February 26, 2020 by
Halle Sobel, M.D., left, and Elly Riser, M.D.
In 2013, the pioneering efforts of John Brooklyn, M.D.,
UVM clinical associate professor of family medicine, catapulted Vermont into the spotlight as a national leader in the treatment of opioid use disorder with the state’s launch of the “hub and spoke” model. The model was hailed as the first effective clinical approach to treating widespread opioid addiction, in part, because it encourages and trains clinicians and care providers to approach opioid use disorder as a chronic condition that may be addressed in a primary care setting.
Now, UVM Associate Professor of Medicine Halle Sobel, M.D., and Elly Riser, M.D., UVM clinical instructor in medicine, are working to bring that understanding and training to physicians at the beginning of their careers – during medical school.
On September 30, 2019, Sobel received a three-year, $101,555 grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to support the creation of a longitudinal addiction medicine curriculum for medical students at the Larner College of Medicine. “We educate medical students on how to manage diabetes with insulin; we should be doing the same with opioid use disorder,” she says.
The College already introduces medical students to addiction and opioid use disorder in several sections of the first level of the Vermont Integrated Curriculum, but Sobel and Riser hope this new approach will further expand and standardize students’ addiction medicine education. By incorporating concrete steps and training into all four years of the curriculum, they believe they can both better prepare future physicians and combat one of the main hurdles in the fight against this national epidemic – the drastic gap between the number of clinicians able to provide medication assisted treatment (MAT) and the number of patients in need of it. Through MAT, clinicians are able to combine previously accepted methods of treating substance use disorder, including counseling, behavioral therapies, and educational services, with medications including buprenorphine. SAMHSA reports that the treatment has been shown to “improve patient survival, increase retention in treatment…[and] increase patients’ ability to gain and maintain employment,” through providing a “more comprehensive, individually tailored program,” than previously offered for this patient population.
In addition to streamlining the first- and second-year curricula, Riser’s and Sobel’s approach will require each third-year medical student to complete DATA 2000 waiver training prior to beginning their clinical clerkships. The training, which will be delivered by grant co-investigators Brooklyn and UVM Assistant Professor of Psychiatry Sanchit Maruti, M.D., is necessary in order for physicians to apply for a license to prescribe buprenorphine in an outpatient setting as part of MAT. The drug is the preferred medication in MAT, because, Sobel explains, “[buprenorphine] can be prescribed by primary care physicians and can reduce cravings for opioids and help patients maintain long-term recovery. Methadone is another commonly used drug for MAT but needs to be prescribed in addiction treatment centers and may be better for people with higher levels of drug dependence.”
Although the students won’t be able to prescribe these medications until after they’ve completed residency and are registered with the U.S. Drug Enforcement Administration (DEA), Sobel and Riser believe this initial step will encourage students to apply for the license and reduce one of the barriers to do so when they become physicians.
“I’ve been in practice for almost 20 years and this has been the most rewarding patient population to take care of,” Sobel says. “I want to expose students to that – to see how rewarding it is to see people in recovery and help them get back on their feet.”
In addition to the waiver training, third-year medical students at the College will participate in targeted group case studies directed by Brooklyn during the Bridge Week prior to the psychiatry clerkship and fourth-year students will be offered an optional elective during which they can choose to work at an addiction treatment center, residential treatment center, or as a member of a medication assisted treatment team, to further their training.
Throughout the curriculum, Sobel and Riser will work with Leigh Ann Holterman, Ph.D., the director of curriculum evaluation and assessment, to determine if and how students’ understanding of and comfort level with treating patients with opioid use disorder changes. These insights will offer further guidance on how to continue to improve upon the curriculum. Additional support will be provided by Stephen Devoe, M.P.H., M.S., a project director in the Department of Medicine’s Quality Program, and Clinical Clerkship Coordinator Jacqueline Drouin, M.P.A.
The proposed longitudinal addiction medicine curriculum at the College is not a completely new idea. The Warren Alpert School of Medicine at Brown University (Brown)’s longitudinal curriculum, which includes waiver training, was certified by SAMHSA in 2019, and, along with Sobel, 19 additional programs have received grant funding from SAMHSA to be used in the creation of “X Waiver” trainings for their medical, physician assistant, and nurse practitioner students. However, Sobel and Riser are looking beyond the waiver training and the groundwork put in place by other programs to optimize the College’s curriculum even further.
In collaboration with faculty at Brown, the University of Massachusetts Medical School (UMMS), Cate Nicholas, Ed.D., M.S., P.A., Director of Simulation Education and Operations for the UVM Clinical Simulation Laboratory, and Shirley McAdam, Standardized Patient Educator at the UVM Clinical Simulation Laboratory, Sobel and Riser plan to create an objective structured clinical examination (OSCE) that would be used by the three schools to assess how well their students can respectfully interact with and treat patients with opioid use disorder and other addictions. An OSCE is defined by the Healthcare Simulation Dictionary, as "a method of assessment where learners perform specific skills and behaviors in a simulated work environment." These simulated cases are performed by Standardized Patients (SPs), community members who have been highly trained to "portray a patient with a specific condition in a realistic, standardized, and repeatable way."
At the College, OSCEs are routinely used to assess student clinical skills progress across the four years of the curriculum. Although OSCEs for Screening, Brief Intervention, and Referral to Treatment (SBIRT) currently exist, the MAT-specific standardized case presented in Sobel and Riser's planned OSCE is expected to be the first of its kind.
The waiver training component of this new curriculum will launch this March when the Class of 2022 completes a one-week orientation before entering their clinical clerkships.