Systematic Review of Opioid Use Disorder Treatment Training

for Medical Students and Residents

R. Lyle Cooper, Aramandla Ramesh, Paul D. Juarez, Ryan Edgerton, Michael

Paul, Mohammad Tabatabai, Katherine Y. Brown, Patricia Matthews-Juarez

Journal of Health Care for the Poor and Underserved, Volume 31, Number
4, November 2020, Supplement , pp. 26-42 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/hpu.2020.0136

For additional information about this article

https://muse.jhu.edu/article/774186

[ Access provided at 24 May 2021 12:10 GMT from Shandong Normal University ]
LITERATURE REVIEW

Systematic Review of Opioid Use Disorder Treatment

Training for Medical Students and Residents
R. Lyle Cooper Ph.D.
Aramandla Ramesh, Ph.D.
Paul D. Juarez, Ph.D.
Ryan Edgerton, MPH
Michael Paul, MPH
Mohammad Tabatabai, Ph.D.
Katherine Y. Brown, Ed.D.
Patricia Matthews-Juarez, Ph.D.

Abstract: Background. Opioid use and overdose represent a major public health crisis in
the United States. Training in opioid use disorder treatment is a complex and multi- faceted
endeavor with topics that range from harm reduction and overdose reversal to medication-
assisted treatment. Methods. We conducted a systematic review of literature on medical
school opioid training to assess the current state of medical student and resident training to
treat opioid use disorder. Results. Seven total studies were identified that evaluated medical
student or resident trainings. All the studies showed some positive change in knowledge,
confidence, attitudes, and/or practice behavior of the participants. Discussion. Six of the
seven studies were conducted among medical residents, and only two included medical
students. The reviewed studies effectively addressed specific aspects of effective opioid use
disorder treatment. More studies are needed that include medical students, and on effective,
all- inclusive training strategies for opioid use disorder curricula.
Key words: Opioid use disorder, medical students, medical residents, substance abuse treat-
ment, medical education.

I n the United States, 46,802 people died in 2018 from opioid overdose, accounting for
approximately 70% of all drug overdose deaths in the U.S.1 This is significantly higher
than the number dying in car crashes that year, and the rate of death in some states is
triple or even quadruple the rate of car crashes deaths.2 Two factors have contributed
greatly to the high death toll. First, there is currently a very a high frequency of use,
with 11.4 million Americans reporting opioid misuse in the past year.3 Second, the high
potency and availability of synthetic opioid overdose is a significant contributor to the
rise in fatal overdose. Synthetic opioids can be 10 to 1,000 times stronger than heroin,
and two out of three opioid overdoses in 2018 including synthetic opioids.1,3 Opioid use

All of the authors are affiliated with Meharry Medical College. Please address all correspondence to
R. Lyle Cooper, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208; phone:
(615)-327-6355; email: [email protected].

© Meharry Medical College Journal of Health Care for the Poor and Underserved 31 (2020): 26–42.
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 27

