Opioid overdose prevention education for medical students: Adopting harm reduction into mandatory clerkship curricula

Abstract

Background: Opioid overdose deaths constitute a public health crisis in the United States. Strategies for reducing opioid-related harm are underutilized due in part to clinicians’ low knowledge about harm reduction theory and limited preparedness to prescribe naloxone. Educational interventions are needed to improve knowledge and attitudes about, and preparedness to address, opioid overdoses among medical students. Methods: Informed by the Department of Veterans Affairs’ Overdose Education and Naloxone Distribution (OEND) program and narrative medicine, we developed and led a mandatory workshop on harm reduction for clerkship medical students. Using validated scales, we assessed students’ knowledge and attitudes about, and preparedness to address, opioid overdoses before the workshop and 6 weeks after. Results: Of 75 participating students from February through December 2017, 55 (73%) completed pre-workshop and 38 (51%) completed both pre- and post-workshop surveys. At baseline, 40 (73%) encountered patients with perceived at-risk opioid use in the previous 6 weeks, but only 11 (20%) recalled their teams prescribing naloxone for overdose prevention. Among those completing both surveys, knowledge about and preparedness to prevent overdose showed large improvement (Cohen’s d?=?0.85, P?<?.001; Cohen’s d?=?1.24, P?<?.001, respectively) and attitudes showed moderate improvement (Cohen’s d?=?0.32, P = .04). Discussion: Educational interventions grounded in harm reduction theory can increase students’ knowledge and attitudes about, and preparedness to address, opioid overdoses.     

Awareness of state legislation on naloxone accessibility associated with willingness to prescribe naloxone

ABSTRACT

Background: Increasing rates of opioid-related deaths, state naloxone legislation changes, and negativity prompted investigation of predictive factors associated with willingness to prescribe naloxone to populations at risk of overdose, including knowledge of risk factors, assessment of persons at risk, awareness of legislative changes, perceptions of professional responsibility, and confidence around naloxone prescribing and distribution. Methods: Cross-sectional, Web-based, anonymous, voluntary survey to prescribers of 2 regional health care systems serving urban and rural North Dakota, northern Minnesota, and northwestern Wisconsin. Human subject research was approved by university and health care systems' institutional review boards. Results: Overall, 203 of 1586 prescribers responded; however, not all prescribers completed each survey item. A majority (89.4%, n = 127/142) of respondents had never prescribed naloxone for overdose prevention. Willingness to prescribe naloxone for 4 patient care scenarios involving substantial opioid overdose risk ranged from 43.4% to 70.5%. Knowledge mean score was 15.5 (SD = 2.9) out of 22 with median 15 (range: 5–22). Naloxone legislation awareness score was 8.8 (SD = 3.8) out of 15 with median 8 (range: 3–15). There was a statistically significant but modest correlation between willingness to prescribe naloxone and the other variables, including awareness of state naloxone-related legislation (r = 0.43, P < .0001), level of self-confidence about dosing, prescribing, and writing protocols for naloxone (r = 0.37, P < .0001), general knowledge (r = 0.24, P = .0032), and perception of professional responsibility (r = 0.19, P = .03). Multivariate regression analysis indicated willingness to prescribe naloxone was associated with statistically significant predictors, including awareness of the naloxone laws (P = .0016) and self-confidence about dosing, prescribing, and writing protocols (P = .0011). Conclusions: Prescribers who are more aware of state laws regarding naloxone and confident in their knowledge of dosing, administration, and writing protocols may be more willing to prescribe naloxone.     

Medicine Resident Preparedness to Diagnose and Treat Substance Use Disorders: Impact of an Enhanced Curriculum

Background: The authors’ previous study found that despite caring for many patients with addiction, most Massachusetts General Hospital (MGH) internal medicine residents feel unprepared to treat substance use disorders (SUDs) and rate SUD instruction during training as fair or poor. This follow-up study evaluates the impact of an enhanced curriculum on resident perceptions of the quality of instruction, knowledge base, and self-perceived preparedness to diagnose and treat SUDs. Methods: Based on the findings of the earlier study, an enhanced SUD curriculum was designed and delivered to MGH medicine residents. Impact of the curriculum was evaluated using the same Web-based survey that was administered in the earlier study to compare pre- and posttest results. Results: The authors’ earlier study found that 75% of residents felt prepared to diagnose and 37% to treat SUDs and 45% of residents rated the overall quality of SUD instruction as good or excellent. Following the curriculum intervention, 87% of residents reported feeling prepared to diagnose (P = .028) and 60% to treat (P = .002) SUDs. Three quarters of residents rated the overall quality of instruction as good or excellent (P < .001), and 98% reported residency curriculum had a positive impact on their preparedness to care for patients with a SUDs. Residents who reported receiving an adequate amount of SUD instruction were more likely to feel prepared to diagnose and treat addiction (P < .001). Thirty-one percent of residents still rated the overall amount of SUD instruction as too little. The intervention did not significantly improve answers to knowledge questions. Conclusions: An enhanced SUDs curriculum for medicine residents increased self-perceived preparedness to diagnose and treat SUDs and educational quality ratings. However, there was no significant change in knowledge. Implementation of a more comprehensive curriculum and evaluation at other sites are necessary to determine the ideal SUD training model.     

