This February and March, Ohio University Heritage College of Osteopathic Medicine students will be working alongside nurses and naloxone trainers from the Ohio Department of Health as the students learn to administer naloxone to a simulated patient experiencing an opioid overdose. The labs are part of a larger effort to train OHIO’s health care students to become strong frontline responders for patients struggling with opioid addiction and other substance use disorders.
Active learning using virtual reality will also play a role in training at OHIO. During a virtual reality lab, nursing students from the College of Health Sciences and Professions will meet Destiny, a young, unmarried, pregnant Appalachia-area woman who is addicted to opioids. Wearing VR goggles, students feel they are in the examination room, working with Destiny, as the program plays.
The scenario involving Destiny was created by CHSP, with funding provided by Ohio’s Medicaid Technical Assistance and Policy Program, under the direction of John McCarthy, Ph.D., associate professor of communication sciences and associate dean for research and graduate studies, along with Deborah Henderson, Ph.D., professor and director of the School of Nursing. The simulation is designed to help students identify implicit biases in treating patients and practice voicing the best responses during examination and treatment.
CHSP students are also learning from a Narcan administration program created by Sherleena Buchman, Ph.D., an assistant professor in the School of Nursing. An encapsulated virtual reality experience immerses the viewer in a virtual overdose simulation and an instructional video outlines how to recognize the signs of opioid overdose, assemble a naloxone kit and administer the overdose reversal drug.
“Having students prepared to recognize the signs of overdose and be able to react quickly with appropriate treatment is imperative,” Buchman said. “This program helps patients and our community by impacting a generation of students who will now be better prepared in this health care climate.”
Clinical experiences and simulations like these – and especially those that emphasize interprofessional collaboration – are part of intensified efforts by the CHSP and Heritage College to prepare future health care providers to practice during this time of crisis by enhancing curricula on opioid-related prescribing and substance abuse disorders.
These students will be entering practice as the nation faces an epidemic of opioid abuse, with Ohio among the hardest hit of all the states. In 2007, drug overdose became Ohio’s leading cause of accidental death, and it remains so, with the state ranking second in the nation behind West Virginia in number of deaths per 100,000 due to opioid misuse.
“We train primary care physicians to practice in communities of need in Ohio, and this includes people with opioid misuse disorders,” said Jody Gerome, assistant dean for curriculum and associate professor of obstetrics and gynecology at the Heritage College. “The national attention that we’re seeing now parallels the work we have been doing here for some time.”
Gerome explained that, in the medical school’s new Pathways to Health and Wellness Curriculum, launched fall 2018, “… we put the patient experience at the core. Our students are taught a patient-centered approach from the very first day of medical school. They’re learning about substance abuse disorders early in their training and with an emphasis on the perspective of the people who are affected by it.”
“Having our students work in teams is critical to treating those struggling with an opioid use disorder,” said Gerome. “We know that with teams, health care systems reduce their costs, increase patient satisfaction and see improved health outcomes for patients struggling with this. Our students daily work together in teams to solve problems through the lens of a patient, just as they will when they practice medicine.”
“Academic curricula need to be flexible in order to anticipate and react to the needs of society. The opioid epidemic is a harsh truth, and our students need to be prepared to face all the realities that come with treating the population,” said CHSP Dean Randy Leite, Ph.D. “CHSP is at the forefront of being proactive in our training of health care students so that they can make the greatest impact on the health of their communities.”
Students want more clinical training, as well. A 2018 survey by Sophie Mort, a D.O./Ph.D. student, confirmed that health professions students who participated in clinical experiences relating to diagnosing and treating patients, as well as emergency interventions, were more likely to plan on working with patients addicted to opioids and have more confidence in doing so. The research was published in the December 2019 edition of the Journal of the American Osteopathic Association.
“I do think that it’s important to take away that having clinical experiences related to treating acute overdose and exposure to drug-seeking behavior positively influenced students’ intent to work with those with substance abuse disorder and being more confident in doing so,” Mort said. Providing more of these experiences to all health care students should help create a workforce more ready to tackle the opioid crisis, she said.
Associate Professor of Family Medicine Elizabeth Beverly, Ph.D., Mort’s doctoral advisor, said the research reinforced the need for more – and more specific – opioid abuse disorder training.
