Opioids and the Future Physician
Canada’s growing opioid epidemic is casting a shadow on medical education across the country. At Schulich Medicine & Dentistry, curriculum changes are underway to better prepare medical learners for the clinical realities of pain management.
By Emily Leighton, MA’13
At a busy intersection in downtown Ottawa, Dr. Jeffrey Turnbull comes face-to-face with the realities of North America’s opioid crisis.
It’s a cold day in November 2017, and his team is attempting to resuscitate two unresponsive individuals through a chain link fence.
“At that point, I knew we were dealing with a crisis that was beyond our capacity in terms of severity and complexity,” he said. “What was startling to me was that these were young people in their 20s, they were not long-time injection drug users.”
Dr. Turnbull, who completed his internal medicine residency at Schulich Medicine & Dentistry, helped found Ottawa Inner City Health Inc. in the early 1990s in response to the needs of the city’s growing homeless communities. This year, he stepped down from his position as Chief of Staff at The Ottawa Hospital to dedicate more time to the organization and its mission.
Opioid-related emergencies and addiction issues have drastically changed the nature of this work. “On a day-to-day basis, the opioid crisis has consumed everything we’re doing in the delivery of
Canada’s growing opioid epidemic is killing thousands of people each year. As the Public Health Agency of Canada conveys in a 2018 national report, it is having “devastating effects on families and communities.”
In response, medical schools across the country are recognizing their responsibility in preparing learners for the clinical realities of pain
At Schulich Medicine & Dentistry, faculty and staff are working to expand training in pain management, including opioid prescribing practices, within the undergraduate medical curriculum.
“The present crisis has many root causes, and one
Through the curriculum, students learn about the pharmacology of opioid analgesics, the types of acute and chronic pain, the risks of opioid therapy, guidelines on prescribing or withdrawing from use and the history of the opioid crisis.
Dr. Dwight Moulin, a professor with Clinical Neurological Sciences and the Earl Russell Chair in Pain Management, leads undergraduate courses in pain management and opioid use. He advocates for a balanced approach to educating future physicians.
“Pain is the most common complaint that takes people to the doctor,” he said. “So it’s part of a physician’s core knowledge to provide the proper pain assessment, make the right diagnosis and understand treatment
Dr. Moulin says the 2017 update of the Canadian Guideline for Opioids for Chronic Non-Cancer Pain provides an evidence-based framework for safer and more effective opioid prescribing practices.
“We must be very selective about who is treated with an opioid analgesic,” he explained. “In the past, we created unrealistic expectations for patients and for ourselves. The first thing we say to patients now is, ‘I understand you have pain, we’re going to do everything we can to make it tolerable for you, so you can cope and get on with your life, but we can’t eliminate your pain.’”
Dr. Moulin says it is also important that the
“There isn’t a silver bullet for chronic non-cancer pain. It’s a multi-treatment approach, including psychological interventions and physical activity,” he said. “We want learners going into practice being able to complete a good pain assessment, and knowing what all the options are in treating pain.”
The complexities of the opioid crisis, and the differing viewpoints on how to solve it, emphasize the importance of training knowledgeable, competent and empathic physicians.
“We strive to help students better understand chronic and acute care issues, such as pain management, that require a more holistic and interprofessional approach,” said Dr. Tithecott.
Resident doctors are also an important consideration in pain education. With 53 residency training programs at Schulich Medicine & Dentistry, educational needs in learning about pain management vary between specialties and sub-specialties.
Large residency training programs, such as Family Medicine, reinforce safe and appropriate prescribing practices in their core curricula, and more specialized programs devote considerable time to addressing pain management and the opioid crisis.
In 2014, Schulich Medicine & Dentistry established the Royal College Pain Medicine subspecialty, the first program of its kind in Canada. This two-year program trains residents to be experts in prevention, evaluation, diagnosis, treatment and rehabilitation of painful conditions across the spectrum of acute pain, cancer pain and chronic non-cancer pain. As part of the curriculum, residents receive in-depth training in safe and appropriate opioid use, as well as addiction medicine.
Dr. Henry Chapeskie, a family physician and adjunct faculty member who teaches in the undergraduate medical curriculum, believes health care providers need to commit to decreasing the
He no longer prescribes opioids to his patients who are experiencing chronic non-cancer pain, taking a hard line on the issue. “The more ambient exposure to opioids we have in our society, the more addiction and societal problems you will see,” he said. “Opioids are killing people. And the evidence that these drugs are dangerous is not new – we knew this 100 years ago.”
In order for learners to navigate clinical realities effectively, Dr. Chapeskie says they need an understanding of the big picture and the historical context, as well as an appreciation of the risks of opioid therapy.
“There should be mandatory exposure to addiction and recovery in the curriculum. We need to teach students what happens in people’s lives as a result of opioid addiction.” —Dr. Henry Chapeskie
“There should be mandatory exposure to addiction and recovery in the curriculum,” he said. “We need to teach students what happens in people’s lives as a result of opioid addiction.”
In Ottawa, Dr. Turnbull sees this impact play out on a daily basis. He also experiences the connection between opioid use and the social determinants of health, including housing, education and poverty.
“This is as much a reflection of the inequity within today’s society as it is an addiction problem,” he said. “The crisis can’t be solved with one approach – we need strategies in education, prevention, addiction management and treatment, harm reduction, enforcement, poverty reduction and employment.”
Underlying mental trauma and illness also compound the crisis. Dr. Turnbull believes pain education needs to address these factors and demystify drug addiction in order to foster compassionate health care professionals and spaces.
To bring about these changes, advocates are needed. “Future physicians can play an important role, not just as health providers, but as advocates for meaningful policy change and community education,” he said
A group of medical students, as part of the Schulich Medicine & Dentistry Political Advocacy Committee (PAC), have been instrumental in pushing forward a harmreduction initiative in the City of London.
London City Council passed a motion in June 2018 that was originally put forward by medical students to include naloxone kits alongside automated external defibrillators (AEDs) in city-operated facilities in London.
Naloxone is a drug that reverses opioid overdose long enough to seek medical help. The proposal was modelled after a similar initiative in Kingston. Trystan Nault, Medicine Class of 2022, and chair of PAC, says he feels extremely proud to see the idea come to fruition.
“If even a single life is saved as a result of the public knowing that AED machines are stocked with naloxone, then that will be a huge victory for this project and harm reduction in the city at large,” he said.