Alcoholics Anonymous and other mutual help organizations: Impact of a 45-minute didactic for primary care and categorical internal medicine residents

ABSTRACT

Background: Substance use disorders (SUDs) are highly prevalent among primary care patients. One evidence-based, cost-effective referral option is ubiquitous mutual help organizations (MHOs) such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery; however, little is known about how to effectively increase trainee knowledge and confidence with these referrals. The primary aim of this study was to evaluate whether a single 45-minute combined lecture and role play–based didactic for primary care residents could enhance knowledge, improve attitudes, and bolster confidence in referring patients with addictions to community MHOs. Methods: The authors developed a 45-minute lecture and role play addressing the evidence for MHOs, their respective background/content, and how to make effective referrals. Participants were administered a brief survey of their MHO-related knowledge, attitudes, and confidence before and after the session to evaluate the didactic impact. Results: Participants were 55 primary care and categorical internal medicine residents divided among postgraduate year 1 (PGY1; 27.3%), PGY2 (38.2%), and PGY3 (34.5%). They had a mean age of 29 (SD = 2.62); 49% were female, 69% were Caucasian, and 78% reported some religious affiliation. Participants' subjective knowledge about MHOs increased significantly (P < .001), as did their confidence in making referrals (P < .001). Changes in participants' attitudes about the importance of MHOs in aiding successful addiction recovery approached significance (P = .058). The proportion of participants with correct responses to each of 4 knowledge-based questions increased substantially. Conclusions: Primary care and internal medicine residents reported variable baseline knowledge of MHOs and confidence in making referrals, both of which were improved in response to a 45-minute didactic. Role play may be a useful supplementary tool in enhancing residents' knowledge and skill in treating patients with SUD.     

Interest in prescribing buprenorphine among resident and attending physicians at an urban teaching clinic

Background: Opioid use disorders are a major medical and public health concern. Buprenorphine is approved for the treatment of opioid use disorders; however, a shortage of physicians prescribing buprenorphine is a significant barrier to treatment access. The aims of this study were to evaluate opinions of internal medicine attending and resident physicians about buprenorphine and assess interest in becoming waivered to prescribe. Methods: Internal medicine resident and attending physicians at a primary care clinic in a large academic hospital were invited to complete surveys. The study sample was composed of physicians who were not waivered to prescribe buprenorphine. Survey data included demographic information, level of training, buprenorphine waiver status, interest in becoming waivered to prescribe buprenorphine, and beliefs about buprenorphine for treatment of opioid use disorders. High interest in becoming waivered was defined as a Likert response >3 (1 = No interest, 5 = Very interested). Results: Of the 44 physician respondents, 39 were not waivered to prescribe buprenorphine and constituted the sample; of those, 27 were residents and 12 were attending physicians. Twenty-six of the 39 nonwaivered respondents (66.7%) had high interest in becoming waivered. Those with high interest in becoming waivered were significantly more likely to be younger (P = .007) and to strongly believe in buprenorphine effectiveness (P = .023). Discussion: Most physicians in this academic training program showed high interest in prescribing buprenorphine, and belief in buprenorphine effectiveness was associated with high interest in becoming waivered.     

Evaluation of overdose prevention trainings in New York City: Knowledge and self-efficacy among participants 12 months after training

ABSTRACT

Background: Prevention of unintentional opioid overdose deaths is effective through overdose prevention trainings (OPTs), in which laypersons are taught overdose response through six actions. This longitudinal study examines trainee knowledge 12 months after OPT completion. Methods: Participants were enrolled following OPT at six sites. At the 12-month follow-up, participants were asked to name the drug overdoses that naloxone reverses and name overdose response actions. A 6-point scale was created and was comprised of the number of correct overdose response actions mentioned (check breathing; administer sternum rub; call 911; give rescue breathing; administer naloxone; put victim in recovery position). Mean knowledge was compared by participant sociodemographic characteristics, confidence, and site of OPT training (indoors versus outdoors). Results: Of 344 OPT participants, 273 were reached at 12 months. Nearly all (99%) participants identified that naloxone reverses heroin overdoes; 77% identified that naloxone reverses opioid analgesics overdoses; and 68% identified that naloxone reverses methadone overdoses. Overdose response actions most frequently mentioned were giving naloxone (86%) and calling 911 (76%). The remaining four actions were mentioned by less than 40% of participants. Overall mean knowledge score was 2.7 out of 6. Mean knowledge scores were higher for college graduates than those with less than college education (3.2 vs 2.6, P < 0.001), for those who felt very confident (mean score [ms] = 2.9), compared to somewhat confident (ms = 2.4) and a little or not at all confident (ms = 1.5) in their ability to reverse an overdose (P < .001), and for indoor-training recipients (3.0 vs 2.5, P = 0.02). There were no differences in mean knowledge scores for trainees by age, race, or gender. Conclusions: These findings suggest the need for several improvements in OPT curriculum, including emphasis on naloxone reversal of opioid analgesic and methadone overdoses, and all 6 rescue actions. Lower knowledge scores among outdoor-trained participants likely reflect session brevity, suggesting that outdoor trainings need to be enhanced.     

