The results of the current survey of the healthcare professions in Ohio indicate that there are differences in the level and depth of pain management, SUD, and ACEs education provided. The President’s Commission on Combating Drug Addiction and the Opioid Crisis report promotes training all health care professionals in prevention, screening, identification, and treatment of OUD, a subset of SUD [19]. In conducting the present study, we set to establish a baseline for the level and extent of SUD training in a majority of the health professions. It is concerning that not all healthcare professionals who are able to prescribe opioids are educated on how to screen for OUD, the signs of SUD and how to use the PDMP. Here, we found that medical schools spend time on the teaching of the DSM5 criteria for OUD, the addiction cycle, and ethical issues surrounding SUD. On the other hand, less of an emphasis is placed on additional factors influencing pain and the perceptions of pain such as age, cultural beliefs, and gender. This is even more concerning as retrospective chart reviews found providers undertreat pain in patients who are older and in marginalized patient groups [16]. Pharmacy areas of focus tended to be in the areas of neurobiology and pharmacological management with very little emphasis on ethical issues associated with SUD. The dental and optometry programs had a greater focus in these latter areas. With the exception of optometry, none of the programs placed an emphasis in the area of training students on community program options for assisting in the treatment of SUD.
Several studies have reviewed the status of SUD education in the health care professions [24, 25]. The results of these database searches indicate a need for a unified interprofessional approach to SUD education [24]. Additionally, several discipline specific reports have suggested concerted effort needs in dental [1, 32], pharmacy [26], medicine [33] and PA [20, 38] training in these areas. In fact, several authors have suggested that interprofessional education, patient engagement, and OUD should be considered standards in SUD education [23, 25].
The over-prescribing of opioids has been associated with the onset of the first wave of the opioid epidemic [35]. There is, therefore, a critical need to provide adequate education to healthcare professionals in the area of SUD and OUD so as to attenuate this contributory role. A recent study found that physicians trained in “top-tier” medical school programs were less likely to prescribe opioids, suggesting a potential educational difference [30]. In this study, comprehensive data on all opioid prescriptions written by doctors in the United States between 2006 and 2014 were examined for the relationship between opioid prescribing and training. Schnell & Currie [30] found that Doctor of Osteopathic (DO) medicine prescribed more opioids than Doctor of Medicine (MD). Additionally, almost 50% of opioid prescriptions were written by general practitioners. From an educational perspective, Kolodny et al. [18] highlight the importance of prevention strategies, such as adopting the CDC prescribing guidelines and cautioning healthcare providers about prescribing opioids for both acute and chronic pain.
Unfortunately, many healthcare providers lack understanding regarding opioid risks, particularly the risk of addiction, and have an overestimation of opioid benefits. Kolodny et al. [18] conclude that “this pattern highlights the need for prescriber education explicitly correcting misperceptions about opioid pain relievers safety and efficacy.” Additionally, according to the 2019 Health Care’s Hidden Epidemic report, healthcare executives and providers cite a variety of tools that could help healthcare providers, including a more robust SUD education [12]. Adapting curricula to ensure providers can effectively recognize symptoms and risks of addiction will help address the rising opioid epidemic and improve patient outcomes [28].
In October 2019, the All-Ohio Medical School Opioid Use Disorder Collaborative reported on the development of a common medical school curriculum on pain management and OUD [2]. Of the seven medical schools in Ohio, following the meeting, two medical schools planned to add 11 topic areas to their curriculum and three schools plan to add three topic areas to their curriculum. Two schools did not state any plans to adjust their curriculum. The collaborative report noted the lack of participation by other practicing healthcare providers, other specialties, and non-clinical professionals.
Even with training on SUD and pain management, healthcare professionals can be unprepared to engage patients in the care process. In the area of SUD and pain management, patients should be engaged in the goal setting process and have realistic expectations for their care and the management of their pain or SUD. The CDC 2016 guidelines on chronic, non-cancer pain management outline the importance of patients being involved in goal establishment, risks and benefit assessment, and therapy management responsibilities. Patient engagement with shared decision-making and goal-directed encounters can improve health outcomes [8]. One patient-centered communication approach is motivational interviewing, as it allows the healthcare professional to engage in a goal-oriented encounter that is collaborative and caring [22]. Motivational interviewing is respectful of cultural differences and contributing factors, such as the social determinants of health, as the healthcare professional seeks to understand the patient’s perspective. This can be beneficial, given that many of the risks associated with SUD and pain management challenges are rooted in culture as well as the social determinants of health [13]. Of the respondents, over two-third of medicine, APRN, physician assistant, and pharmacy programs included motivational interviewing training. Schools should continue to incorporate this and other forms of patient-centered, goal-oriented communication strategies to address SUD, OUD and ACEs.
Including ACEs screening in healthcare practice provides the opportunity to improve health outcomes for patients, but this practice is not common. Reluctance to use ACEs screening tools may be due in part to perceived barriers. For example, ACEs may be viewed as psycho-social, or outside the expertise of primary care providers [36]. Additionally, providers may feel ill prepared to address any concerns uncovered in the screening process [17]. Identifying cases of trauma, and providing education, or treatment, can lower long-term health costs and support improved healthcare engagement for patients [11]. The significance of educating health care providers about ACEs, may also positively influence a long-term patient provider relationship. Higher ACEs have been associated with patient difficulty maintaining a long-term relationship with primary care providers [11]. Educating healthcare students is a primary strategy in supporting future prescribers in supporting the whole patient. Educating healthcare providers about ACEs should not stop at mere identification but should also include understanding ACEs and related impacts of trauma, incorporating trauma informed practices into daily treatment routines, and communication tools to support patients and their families. To date, there are no practice guidelines for ACEs and opioid prescribing and future work in this area is therefore warranted.
Strengths of this study include the response rates of several health professions programs in the state of Ohio. For example, medicine, pharmacy, dentistry, and optometry all had response rates of 100%. Thus, the information is representative of those health professions programs in Ohio. Furthermore, this is the first study to provide a comprehensive review of all the healthcare programs. However, a corresponding limitation is the response rate of other programs; APRN schools had lower response rates than other professions (27%) and may not be representative of all APRN programs in the state. Future exploration is warranted. The survey did undergo review before distribution and was built out of the literature; some items may not have been clear and could have been improved with pre-testing approaches, such as cognitive interviewing. Underpinning definitions were not outlined at the beginning of the survey; thus, respondents could have interpreted some of the definitions differently. The survey did undergo review prior to distribution, but the review process did not include significant pre-testing or validation. Another strength is that schools were directed to have the most appropriate person at the program complete the survey; however, it is unknown whether those individuals were the ideal individual. An additional limitation is that the survey was completed during the didactic portion of the students training and gaps identified may have been addressed in in residency training.
