Addiction used to be someone else’s problem. Doctors graduating today are eager to take it on
Siva Sundaram got his first lesson in addiction before he started medical school, when he worked at a wilderness program for teenagers who suffered from substance use disorders.
During his two years there, he came to realize the kids were just like him, struggling with the same problems of identity, peer pressure, and independence — and that people with addiction are no different from those with other illnesses.
That insight served him well when he arrived at Harvard Medical School in 2015, just as the ground was shifting in medical education. Governor Charlie Baker that year had called on the state’s four medical schools to ensure their curriculums addressed pain medications and addiction treatment.
Sundaram and other students from all four medical schools proved central to that effort, advocating for improvements and helping to revise the curriculums.
Doctors graduating this spring from the medical schools at Harvard, Tufts, Boston University, and the University of Massachusetts are among the first fully trained to recognize and treat addiction. Notably, many are prepared to prescribe buprenorphine, considered a critical but underused tool in combating opioid addiction.
Medical schools historically regarded addiction as someone else’s problem, not the job of medicine, said Sundaram, who is heading to a residency in psychiatry at the University of California San Francisco. “For my generation of students, we feel a great sense of opportunity to do things better,” he said.
Among those who joined the curriculum effort was Jamie Lim at Boston University.
“We see people struggling with these disorders on a day-to-day basis — on the street and also seeing them in the hospital,” said Lim, who graduates this year and will stay in Boston for his pediatrics residency. “I feel like I learned medicine through the lens of addiction. Addiction really teaches you to be nonjudgmental, very forgiving, and makes you aware of a lot of social determinants of health.”
At the governor’s prodding in 2015, the four medical schools’ deans developed a set of “core competencies” in pain and addiction. Members of a student coalition volunteered for the nuts-and-bolts labor of combing through the curriculums and identifying the gaps.
“Students have been key partners. They’re great advocates for their patients,” said Dr. Melissa Fischer, associate dean for medical education at UMass. “It gives me great hope for the future.”
In scrutinizing the curriculum, Sundaram noticed that students traditionally received thorough lessons in how to prescribe drugs for diabetes and heart disease, but learned little or nothing about buprenorphine, methadone, and naltrexone, the medications that treat opioid addiction.
In fact, to prescribe buprenorphine, an opioid, federal law requires physicians to take a separate, eight-hour course and then apply for a waiver from an old law that prohibits prescribing opioids to addicted people. Doctors are expected to take this course when they’re already practicing, and many are too busy or not interested.
Currently only 5 percent of physicians nationwide have obtained the buprenorphine waiver. Yet the drug, often referred to by the trade name Suboxone, has been shown to be extremely effective for people addicted to opioids; it quiets cravings, helps keep people in treatment, and prevents overdoses.
Sundaram came across an article about a first-in-the-nation effort in Rhode Island to incorporate buprenorphine training into the curriculum at Brown University’s Warren Alpert Medical School.
He and others wondered: Why wasn’t this happening in Massachusetts? The student coalition, which meets occasionally with Dr. Monica Bharel, the Massachusetts commissioner of public health, raised the issue, and found she was already thinking about it.
“When I graduated from medical school,” Bharel said recently, “I was prepared to care for individuals with diabetes or high blood pressure. My goal is to do the same for addiction.”
It turns out the federal law on buprenorphine prescribing provided two ways to meet the requirements: take the mandated eight-hour course, or undergo training approved by the state authority that licenses physicians.
After Bharel agreed to tackle the issue, Sundaram developed a checklist of every item taught in the eight-hour training and brought it to a follow-up meeting with Bharel, students, and faculty. Students and faculty compared the checklist to the curriculum and found that only a few supplemental courses were needed to meet all the federal requirements.
Those supplemental electives were offered this year, and the dozens of students who took them will be eligible to apply for the buprenorphine waiver as soon as they get their full medical licenses.
By 2020, Bharel expects that will be true for all Massachusetts medical graduates, potentially eliminating a longstanding barrier to access to the medication.
Rhode Island has already accomplished that: All of this year’s Brown medical graduates are fully trained in buprenorphine prescribing, according to Dr. Paul George, associate director of medical student education.
No matter what specialty a doctor chooses, he or she will encounter patients with addiction, said Dr. Daniel Alford, Boston University’s associate dean for continuing medical education. “Addiction is such a common problem,” he said. “It’s going to impact the work you do.”
Currently, the buprenorphine authorization that medical students receive in Massachusetts and Rhode Island applies only in the states where they studied. Those who move to other states will still have to take the eight-hour course if they want to prescribe buprenorphine.
But that barrier is also starting to fall, said Dr. Elinore F. McCance-Katz, assistant secretary for mental health and substance use at the US Substance Abuse and Mental Health Services Administration.
Under federal opioid legislation signed into law in October, schools that train doctors, nurse practitioners, and physician assistants can revise their curriculums to encompass buprenorphine training, as the Massachusetts and Rhode Island medical schools did. But instead of seeking approval from state licensing authorities, the schools can apply to one of several designated agencies whose approval will be effective nationwide.
McCance-Katz said it’s time for all health care professional schools to step up to the plate. “With an illness as prevalent as opioid use disorder and the devastation it’s having on American families,” she said, “all health care professionals should be trained in assessment and treatment.”