Adoption of the 275-patient buprenorphine treatment waiver for treating opioid use disorder: A state-level longitudinal analysis

Abstract

Background: Increasing access to buprenorphine treatment is a critical tool for addressing the opioid epidemic in the United States. In 2016, a federal policy change allowed physicians who meet specific requirements to treat up to 275 concurrent buprenorphine patients. This study examines state-level measures of buprenorphine treatment supply over 21?months since this policy change and estimates associations between the supply of 275-patient waivers and state characteristics. Methods: Monthly state-level measures of the number of physicians holding the 275-patient waiver per 100,000 residents were constructed from September 2016 to May 2018 using the Drug Enforcement Agency’s Controlled Substance Act database. State characteristics were obtained from publicly available sources. Mixed-effects regression models were estimated to examine change over time. Results: During the 21-month period, the number of physicians waivered to treat 275 patients increased from 153 to 4009 physicians. The mean supply of 275-patient physicians per 100,000 state residents significantly increased from 0.07 (SD?=?0.21) in September 2016 to 1.43 (SD?=?1.08) in May 2018 (t?=??9.84, df?=?50, P?<?.001). The final mixed-effects regression model indicated that Census division and the preexisting supply of 100-patient waivered physicians were correlated with the rate of growth in 275-patient waivers over the study period. Conclusions: Although uptake of the 275-patient waiver has exceeded initial projections, growth is uneven across the United States. Unequal patterns of growth pose a challenge to efforts to increase treatment availability as a means of addressing the opioid epidemic.     

Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities

IntroductionOpioid-related overdose death rates in rural communities in the United States are much higher than their urban counterparts. However, basic life support (BLS) personnel, who are more common in rural areas, have much lower rates of naloxone administration than other levels of emergency medical services (EMS). Training and equipping basic level Emergency Medical Technician (EMTs) to administer naloxone for an opioid overdose could yield positive outcomes.MethodsFollowing a legislative change that allowed EMTs to administer naloxone in one rural state, we evaluated an EMT training program by examining EMTs' opioid overdose knowledge and attitudes before and after the training.ResultsOne-hundred-seventeen rural EMTs participated the training. They demonstrated statistically significant improvements on almost all of the knowledge questions after the training (p's = 0.0469 to <0.0001). The opioid overdose competency and concern scales showed statistically significant improvement (p < 0.0001) and reduction (p < 0.0001), respectively. Furthermore, statistically significant changes in knowledge and opinions of state law regarding naloxone administration were observed. Significantly more EMTs supported the idea of expanding naloxone to people at risk for overdose (p = 0.0026) after the training.ConclusionsAt a time when states are passing legislation to expand first responders' access to naloxone, this study provides evidence about authorizing EMTs to administer naloxone.     

An Initial Evaluation of Web-Based Opioid Overdose Education

Background: Fatal opioid overdose is a significant public health concern in the United States. One approach to reducing fatalities is expanding overdose response education to broader audiences. This study examined responses to a web-based overdose education tool. Methods: The results of 422 anonymous surveys submitted on www.stopoverdose.org were analyzed for participant demographics, knowledge of opioid overdose recognition and response, and knowledge of Washington's Good Samaritan overdose law. Characteristics, knowledge, and planned behavior of respondents with professional versus personal interest in overdose education were compared. Results: Most respondents were age 35 or older (57%) and female (65%). The mean score on the knowledge quiz for overdose recognition and response items was 16.2 out of 18, and 1.5 out of 2 possible points for items concerning the law. Respondents indicating professional interest were significantly more likely to be 35 or older (p = .001) and to have received prior overdose education (p < .001), but less likely to know someone at risk for opioid overdose (p < .001) or report planning to obtain take-home naloxone (p < .001). No significant differences were found in overdose knowledge scores between groups. Conclusions: Online training may be effective among individuals with professional and personal interest in overdose, as general knowledge scores of overdose response were high among both groups. Lower scores reflecting knowledge of the law suggest that the web-based training may not have adequately presented this information. Overall, results suggest that a web-based platform may be a promising approach to basic overdose education.     