“They have to work with this patient population. They’re going to see them in the future during residency,” said Beverly, who holds the Heritage Faculty Endowed Fellowship in Behavioral Diabetes, Osteopathic Heritage Foundation Ralph S. Licklider, D.O., Research Endowment.
“Training in simulated clinical settings in the first years of medical school is crucial,” said Sarah Adkins, PharmD, clinical pharmacist and associate director of the Diabetes Institute at the Heritage College.
Adkins and a team of interprofessional health care providers developed the naloxone training for second-year medical students to place students into a drug dependency and addiction scenario. Training also includes cases and instruction focused on the stages of substance abuse disorders, the pharmacologic and sociodemographic factors that can contribute to abuse and safe prescribing practices. “There has been significant attention to detail in the new curriculum,” said Adkins. “We want students to participate in active, experiential activities around substance abuse, much of it opioid-related.”
Medical students on third- and fourth-year clinical rotations at hospital sites are “getting significant exposure to this issue on almost every rotation,” said Andy Culver, D.O., assistant dean for clinical education and discipline director for emergency medicine at the Heritage College. He described how physicians in every field of medicine are increasingly treating patients who are misusing opioids, or they are working with family members of someone struggling with a substance abuse disorder.
“Depending on the patient population at the particular site where a student is rotating, students are exposed to the many different aspects of diagnosis and treatment of opioid misuse disorders that are unique to each specialty,” he said.
Culver and other curriculum developers want students to receive even more instruction in the new medical school curriculum. Starting next fall, curriculum developers plan to bring all third-year students back to the Athens, Cleveland and Dublin campuses from their clinical sites for training intended to more deeply prepare them for opioid-related patient encounters at their hospitals.
CHSP students are also exposed to a wide variety of training related to treating and assisting those struggling with substance use disorder, with an emphasis on opioids. In addition to nursing students who train in the use of Narcan, social work students are educated on chemical dependency, addiction and evidence-based treatment and prevention, while physical therapy students are trained in pharmacology techniques and assessments related to addiction and the use of Narcan. Additionally, CHSP students have the opportunity to participate in clinical rotations with organizations that focus on behavioral health and substance misuse.
The Heritage College has been addressing the need for increased opioid-specific training for years. The Heritage College answered the nationwide call from the White House in March 2016 to require that students undergo a form of prescriber education in line with the latest Centers for Disease Control guidelines for prescribing opioids before they can graduate. Since the fall of 2016, the college has required all students to take this type of prescriber education. And curricular enhancements have continued to be added since then.
Additionally, given the grip of a terrible opioid crisis in Ohio, the state’s seven medical schools have been working collectively through the Ohio Council of Medical School Deans to intensify efforts to prepare future doctors to practice by sharing teaching and learning resources and piloting key instructional methods and assessments on prescribing and addiction.
In 2019, the Ohio Mental Health and Addiction Services funded the All-Ohio Medical School Opioid Use Disorder Collaborative to create a comprehensive opioid and pain management medical student curriculum. Drs. Beverly; Adkins; Sebastian Diaz, Ph.D., J.D., associate professor of family medicine; Cheryl Hammes, D.O., associate clinical professor of osteopathic manipulative medicine; and Stevan Walkowski, D.O., associate professor of osteopathic manipulative medicine and chair of the department, developed the curriculum in partnership with the six other Ohio medical schools, led by Northeast Ohio Medical University. The final curriculum was launched to 41 representatives of the schools during a three-day summit at NEOMED last August. The curricular modules comprise 65.3 hours of instruction on 37 topics and promote longitudinal implementation, allowing each medical school to adapt them to their unique programming while maintaining the integrity of the content.
“We’re in a crisis, and it’s important that higher education asks, ‘What more can we do?’” said Kenneth Johnson, D.O., executive dean of the Heritage College and chief medical affairs officer for Ohio University. “We want every medical student in Ohio to graduate with even more knowledge and resources to deal with the complexities around prescribing controlled substances and to understand opioid addiction and the variety of alternatives for managing pain.” Dr. Johnson is the chair of the Ohio Council of Medical School Deans.