and associated overdose represent a major public health crisis in the U.S., but there are
effective treatments available to curtail use and defray the harms associated with use.
Effective treatments for opioid use disorder (OUD) include several medications to
treat overdose, craving, and withdrawal, as well as psychosocial interventions. Metha-
done, the oldest of the medications used to treat opioid use disorder (OUD) has been
in use since 1972.4 Methadone is a full opioid agonist, meaning this drug fully activates
the opioid receptors in the brain, resulting in a full effect of the opioids. This full ago-
nist is used as a “replacement” for illicit use by providing a longer effect and reliable
supply that frees the person with OUD from the need to find and use drugs. Further,
as tolerance builds to the drug, the user feels less euphoric effects but does not enter
withdrawal. Methadone as a treatment for OUD has demonstrated efficacy in reducing
opioid use,5 as well as the harms associated with OUD such as, fatal overdose,6 HIV
and hepatitis C (HCV) infection,7,8 decreasing incarceration rates,9 and increasing
employment.10 However, laws regarding its distribution confine the use of this effective
medication to specialty clinics.4,10,11
Buprenorphine is a partial opioid agonist. Partial agonists activate opioid recep-
tors, but not to the extent of a full agonist, and as such do not provide the full effect
of other opioids. Buprenorphine also acts as an antagonist, meaning it blocks other
opioids from binding to opioid receptors in the brain. Buprenorphine can be prescribed
by any licensed physician who takes an eight- hour training on addiction, OUD, and
effectively administering buprenorphine (referred to as the Drug Abuse Treatment Act
[DATA] 2000 training).28 As a partial mu agonist, it blocks the effects of exogenous
opioids, decreases the use of illicit opiates, and prevents opioid withdrawal.12 A wealth
of studies supports its efficacy in terms of retention in treatment,13 reduced opioid use,14
and reduced harms associated with OUD, such as reduced overdose risk,15 HIV/HCV
prevention,16,17 increased job stability,18 reduced incarceration,19 and reduced emergency
department visits.20
Naltrexone is a full opioid antagonist. An antagonist blocks the effect of other opi-
oids, by binding tightly to the opioid receptors and not allowing other drugs to bind.
This, in effect, stops other opioids from producing the desired effects. Naltrexone can
be prescribed either as a pill or an extended- release injection. Unlike methadone and
buprenorphine there are no restrictions on prescribing naltrexone, however physicians
must medically manage withdrawal for seven to 10 days before initiating treatment.
Naltrexone has shown efficacy in reducing opioid use,21 and increasing quality of life.22
Getting patients on naltrexone and keeping them engaged once treatment has begun has
been challenging. Jarvis et al., in their 2018 systematic review of injectable naltrexone,
found that many patients who intend to start naltrexone do not, and among those who
do start many prematurely discontinue.21
In addition to the above- described OUD treatment medications, there are many
harm reduction interventions that have shown efficacy. Syringe services programs (SSP),
previously referred to as syringe exchange programs, have recently gained increasing
support in the U.S. and have been employed more broadly to curtail outbreaks of HIV
among people who inject drugs (PWID).22,23 Use of SSPs has also been correlated to
reduced HCV risk24 and injection site infections,25 and has been used as a platform
to engage patients in other risk reduction interventions and OUD treatment.26,27,28–34
28 Opioid use training in medical school

Another medication, naloxone, has become an important tool in harm reduction

treatment. Naloxone is an opioid antagonist, like naltrexone, however when it is intro-
duced into the body of a person experiencing opioid overdose it reverses the effect of
the opioids. Naloxone has a stronger affinity to opioid receptors than other opioids and
in effect removes the opioids from the receptors, thus reversing their effect. Naloxone
can be delivered intranasally or via muscular injection and has been found to be asso-
ciated with community- wide fatal overdose reductions in areas that adopt widespread
training and distribution.35–37
Medication- assisted treatments such as those described above have resulted in
increased involvement by physicians in the treatment of OUD and other substance
use disorders. However, psychosocial interventions such as motivational interview-
ing38 and cognitive behavioral therapy39 are also important and effective tools in the
treatment of OUD.
Given the existence of effective medications to treat OUD, the current push to
provide these interventions in a more widespread manner, the ongoing crisis of fatal
opioid overdose, and the effects of OUD on the health and lives of more than 11 million
Americans, physician training should be enhanced to address this problem. Training
methods that address a full continuum of treatment services are desperately needed
to curtail this public health crisis. This continuum should include interventions rang-
ing from harm reduction and overdose reversal to medication- assisted psychosocial
treatments and treating co-occurring chronic pain and OUD to prepare the physician
workforce to address OUD.
As a first step to improving physician training, we sought to identify medical school
training approaches that demonstrate an appreciable effect on the knowledge, attitudes,
and skills of physicians in treating OUD. We have chosen to focus on medical school
training as we hope the findings can influence training for physicians particularly. While
training in effective OUD treatment may be similar in many countries, we have focused
on the United States because the opioid crisis is particularly severe in this country. Fur-
ther, the practice landscape in the U.S. is particularly important in terms of the initial
role the medical profession played in increased rates of opioid users and the insurance
reimbursement that is particular to this country. Further, we only included studies that
measured the outcome of a training approach in order to highlight approaches with
some evidence of effectiveness.