Opioid overdose prevention training with naloxone,an adjunct to basic life support training for first-year medical students

ABSTRACT

Background: Opioid overdose deaths have reached epidemic proportions in the United States. This problem stems from both licit and illicit opioid use. Prescribing opioids, recognizing risky use, and initiating prevention, including opioid overdose prevention training (OOPT), are key roles physicians play. The American Heart Association (AHA) modified their basic life support (BLS) algorithms to consider naloxone in high-risk populations and when a pulse is appreciated; however, the AHA did not provide OOPT. The authors' intervention filled this training deficiency by teaching medical students opioid overdose resuscitation with a Train-the-Trainer model as part of mandatory BLS training. Methods: The authors introduced OOPT, following a Train-the-Trainer model, into the required basic life support (BLS) training for first-year medical students at a single medical school in a large urban area. The authors administered pre- and post-evaluations to assess the effects of the training on opioid overdose knowledge, self-reported preparedness to respond to opioid overdoses, and attitudes towards patients with substance use disorders (SUDs). Results: In the fall 2014, 120 first-year medical students received OOPT. Seventy-three students completed both pre- and posttraining evaluations. Improvements in knowledge about and preparedness to respond to opioid overdoses were statistically significant (P < .01) and large (Cohen's D = 2.70 and Cohen's D = 2.10, respectively). There was no statistically significant change in attitudes toward patients with SUDs. Conclusions: The authors demonstrated the effectiveness of OOPT as an adjunct to BLS in increasing knowledge about and preparedness to respond to opioid overdoses; improving attitudes toward patients with SUDs likely requires additional intervention. The authors will characterize knowledge and preparedness durability, program sustainability, and long-term changes in attitudes in future evaluations. These results support dissemination of OOPT as a part of BLS training for all medical students, and potentially all BLS providers.     

Knowledge of and interest in opioid overdose education and naloxone distribution among US veterans on chronic opioids for addiction or pain

Aims: The Veterans Health Administration (VHA) is implementing opioid overdose (OOD) education and naloxone distribution to reduce rising rates of OOD deaths. This study assessed knowledge and interest in OOD prevention with naloxone at a VHA hospital where naloxone kits were not yet available. Methods: Veterans receiving opioids for ≥3 months, including 52 from the Opioid Substitution Clinic (OSC) and 38 from the Pain Management Clinic (PMC), were interviewed about their attitudes and experience with OOD and naloxone. Findings: 52% of OSC and 21% of PMC veterans reported having ever experienced an OOD. Less than half had heard of naloxone and none owned a naloxone kit. After a brief explanation, 73% of OSC and 55% of PMC veterans reported wanting a kit. Veterans who reported wanting a kit were more likely to have witnessed (p?<?0.001) and/or experienced (p?<?0.001) an OOD and were more likely to have used intravenous drugs in their lifetimes (p?<?0.05). Conclusions: Participants were not well informed about naloxone but many OSC veterans had a history of OOD and were interested in having a naloxone kit. There was also a subgroup of veterans prescribed opioids for chronic pain who had a history of OOD and were interested in naloxone.     

Drug overdose mortality among stateside Puerto Ricans: Evidence of a health disparity

BackgroundThis study compared drug overdose mortality rates in Puerto Rican-heritage and Non-Hispanic (NH) White individuals in the United States (US), examining time trends and recent variation by age, sex, state of residence, and drugs involved in overdose.MethodsDeath certificate data from the National Center for Health Statistics, as well as American Community Survey population estimates, were used to calculate age-specific and age-adjusted drug overdose mortality rates for Puerto Rican-heritage and NH White residents of the 50 United States or District of Columbia (DC). Rates for 2018 were compared between Puerto Rican-heritage and NH White individuals, overall and by sex, age, state, and specific drug involved in overdose. Joinpoint Regression was used to examine trends in drug overdose mortality rates from 2009 to 2018.ResultsFrom 2009 to 2018, the age-adjusted drug overdose mortality rate in stateside Puerto Ricans doubled among women (from 6.0 to 12.5 per 100,000) and nearly tripled among men (from 15.3 to 45.2 per 100,000). In 2018, the age-adjusted drug overdose mortality rate was significantly higher in Puerto Rican-heritage than NH White individuals (28.7 vs. 26.2 per 100,000, respectively). The 2018 drug overdose mortality rate was highest among Puerto Rican-heritage men ages 45–54 (104.1 per 100,000).ConclusionFindings emphasize the necessity of policies, programs, and interventions to mitigate risk of fatal overdose in stateside Puerto Rican communities.