[The following notes were generated by Michele Haight, PhD.]

IAMSE Webinar Series, Winter 2020

Speakers: Lee Jones
Title: “Medical Students and Substance Use: Challenges and Supports”
Series: How is Health Science Education Tackling the Opioid Epidemic?

• According to a 2019 CBS News Poll, views and opinions towards marijuana in the US are changing with a trend toward legalizing marijuana.
• Marijuana is the most commonly used psychotropic drug by young adults in the US, second only to alcohol.
• Effects of marijuana use:
  • Smoking has immediate effects that last 1-3hrs. Peak levels of intoxication for smoking marijuana occur 30 minutes after smoking and last for several hours.
  • GI ingestion effects occur within 30-60 min. and last “many hours.” This poses a greater risk for overdose.
  • THC is detected almost immediately in the bloodstream. It is fat-soluble and able to be detected in the urine anywhere from one day to more than a month after ingestion.
• Common effects of Marijuana include:
  • Euphoria
  • Sense of relaxation
  • Altered senses/altered sense of time
  • Changes in mood
  • Impaired body movement
  • *Difficulty thinking and problem-solving
  • *Impaired memory
  • Hallucinations (heavy use)
  • Delusions (heavy use)
  • Psychosis (heavy use)
    * Of concern for physicians/physician trainees
• Drug Detection Time in the Urine:
  • Single use. 3 days
  • Moderate use 5-7 days
  • Chronic use (daily) 10-15 days
  • Chronic heavy smoker >30 days (after cessation)
• In the US, there are currently 2 FDA-approved THC medications : Dronabinol/Marinol and Nabilone. Dronabinol tests positive for THC on urine tests but Nabilone tests negative for THC.
• According to Crean et al. (2011), marijuana impairs cognitive functions on many levels including basic motor coordination and more complex executive function tasks. These deficits vary depending on the quantity, recentness, age of onset and duration of the marijuana use.
• Summary of research findings on the effects of cannabis (Crean et al., 2011)

The table shows mixed findings based on the types of effects, acute, residual or long-term as well as the focused area of executive functioning.

• Cannabis Use Disorder/Cannabis Withdrawal Disorder are included in the DSM-5.
• According to Hasin et al. (2015), nearly 30 % of marijuana users manifested a marijuana use disorder between 2012 and 2013.
• Marijuana laws vary by state. Currently, 26 states plus DC have decriminalized small amounts of marijuana. Eleven states and DC have legalized recreational marijuana. However, institutions that receive federal research or financial aid monies must have policies that comply with federal drug laws that consider marijuana illegal.
• Marijuana is a DEA Schedule 1 Substance. Physicians cannot legally prescribe a Schedule 1 controlled substance.
• The Federation of Sate Medical Boards (FSMB) “…advise their licensees to abstain from the use of marijuana for medical or recreational purposes while actively engaged in the practice of medicine…”
• Physician trainee issues with medical and recreational marijuana:
  • ADA protections for protected disabilities do not extend to the use of non-FDA approved medications (marijuana). Graduates have been granted ADA protections if pre-employment drug screens were positive for an FDA-approved medication (Dronabinol/Marinol).
  • Institutions that employ residents are within their rights to deny employment because of a positive cannabinoid screen for marijuana use.
  • Matching in a state that has legalized medical and/or recreational marijuana does not protect graduates from adverse consequences (such as Match revocation) related to the use of legalized and/or medical marijuana.
  • An increasing number of clinical rotations, including medical school clinical sites, are requiring substance abuse screening, including marijuana.
  • It might be worthwhile to explore with one’s treating clinician FDA-approved treatments instead of medical marijuana.
• For practicing physicians, even if a state approves of medical and recreational marijuana use, other institutions within the state might still require a negative test for marijuana.
• Second-hand marijuana smoke exposure can produce a positive screening result, depending on the amount of time of exposure. However, a more recent study indicates that a positive screening for second-hand marijuana smoke is not likely.
• Repeated dissemination of information to medical students related to potential consequences of medical and/or recreational marijuana use and the Match is done at UCSF SOM and is highly recommended for all medical schools.
• The article referenced below provides a guide for developing support systems for substance use disorders in physician training.

   

“A Lethal Hidden Curriculum — Death of a Medical Student from Opioid Use Disorder.” Catherine R. Lucey, M.D., Lee Jones, M.D., and Abigail Eastburn, M.D. August 29, 2019, N Engl J Med 2019; 381:793-795. DOI: 10.1056/NEJMp1901537

[The following notes were generated by Michele Haight, PhD.]

IAMSE Webinar Series, Winter 2020

Speakers: Suzanne Lady and Narda Robinson
Title: “Informing Pain Management Curriculum: A Multi-Disciplinary Discussion on Alternatives to Opioids”
Series: How is Health Science Education Tackling the Opioid Epidemic?