Methods
We used the PRISMA guidelines to conduct a systematic review of the OUD treatment
training literature. We adopt a broad definition of treatment to include medication-
assisted treatments, harm- reduction approaches, psychosocial treatments, and treatment
of co-occurring OUD and other mental and physical health disorders. More particularly,
we sought to identify original studies that focus on the effectiveness of medical student
and resident training to improve physician delivery of OUD treatments.
Search strategy. We conducted a systematic review of current literature to describe
the current research on outcomes of medical student and resident training to treat OUD
in the U.S. Articles published between 2000 and May 2020 were identified through
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 29

searches of Google Scholar, PubMed, OVID, ERIC, SCOPUS, Web of Science, CINAHL,
and PsychInfo. We used a search string including: (opioids OR opioid addiction OR
opioid use disorder OR opioid related disorders) AND (medical students OR residents
OR medical education OR training OR curriculum). For each database, the search was
performed using the aforementioned terms and an alert was created to notify the team
of any new articles that might be published after the search was conducted, leading to
the identification of 13,061 articles. The results were then exported to EndNote (ver-
sion X8) where all the citations were combined into one database. Duplicates and any
material that was not published in a peer reviewed journal (book chapters, serials etc.)
were removed. After this stage, 11,014 articles were left for further review.
Eligibility criteria and study selection. During the title and abstract review, each
title and abstract was reviewed in light of our inclusion criteria. These criteria include:
(a) published in or after 2000 when the data waiver program started; (b) includes an
educational intervention on treating OUD; (c) and an assessment of student/resident
learning; (c) presents primary data; (d) published in English; and (e) includes students
and residents practicing in the United States. Multiple authors (RLC, AR, RE, MP)
participated in the title and abstract review to ensure the validity of the final list of
citations. Groups of two reviewers assessed each article based on the inclusion criteria,
and in the case of discordance between reviewers’ assessments, the other two authors
reviewed the article and consensus on inclusion/exclusion was reached. This stage of
the review led to the removal of 10,683 articles, leaving 40 articles for full text review.
Finally, the same team of four reviewers reviewed the remaining 40 articles and an
additional 33 were removed based on the inclusion criteria, leaving seven articles
which are summarized in this review. Figure 1 provides a PRISMA diagram of each
step of the review process.
Data extraction. We extracted the following data from each study: subject/participant
description; study design; training intervention employed; findings; and conclusions.
These data were summarized and reported in Table 1, and these findings are synthesized
in the results section. Four authors (RLC, AR, RE, MP) participated in the extraction.
Quality assessment. All studies were rated on a 1 (low quality) to 5 (high quality)
scale by one author (RLC). Congruence of the study design to the research question,
implementation fidelity, appropriateness of statistical analysis, and the degree of control
of threats to validity were all considered in the ratings. A rating of 1 indicated a study
had uninterpretable results, whereas a 5 indicated a high- quality study, such as a well-
designed randomized controlled trial. Because of the dearth of studies, manuscripts
were not excluded based on quality, rather the strengths and weaknesses of the studies
are discussed in the findings.
Data analysis and synthesis. Heterogeneity of study design, measures, and samples
precluded a quantitative synthesis of the study findings. Therefore, a qualitative synthesis
of the included studies was conducted.

