Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

An online global survey and follow-up expert groups on the scope and needs related to training, research, and mentorship among early-career addiction medicine professionals

Addiction medicine is a rapidly growing field with many young professionals seeking careers in this field. However, early-career professionals (ECPs) face challenges such as a lack of competency-based training due to a shortage of trainers, limited resources, limited mentorship opportunities, and establishment of suitable research areas. The International Society of Addiction Medicine (ISAM) New Professionals Exploration, Training & Education (NExT) committee, a global platform for early-career addiction medicine professionals (ECAMPs), conducted a two-phase online survey using a modified Delphi-based approach among ECAMPs across 56 countries to assess the need for standardized training, research opportunities, and mentorship. A total of 110 respondents participated in Phase I (online key informant survey), and 28 respondents participated in Phase II (online expert group discussions on three themes identified in Phase I). The survey found that there is a lack of standardized training, structured mentorship programs, research funding, and research opportunities in addiction medicine for ECAMPs. There is a need for standardized training programs, improving research opportunities, and effective mentorship programs to promote the next generation of addiction medicine professionals and further development in the entire field. The efforts of ISAM NExT are well-received and give a template of how this gap can be addressed.

Non-communicable Disease Risk Reduction Teaching in India: A Curricular Landscape

Non-communicable diseases (NCDs) have today become a growing epidemic, surpassing infectious diseases and adversely impacting national health systems, policies, and socio-economic developments. Management of NCD and its risk factors such as tobacco use, poor diet, physical inactivity, and obesity has garnered paramount importance under the Sustainable Development Goals (SDGs). However, the educational settings for healthcare professionals to prepare them for delivery of preventive interventions w.r.t. to NCD risk factors require a stronger foundation. In the present work, a landscaping exercise of the teaching of NCD risk factors in the extant Bachelor of Medicine and Bachelor of Surgery (MBBS) curricula of healthcare professionals from select medical colleges in India has been undertaken. Our assessment indicates that in the present MBBS curriculum, effort is largely directed upon teaching only specific aspects of NCDs, such as hypertension, diabetes, mental illness, blindness, and cancer with greater inclination toward clinical aspects. With regard to NCD risk factors, there is inadequate focus on the healthcare promotion aspects. The overall syllabus also does not address long-term health implications of tobacco smoking, lack of proper diet or physical activity, excessive alcohol consumption etc. It also does not reflect any practical trainings or sessions related to health promotion or behavior change activities. As a way forward, we suggest that NCD risk reduction aspects be incorporated extensively into existing health professional education through the development of a curricular framework and an intervention plan contextualized to India. Findings from this study are expected to help provide critical inputs for the design and development of a curricular plan with thrust on tobacco cessation, physical activity, healthy diet, and restricted alcohol consumption, leading to creation of a health competent workforce engaged in NCD prevention and health promotion.

Why aren't Australian pharmacists supplying naloxone? Findings from a qualitative study

BACKGROUND

Opioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists' perspectives or experiences of this change.

METHODS

Thirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016-2017 to investigate pharmacists' attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply.

RESULTS

Around half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges.

CONCLUSION

Pharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists' knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).

Opiate use disorders and overdose: Medical students' experiences, satisfaction with learning, and attitudes toward community naloxone provision

INTRODUCTION

Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment.

METHODS

We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees.

RESULTS

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

CONCLUSIONS

Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Two birds with one stone: experiences of combining clinical and research training in addiction medicine

BACKGROUND

Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting.

METHODS

We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10).

RESULTS

We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training.

CONCLUSIONS

Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.

The influence of medical student gender and drug use on the detection of addiction in patients

Little is known about medical students' interest in their training on drug addiction, their personal experience of consumption, and whether these aspects influence the detection of addiction in patients. Eighty-eight and one half percent considered that drug dependence issues are important to their professional future. The students report consuming alcohol (69%), cigarettes (19.5%), and illegal drugs (15.8%). Female students consumed fewer illegal drugs than the men (p =.022). Male students consumed more illegal drugs more frequently (p =.005), knew more consumers (p =.023), and those who drink alcohol consumed more illegal drugs than women who drink alcohol (p <.005). Drug and alcohol consumption among medical students may serve to normalize consumption and thus, may prevent the detection of addicts. It is important to educate and raise awareness about drugs and alcohol use, as this may influence detection. The focus should be particularly on the male group.