• “Pain as the 5^th Vital Sign” was an initiative launched in 1999 by the American Pain Society to bring awareness to practitioners and the public that patients experiencing pain were being under-treated. Each patient encounter required a pain rating assessment. As a result, pain became a huge clinical focus.
• During the 2000s, drug manufacturers funded publications and CME events for physicians to encourage the expanded use of opiates.
• In response to the opioid crisis, in 2007, he ACP and APS published guidelines for non- addictive, OTC pain medications as alternative treatment options for low back pain which included: analgesics, NSAIDs and secondarily, muscle relaxants.
• Recent studies do not necessarily support the efficacy of these suggested pain medications, especially in light of their side effects.
• Guideline recommended CAM treatments for pain include: Tai Chi, Yoga, Diet Modifications, Exercise, Mind/Body techniques, Acupuncture, Physical Therapy, Massage Dietary Supplements, Cognitive-based Therapy and Spinal Manipulation.
• Pain is influenced by a person’s biology, pain beliefs and attitudes and their social support system or lack thereof.
• Given the complexity of pain management, it is necessary to teach and approach pain management from a bio-psycho-social perspective.
• Spinal manipulation, one aspect of manual therapy, is a hands-on treatment which is often done by chiropractors, osteopaths, physical therapists, and medical doctors. It includes additional recommendations for exercises, making healthy lifestyle and dietary choices and engaging in stress reduction through mind/body medicine techniques.
• International and Interdisciplinary Guidelines on treating low back pain include the following:
• The following are recommendations for acute low back pain:
• The evidence demonstrates that manipulation enhances function while medications do not.

• Integrative medicine is a field that uses practices that traditionally have not been part of conventional medicine but are now being combined with conventional medicine as evidence for safety and effectiveness increases.
• In terms of pain management, we need to:

1. 1. bring together conventional and complementary medicine practitioners along with other disciplines that treat pain to create a team-based approach to pain management.
   2. include pain medicine as a mandatory part of the medical school curriculum.
   3. provide integrative medicine learning opportunities and experiences from day one in the curriculum.
   4. create interdisciplinary opportunities for multiple integrative medicine professionals to train together such as integrated clinical preceptorships and residencies.
   5. see patients as a whole and learn to palpate from year 1; if you do not touch patients, how do you know where they hurt and the quality of their pain?
   6. build a healthier workplace culture for overworked and overstressed practitioners

• Pain care is changing to multi-modal, evidence-informed options.
• Prescribing opioids is the path of least resistance for overworked practitioners.
• PRIMA (The Pain, Rehabilitation and Integrative Medicine Advantage) is a parallel training pathway for human and veterinary medicine. From the beginning of training acupuncture, biotherapy, manual therapy botanical medicine, phototherapy, movement therapy, etc. are taught alongside a more conventional curriculum. This gives broader meaning to the basic science topics and helps learners to incorporate CAM to facilitate healing without solely relying on medications and procedures. The 5 modalities of PRIMA practice are: medical acupuncture, medical massage, laser therapy, botanical medicine, and movement therapy.
• Challenges are to incorporating integrative therapies with conventional medicine include the following:

1. 1. lack of faculty support
   2. insufficient awareness of scientific support for integrative therapies
   3. prescribing habits of practitioners
   4. corporate influence over curricula
   5. reimbursement

• The solutions to the opioid crisis are not:

1. 1. more expensive tests
   2. more education solely about opioids
   3. drugs and procedures
   4. disengaged patients

• In current medical education, there is a lack of instruction in pain medicine, a lack of awareness of non-opioid options and insufficient scrutiny of corporate influence in physician training. There needs to be a longitudinal, 4-year, comprehensive integrative pain medicine curriculum for all physician trainees devoid of corporate influence.
• Sample Integrative curriculum:
  • Integrative Curriculum, Year 1 (14 hours) – acupuncture anatomy, neurophysiology, problem-based learning, experiential laboratory, Photomedicine physiology, clinical applications, experiential laboratory
  • Integrative Curriculum, Year 2 (14 hours) – Medical massage anatomy, physiology, techniques, experiential laboratory, Botanical medicine pharmacology, clinical practice, experiential laboratory
  • Integrative Curriculum, Year 3 (14 hours) – Integrative medical approaches to orthopedic and neurologic disease and injury, integrative rehabilitation and physical medicine, experiential laboratory
  • Integrative Curriculum, Year 4 (150-300 hours) – Hybrid online/onsite medical acupuncture comprehensive program
• Final Thoughts: We need to move away from opioid reliance by learning new ways to heal and be healed by various integrative therapies in order to help our patients take control of their lives and be well.