Results
Out of the total 11,014 unduplicated, peer- reviewed publications screened from the
aforementioned databases, seven studies were identified that focused on training medical
30 Opioid use training in medical school

Figure 1. .PRISMA diagram: opioid use disorder.

students, or residents, to improve their knowledge, attitudes, confidence and practice

behavior in the area of OUD treatment using a variety of educational intervention
strategies. This study was funded to examine best practices in treating three vulnerable
populations. Two of the three were not included in any of the articles in our review
(migrant farmworkers and LGBTQ persons). One training curriculum had a strong
emphasis on homeless people with OUD, one of the vulnerable populations targeted
with our grant funding.
Study characteristics. The subjects, research design, intervention, findings, and
conclusions for all seven of the included articles are summarized in Table 1. Two stud-
ies included medical students, one as a part of interdisciplinary training with nursing,
pharmacy, social work, and physical therapy students;31 another included students with
residents.28 All but one study included residents, out of which, one included residents
in primary care30 and another residents in emergency care;29 the remaining four stud-
ies included internal medicine residents.28,32,33,34 Sample size of the participants ranged
from seven to 120 for medical students and from 93 to 160 residents. The time elapsed
between pre- and post- tests to assess knowledge retention varied from one to three
months for medical students and one to 12 months for residents.
Training methods used to deliver opioid treatment curricula varied. All seven studies
Table 1.
ARTICLE SUMMARIES

Subjects/
Source Participants Design Intervention Findings Conclusions

Brown, et al. 36 internal Pre-test and immediate 4 week structured curriculum Mean post-test score was sig- Knowledge of addiction can be
(2013) medicine resi- post-test of knowledge including an overview of addiction, nificantly higher at posttest improved using various educational
dents as well as regarding addiction opioids and chronic pain, benzodi- strategies; studies with large samples
medical medicine training azepines and illicit stimulants, and are necessary for validating these
alcohol findings; further study is needed to
determine if improved knowledge of
trainees translates to improvements
in health outcomes.
Kim,et al. 23 emergency Post test only compari- Both the treatment and comparison Internet-trained residents Brief web-based training was suf-
(2016) medicine resi- son group design using group read a toxicology book, the performed significantly better ficient to teach basic principles of
dents (yr 1) an scored simulated treatment group additionally was on two of three evaluations of managing a patient experiencing
opioid-poisoned patient exposed to an internet module on a simulated patient interaction: acute opioid poisoning; further study
interaction as the out- opioid overdose management the checklist of skills and time- is needed to examine the effect of the
come measure weighted checklist of skills; web module in clinical settings, and
treatment and control were with larger samples
equivalent in a general rating
of the interaction
Kunins, et al. 71 residents Cross-sectional natu- All residents completed BupEd Retention rates in buprenor- BupEd training led to most residents
(2013) in the primary ral comparison group which included: a 1-hour session on phine for patients served by gaining experience with buprenor-
care-social in- comparing the patient buprenoprine; a 2-hour interactive residents and attendings were phine treatment; a high percentage
ternal medicine outcomes of those cared session on motivational interviewing; not significantly different getting a buprenorphine waiver; a
program for by residents in the a monthly 1-hour case conference 27.5% of graduates in the high relative percentage prescrib-
intervention, and attend- for residents on abulatory rotations treatment group obtained a ing buprenorphine in practice; and
ings that did not receive and; a supervised clinical experience DATA waiver, and 17.5% had patient outcomes of residents were
the training. providing buprenorphine treatment. prescribed buprenorphine in similar to that of attendings and to
This is in addition to an 8 hour practice. nationally reported rates
general addiction treatment training
(continued on p. 32)
Table 1. (continued)
Subjects/
Source Participants Design Intervention Findings Conclusions

Monteiro, et 120 Medical Pre-test,post-test design Small group interprofessional educa- Students showed increased The IPE workshop was effective in in-
al. (2017) students using the Opioid Over- tion (IPE) training consisting of a scores on the OOKS on all creasing student knowledge of opioid
dose Knolwedge Scale recovering patient panel, naloxone items except naloxone onset overdose management, and knowl-
(OOKS); post test was training, standardized patient inter- time edge was retained at three months
administered at 12 weeks action, and a team based care plan post training
post training was developed from a paper-based
complex patient case
Ruff et al. 91 second and Pre-test, post-test 4.5 total hours of ambulatory train- Residents reported statistically Brief training led to increases in
(2017) third year resi- measuring confidence in ing including didactics on OUD and significant improvement in resident knowledge and confidence
dents identifyinf OUD patients; chronic pain; opioid monitoring; confidence in skills treat- in managing patients with chronic
managing chronic pain prescribing exit strategies; motiva- ing chronic pain, identifying pain; but not to an increase in the use
patients; weighing risks tional interviewing; brief interven- which patients have developed of opioid prescritption monitoring
and benifits of opioid tion role play and debrief; and 2 an OUD, and understanding protocols
treatment for chronic weeks in continuity clinic how to monitor benefit vs
pain; comfort working harm in patients on chronic
with chronic pain pa- opioids; trending but non-
tients; and use of opioid significant improvement in
prescription monitoring comfort treating chronic pain
protocols patients; and no incrase in the
self-reported use of opioid pre-
scription monitoring protocols
(continued on p. 33)
Table 1. (continued)
Subjects/
Source Participants Design Intervention Findings Conclusions

