs.

The study showed that Internal Medicine residents cared for patients with opioid use disorder frequently: 73% of the survey respondents said they cared for such patients more than once per month. But only 82% reported having substance use disorder educational curricula. Specifically, 75% said their program didn’t provide training in the treatment of opioid use disorder with buprenorphine.

Respondents’ answers to questions about buprenorphine as used to treat opioid use disorder were uneven. While 88% correctly answered that buprenorphine was a partial opioid agonist, only 16% knew that buprenorphine has a higher affinity for opioid receptors than methadone, morphine, and naloxone. Seventy-six percent were aware of the dangers of precipitated withdrawal, and 69% knew that methadone cannot be prescribed from an office-based setting for the purpose of treating opioid use disorder.

However, only 17% knew that weeklong tapers of buprenorphine are not supported by medical evidence, and 56%, more than half, mistakenly thought resident physicians can’t prescribe buprenorphine.

Residents who indicated an interest in treating patients with buprenorphine scored better than those not interested in getting a buprenorphine waiver to prescribe.

Of the Internal Medicine residents who answered the study, only 2% already had waivers to prescribe buprenorphine. However, the vast majority, at 89%, felt deregulation of buprenorphine to allow any physician with a DEA license to prescribe buprenorphine was a good idea. (This study was done prior to the change in rules earlier this year that allows just that.)

The surveyed residents were also asked about their attitudes towards barriers to prescribing buprenorphine. When asked if they were willing to get trained and prescribe buprenorphine if it was offered by their hospital, 82% agreed. When asked if they felt they had been adequately educated about treatment of opioid use disorder, only 19% said they had, and 48% said they didn’t feel educated, while 33% felt neutral about the question. When the residents were asked if they agreed that opioid misuse and addiction was a serious national crisis, over 80% strongly agreed.

When the respondents were asked about obstacles to the prescribing of buprenorphine, by far the most common response was limited knowledge about diagnosing and managing opioid use disorder. Other answers were a lack of awareness of medication, laws preventing residents from prescribing buprenorphine, and limited understanding of the legal process to obtain a buprenorphine waiver. Less than 5% of survey respondents said they lacked interest in prescribing buprenorphine, around the same percentage who feared legal action against residents who prescribe buprenorphine.

Let’s talk about some interesting things about the study. For example, only around sixteen percent of the residents who were sent this survey responded. That’s a low rate of participation. However, the Internal Medicine (IM) residents who did responded to this survey were relatively diverse. More than half were female, and evenly divided over the three years of residency. Ethnicity was 42% white, 24 % Hispanic or Latino, 23% Asian, and 7% Black or African American.

That’s more diverse than my Internal Medicine residency, way back in 1987. We were 28% female and 85% white, with 15% black, with no Asian or Hispanic residents. And we were the most diverse class to date. The IM residents in the two years prior to mine were 100% white and 7% female. I’m glad residents are more diverse now.

Were minority residents more likely to respond to the survey for some reason? And were residents already interested in treating patients with opioid use disorder more likely to answer the survey? There’s no way to know.

This study indicated IM residents are not getting valuable information about treatment of opioid use disorder. We are now several decades into the opioid epidemic. It’s been over two decades since DATA 2000 was passed, allowing patients to be treated with buprenorphine in office-based settings. That’s a whole generation of physicians.

Why have medical schools and residencies been so slow to teach young doctors about opioid use disorder and its treatments? I used to think it was only because treatment with buprenorphine was so new, but it’s not new anymore.

I’m proud of North Carolina’s efforts to change this. We are fortunate to have the Governors Institute of Substance Abuse, a non-profit foundation that seeks to prevent, identify, and treat substance use disorders. Starting four years ago, they helped to convince and encourage our state’s medical schools and primary care residency programs to teach about opioid use disorder and its treatments. As a result, four (UNC at Chapel Hill, Wake Forest, East Carolina, and Campbell University) of our state’s medical schools already offer eight hours of training on opioid use disorder. Nurse practitioner training programs in NC now mandate a 24- hour training course on opioid use disorder.

This present study of survey responses by IM residents points to significant gaps in the education of young physicians, even twenty years into the opioid epidemic. That’s disappointing. Usually I’m not a fan of governmental mandates in education, but it’s starting to look like some states will need that to change. It’s important. The lives or many people depend on this.

Imagine a chronic illness that causes disability and death. Now imagine there’s a new drug developed that reduced the risk of dying by three-fold. Not by three percent, but it reduces the risk of death three times over.

Now imagine a patient who dies from this chronic illness. Imagine that this unfortunate patient was never offered the life-saving medication. In fact, this patient’s physicians never even told the patient about this l medication, which had been approved twenty years earlier.

It would be a travesty. Malpractice lawyers would salivate to get such an easy case. The negligent physician would be called to account for his actions and possibly investigated by the medical board. There would be consequences.

That’s where we are now, except the chronic illness is opioid use disorder, and there are no lawyers, no consequences for all the missed opportunities to treat this deadly illness.

Why do we allow this to happen, this many years into the opioid epidemic?

3 responses to this post.

  1. This overall dynamic is why the MATE Act is so important. NAMA Recovery, alongside AATOD and ASAM (among other national professional and advocacy organizations), was proud to endorse the MATE Act this year at re-introduction. With the bare bones training to obtain an X waiver under threat & no federal educational requirements for physicians who work in OTPs to write orders for methadone and Buprenorphine, the MATE Act has never been more important. Patients deserve access to trained providers, and combatting the opioid crisis demands federal policy ensures base level training for all physicians who have a DEA registration that allows for opioid prescribing.

    Reply

  2. Posted by william taylor, MD on July 19, 2021 at 3:13 pm

    On behalf of my pain patients with Ehlers-Danlos, multiple failed back operations, and paraplegia, I feel called on to register at least a mild objection to your illustration. Our fellow human beings who are unfortunate enough to have unrelenting severe pain also face incredible difficulty accessing medical care and, yes, pharmacy services.

    Reply

    • Posted by Kim on July 19, 2021 at 11:29 pm

      You are so correct. After breaking my neck in 2015 and on pain meds that we’re managing my pain I was forced to a taper I did not agree to. I was given no comfort meds or anything just reduced to under 90 mme. I am now at a methadone clinic unfortunately.

      Reply

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