Special Report: Overprescribed - Preparing LECOM Students to Help Tackle the Opioid Epidemic
They used to be in the minority, now 26% of first-year medical students are future Osteopathic physicians. That means LECOM medical, dental, and pharmacy students have the potential to impact the nation's opioid addiction crisis. What is their curriculum offering to help?
They used to be in the minority, now 26% of medical students are future Osteopathic physicians. That means LECOM medical, dental, and pharmacy students have the potential to impact the nation's opioid addiction crisis.
Third year medical student Chris Kordick, said they've seen a lot. "We've really had our eyes opened to a lot of the tragedies that have occurred nationally, a lot of the deaths that are unnecessary due to overdose," Kordick said. And they feel the urgency of the moment. "There is a movement saying we really need to look at our practice patterns," Kordick added, "and we really need to see when we get out and we're trained and we're fully credentialed how are we going to make a difference."
The CDC shows opioid prescribing patterns are still a major piece of the puzzle. Rates have tapered off since 2012 when Pennsylvania doctors wrote as many as 82 - 95 opioid prescriptions per 100 patients. Nationally it is still 66.5 prescriptions per 100 patients, with about one third of those filling more than one prescription.
The opioids may be prescribed after an ER visit, post-surgery, or for chronic pain, but what is increasing under scrutiny is whether all those Hydrocodone, and Oxycontin prescriptions, for example, necessary?
LECOM is addressing that question across their medical curriculum.
According to Erika Allen, Ph.D., Assistant Professor of Pharmacology, it's taught in Pharmacology, where students learn how opioids work in the body. "They do alleviate pain, the problem with opioids is that patients become tolerant to it, so that's where the increase in dose happens," Allen said.
It's also taught in the course Drugs of Abuse, where Allen teaches that the influence of pharmaceutical marketing to doctors can't be ignored. "It's the newer formulations that we think about causing the addiction that's present and also the marketing by the pharmaceutical companies, it has gotten it more in the light of the physicians, so they just got used to prescribing it more and more," she said.
With that trend, pharmacists become a second layer of gate-keeping. "Pharmacists actually have a legal responsibility to make sure that the prescription is valid," said Kim Burns, R.Ph,J.D., Professor of Pharmaceutical Sciences.
Burns teaches the required 30 hours of pharmacy law, five of those hours on controlled substance laws, and what is known as "Corresponding Responsibility," where students learn to look for red flags and ask questions. Is the prescription for a legitimate medical purpose, and from a doctor who should be prescribing opioids in the normal course of practice? "The pharmacist can also watch and see if the patients are trying to get the meds filled too soon, if the doses are way too high, there's a number of things they can help with, with that too," Burns said.
And Burns said, legally they have to offer counseling on every new prescription. "Just to make sure that the patients also understand to the risks of becoming addicted or the risks of taking drugs and the possible side affects and what it can lead to," Burns added.
In osteopathic medicine, in existence since 1892, the mission has always focused on integrating body, mind and spirit, giving D.O.'s tools other than pills to treat pain---things like manipulative medicine, and acupuncture. According to Jan Hendryx, D.O., Professor from LECOM's Integrative Medicine Clinic, students first need to learn where the pain is coming from--muscles, bones, joints, nerves or ligaments. "Well the students in the first two years have a 200-hour course in diagnosing and treating the musculoskeletal system using osteopathic manipulative treatment."
Hendryx brings a different perspective to pain. "So I've been practicing acupuncture for 28 years now and I combined acupuncture and osteopathic treatment of both acute and chronic pain issues so I've got that kind of unique perspective." It's a perspective he says runs counter to our cultural bias toward medication. "The culture is medication oriented, the medical system in general is medication oriented there's a pill for everything, and there's multiple pills for everything," Hendryx said.
Student doctor Chris Kordick is doing a rotation in the LECOM Integrative Medicine Clinic, learning from Hendryx. He believes when you move from the classroom to the clinic, and face patients expecting to leave with a prescription, that's where you learn the art of prescribing. "They've walked us through kind of a ladder of, we start here and then we move here, and then we give the opioid," Kordick said, "so they have made it very clear in terms of our decision making, but again, it comes down to the art of prescription and you have to have that sense and that judgment of does the patient need this, are they in pain am I doing them right by prescribing this?"
In the behavioral health curriculum, students learn that "judgment" about prescribing involves understanding the addictive process, and the biological, genetic and environmental factors that play into it, because according to Melanie Dunbar, Ph.D., Director of Behavioral Health at LECOM, one person taking an opioid may get hooked, another may not. "Asking the questions in assessment about family background, family history and other risk factors," Dunbar said, "so we're educating them on those things so that as the physician they're asking the questions, getting all the relevant information to make the best decisions about prescribing."
In response to the opioid crisis, Pennsylvania Governor Tom Wolf and lawmakers have just started requiring an additional four hour course in addictive opioids for medical students to become licensed. Once practicing to renew their licenses every two years, doctors must now complete two hours of continuing education in pain management, identifying addiction, or the practices of prescribing opioids.
Dr. Frank Tursi who sits on the licensing board through the Pennsylvania State Board of Osteopathic Medicine said it's a good start to put new and seasoned doctors on the same page. "Too many people out there have forgotten that these are potent drugs, not that they're not useful, not that they don't have a place, but they are drugs...and it's to make sure that there's not an underestimating of the use of them. There may be some people who have forgotten physician-wise that it only takes up to one week to sensitize some people to that opioid," Tursi said.
And the more they learn, the more motivated LECOM medical students are to take on the problem of opioids overprescribed. "We're being exposed to, quite frankly, the crux of the problem now," said student doctor Chris Kordick, "...and by the time we're out and able to make those changes, I think we'll have a very good handle on how to do so and a majority of us are willing to do so."