Spotlight on the Safety Net

Medical schools, including those in North Carolina, have not historically invested significant time or resources into preparing future physicians to prevent and treat substance use disorders (SUD), despite the considerable role of alcohol and drugs in the development and maintenance of a great number of chronic conditions and diseases. The current focus on opioid use disorder (OUD) and the epidemic of overdose deaths has, however, led to many new initiatives and additional funding to improve how physicians, physician assistants (PAs), nurse practitioners (NPs), and other health care providers prevent, identify, treat, and support the recovery of their patients who have, or are at risk of developing, an OUD.

Because of the important role of prescribers in the development of this epidemic, much of the focus of educational outreach to health care providers has been on safer opioid-prescribing practices. Another area of focus is expanding access to pharmacotherapy for OUD. There are three FDA-approved medications shown to be effective (methadone, buprenorphine, and to a lesser extent naltrexone) that constitute the standard of care for OUD, but which are grossly underutilized. Expanding access to buprenorphine, a partial agonist that can be prescribed in an office setting, offers the most opportunity to significantly expand access to medication assisted treatment (MAT) for OUD.

One reason for limited access to MAT for OUD is that physicians and other prescribers must take a specific course (offered online and in person) on OUD treatment in order to be able to prescribe buprenorphine for addiction; the training is not needed if prescribing for pain [1]. The training for physicians is eight hours; the training for PAs and NPs is 24 hours. Prescribers must complete the training in order to get the DATA 2000 waiver that enables them to provide opioid treatment with buprenorphine in an office-based setting (also known as office-based opioid agonist treatment, or OBOT). Most training efforts have focused on practicing primary care providers, but these efforts have fallen short in North Carolina and elsewhere. In fact, North Carolina is one of 11 states with buprenorphine prescribers per opioid death rates well below the national average [2].

In order to increase the pipeline and ultimately the number of prescribing providers, in 2018 the Substance Abuse and Mental Health Services Administration (SAMHSA) issued an RFP for programs at medical, PA, and NP schools aimed at expanding access to MAT for SUDs [3]. The Governor's Institute, a Raleigh nonprofit focused on improving how the health care professions prevent, identify, and treat SUDs, applied on behalf of four North Carolina medical schools and was awarded the 3-year grant that runs from September 30, 2018, to September 29, 2021. Governor's Institute Executive Director Dr. Sara McEwen is the program director for the grant. The University of North Carolina School of Medicine, ECU Brody School of Medicine, Wake Forest School of Medicine, and Campbell University School of Osteopathic Medicine all committed to: integrating into their standard curriculum eight hours of OUD training sufficient to make students eligible to apply for the waiver once they have been issued a number by the Drug Enforcement Administration that allows them to prescribe controlled substances; expanding opportunities for students to gain clinical exposure to OBOT in practice; and building faculty capacity to prescribe and to supervise residents and mentor students on OBOT. The expectation is that this will also lead to broader inclusion of SUD-related content throughout the curriculum.

The Governor's Institute is working with Dr. Stephen Wyatt, a North Carolina addiction medicine physician with extensive OBOT experience as well as experience teaching and mentoring, and a medical curriculum expert to adapt the existing online training for a student audience. This training will be included in the curriculum starting with the 2019-2020 academic year at the aforementioned four schools. The online training will be supplemented with in-person discussion with OBOT providers (four hours is recommended) and all students will be offered opportunities to shadow OBOT providers. This clinical exposure will provide students opportunities to see and discuss clinical issues, challenges, solutions, and benefits associated with OBOT; increase readiness; and dispel stigma by demonstrating positive interactions and outcomes with MAT. Many providers who have completed the training do not go on to become active prescribers; it is expected that this increased exposure through the Governor's Institute program will increase the number of active prescribers. Additional initiatives in North Carolina are training students in primary care residency programs (eg, MAHEC) and providing clinical support and mentoring to newly waivered OBOT providers (eg, UNC ECHO for Rural MAT).

The three-year grant period will provide opportunity for schools to make the changes necessary to ensure sustainability of the curriculum change, develop faculty expertise and clinical exposure opportunities, and integrate general SUD education more prominently throughout the curriculum. The four schools collectively turn out approximately 545 physicians each year. We know that not all providers will proceed to get the waiver and prescribe, but increased knowledge and improved skills around OUDs in particular and SUDs in general are critically important regardless of specialty, as all clinicians play a role in prevention, treatment, and/or supporting patients in recovery. Grant-generated training and resources will be made available to all North Carolina medical, PA, and NP students, with active outreach in year three.

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