An addiction medicine curriculum at Stanford School of Medicine trains students to better understand causes of and treatments for substance use disorders.
April 13, 2022 - By Gordy Slack
As recently as a decade ago, not one hour of medical school was spent treating patients struggling with addiction.
“Addiction was more commonly viewed as a moral issue, a matter of willpower and not a disease. There was not a lot of compassion for addicted patients,” said Stanford Medicine psychologist Keith Humphreys, PhD, who chairs a commission that, in coordination with The Lancet, produced a 50-page report on the opioid crisis.
To correct that perspective among physicians, the report recommends, among many other proposals, that medical schools increase their investment in addiction training. The Stanford-funded report was developed by a 17-member commission, including Stanford scholars and other health experts from the United States and Canada.
The opioid epidemic, responsible for more than 600,000 overdose deaths in the U.S. and Canada since 1999, with a spike in the past two years, has changed the medical establishment’s approach to addiction.
For one thing, Humphreys said, opioid addiction’s disregard for income, education, age, race, gender and social class has made it impossible to dismiss it as the moral failings of any particular group of people.
“It’s not just out in the hills of West Virginia or just in the roughest neighborhoods in the Tenderloin. It is everywhere, including here on campus,” said Humphreys, lead author of the report, the Esther Ting Memorial Professor, and professor of psychiatry and behavioral sciences. “We’ve had students, faculty members, family members who have these problems. We see it in rural areas, in the suburbs and in cities. We see it in people who are in difficulty financially and people who are financially fine.”
What’s more, said Anna Lembke, MD, professor of psychiatry and behavioral sciences, “This crisis began with physicians increasing opioid prescriptions fourfold between 1999 and 2012. And it was that over-prescribing that led to the problem we have today. Physicians were part of the cause of the crisis, and we are going to have to play a key role in resolving it.”
Training future physicians
Lembke launched the medical school’s addiction medicine curriculum five years ago largely in response to the intensifying opioid crisis. But she also recognized that many physicians daily address health issues related to one kind of addiction or another, so the curriculum focuses on substance use disorders in general.
More than five hours of course time is devoted to addiction-related teaching. It might not sound like much, but it’s a huge improvement from nothing, said Lembke, also an author of the Stanford-Lancet report.
“It’s a fundamental paradigm shift to have medical students and early-career physicians introduced to addiction medicine and aware of the importance of safe prescribing and safe stewardship,” Lembke said. “They are the teachers of tomorrow, the ones who will create the culture that gets passed down.”
Lembke introduces first-year students to the subject, covering addiction epidemiology and fundamental interventions. The key message, Lembke said, is that “Addiction is a disease. And it is a disease that can be treated.”
In year two, Lembke covers the spectrum of medications that can be effectively used to treat addiction. “A lot of doctors still don’t know that there are medical interventions that work,” she said.
She also teaches second-year students the neurobiological mechanisms of addiction, treatment and recovery, as well as emergency department care related to addiction. Lembke noted that about one in four patients in the ED require treatment for a substance use disorder.
“Having compassion for those patients, understanding the disease and being able to refer patients to effective treatment make a big difference,” Lembke said.
Lembke and her team have produced two online courses, available to anyone. One takes a biopsychosocial approach, exploring the neuroscience of addiction and the complex relationships between prescribers and patients. The other addresses the problems that occur when physicians end pain prescriptions abruptly and their patients turn to illegal alternatives, such as heroin or fentanyl.
A nuanced approach to prescribing
A complicating factor of the opioid epidemic is that, unlike street drugs like cocaine, opioids play an essential role in medical practice — in clinical pain management and in anesthesia, Humphreys said. For that reason, a nuanced understanding of how and how not to prescribe opioids must be an essential part of physician training.
“Helping med students understand that they have a lot of flexibility clinically makes a big difference,” he said. “Prescribing opioids should no longer be the reflexive response to a patient in pain it once was. There are about 100 medications that can affect pain that aren’t opioids.”
Having compassion for those patients, understanding the disease and being able to refer patients to effective treatment make a big difference.
He added that there are behavioral interventions and psychotherapeutic interventions for pain as well as pharmacological ones.
The medical school has deepened its addiction-related training with the Stanford Addiction Medicine Fellowship, a one-year post-doctoral program that trains physicians to screen and intervene for substance use disorders and other addictions within a variety of treatment settings.
The focus on training is paying off in important ways, Lembke said. “There’s a universe of difference in the level of interest this generation of students, residents and fellows has in helping people with addiction and learning about treatments.”
Humphreys said he can’t “begin to do justice to the improvement in the way medical students and residents talk about opioids than they did 20 years ago. Back then, the attitude was, ‘The more prescriptions the better, let’s stop worrying so much about all this addiction stuff,’” he said. “Today our medical students are thoughtful and careful … very careful.”
Still, Lembke said, there’s a long way to go.
“This epidemic was decades in the making, and we’ve got at least 20 more years before we see the end of it,” she said. “But now at least we’re heading in the right direction.”
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