Training in addiction medicine should be standardised and scaled up

Most health systems lack sufficient doctors trained in addiction medicine to reduce the public health consequences of this increasing societal problem, writes J Klimas

Effectiveness and Organization of Addiction Medicine Training Across the Globe

BACKGROUND

Over the past decade, addiction medicine training curricula have been developed to prepare physicians to work with substance use disorder patients. This review paper aimed at (1) summarizing scientific publications that outline the content of addiction medicine curricula and (2) evaluating the evidence for efficacy for training in addiction medicine.

METHODS

We carried out a literature search on articles about addiction medicine training initiatives across the world, using PubMed, PsychINFO and EMBASE with the following search terms 'substance abuse, addiction medicine, education and training.'

RESULTS

We found 29 articles on addiction medicine curricula at various academic levels. Nine studies reported on the need for addiction medicine training, 9 described addiction medicine curricula at various academic levels, and 11 described efficacy on addiction medicine curricula.

CONCLUSIONS

Several key competences in addiction medicine were identified. Efficacy studies show that even short addiction medicine training programs can be effective in improving knowledge, skills and attitudes related to addiction medicine. A more uniform approach to addiction medicine training in terms of content and accreditation is discussed.

Smyth B, Bury G, Cullen W. Development and process evaluation of an educational intervention to support primary care of problem alcohol among drug users

Purpose

– The purpose of this paper is to describe the development and process evaluation of an educational intervention, designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users.

Design/methodology/approach

– The educational session was developed as part of a complex intervention which was informed by the Medical Research Council framework for complex interventions. A Cochrane review and a modified Delphi-facilitated consensus process formed the theoretical phase of the development. The modelling phase involved qualitative interviews with professionals and patients. The training's learning outcomes included alcohol screening and delivery of brief psychosocial interventions and this was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play.

Findings

– Participants (n=17) from three general practices and local medical school participated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. Most useful components of the session were the presentation, handout and group discussion with participants appreciating the opportunity to share their ideas with peers.

Originality/value

– Training primary healthcare professionals in alcohol screening and brief psychosocial interventions among problem drug users appears feasible. Along with the educational workshops, the implementation strategies should utilise multi-level interventions to support these activities among GPs.

Substance misuse teaching in undergraduate medical education

BACKGROUND

Over 12,000 hospital admissions in the UK result from substance misuse, therefore issues surrounding this need to be addressed early on in a doctor's training to facilitate their interaction with this client group. Currently, undergraduate medical education includes teaching substance misuse issues, yet how this is formally integrated into the curriculum remains unclear.

METHODS

Semi-structured interviews with 17 key members of staff responsible for the whole or part of the undergraduate medical curriculum were conducted to identify the methods used to teach substance misuse. Using a previously devised toolkit, 19 curriculum co-ordinators then mapped the actual teaching sessions that addressed substance misuse learning objectives.

RESULTS

Substance misuse teaching was delivered primarily in psychiatry modules but learning objectives were also found in other areas such as primary care placements and problem-based learning. On average, 53 teaching sessions per medical school focused on bio-psycho-social models of addiction whereas only 23 sessions per medical school focused on professionalism, fitness to practice and students' own health in relation to substance misuse. Many sessions addressed specific learning objectives relating to the clinical features of substance dependence whereas few focused on iatrogenic addiction.

CONCLUSIONS

Substance misuse teaching is now inter-disciplinary and the frequent focus on clinical, psychological and social effects of substance misuse emphasises the bio-psycho-social approach underlying clinical practice. Some areas however are not frequently taught in the formal curriculum and these need to be addressed in future changes to medical education.

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment

Background

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care.

Methods

This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer.

Results

We identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment.

Conclusions

Problem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored.

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

BACKGROUND

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

AIMS

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

METHODS

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified 'Delphi-facilitated' consensus among the group members.

RESULTS

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

CONCLUSIONS

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.