Taylor, et al. 160 Internal Pre and posttest A 2-part curriculum on harm reduc-   The proportion of residents Naloxone prescription rates rose
(2018) medicine resi- knowledge survey was tion including 1 hour of lecture prescribing nalaoxone in in- significantly from pre to posttest;
dents administered; per week and 1 hour of interactive small or patient and outpatient settings however the response rate was to
naloxone prescriptions medium group teaching significantly increased from low to interpret the findings of the
by residents and faculty pre to posttest; Knowledge knowledge survey
were extracted from the scores began high and actually
electronic health record decreased at posttest. Response
rates on the pre and posttest
were very low (< 28% at pre
and posttest)
Wakeman, 97 internal Pre-test delivered at The curriculum consisted of 10 di- Additional curriculum was The curriculum was associated with
et al. (2015) medicine the end of the previous dactic sessions, 1 case-based resident not associated with improved increased resident preparedness
residents academic year, post-test report, 4 ambulatory lectures, and 1 knowledge scores; significantly to diagnose and treat SUDs.
administered at the end panel of patients in recovery. more residents reported being However, the self-reported level of
of the following academic This training was added to the more prepared to diagnos preparedness was not equivalent to
year to assess quality and original curriculum that consisted of and more prepared to treat self-reported preparedness to treat
quantity of instruction 2 didactic sessions and 3 ambulatory addiction from baseline to other chronic diseases
as well as knowledge and lectures posstest
confidence questions
regarding substance use
disorder diagnosis
34 Opioid use training in medical school

reported having some didactic component in the training,28–34 small groups were used
in three of the eight studies,31–33 and case- based learning was used in three studies.30,31,34
Two of the study curricula included clinical OUD treatment rotations.30,32 All of the
educational interventions (except one) resulted in improved knowledge, confidence,
attitudes, or practice behaviors regarding work with patients experiencing OUD. One
study that evaluated learning via standardized patients showed improved performance,
and the three studies that measured actual changes in practice behavior also indicated
improved outcomes. None of the studies described a theoretical framework around
which the curricula were designed.
Quality ratings of studies. Study quality ratings fell within the low to moderate
range. Four of the studies received a three, while the remaining three received a two.
The most common threats to validity included the lack of a comparison group, use of
non- standardized outcome measures, small samples, and high risk of selection bias.
Impact of interventions on knowledge. Programs designed to increase knowledge
regarding OUD treatment used didactic and case- based lectures, standardized patient
encounters, case studies, naloxone training, and panels of recovering patients. These
trainings were delivered to medical students and residents, as well as an interdisciplin-
ary group including medical students. Researcher- developed knowledge measures were
developed for four of the studies, and the Opioid Overdose Knowledge Scale (OOKS)
was used in one study. A pre- test, with an immediate post- test was the most frequent
design used to assess knowledge gains. One study used a delayed post-test and still
found significantly increased knowledge indicating some durability in these gains. All
the studies except one reported positive change in knowledge from pre- to post- test.
Impact of interventions on confidence. The two studies that examined confidence
focused on managing patients with co-occurring chronic pain and OUD32 and diagnosis
and treatment of substance use disorders, including opioids.34 The content covered in the
training interventions included chronic pain and opioid use disorders; opioid monitor-
ing; discontinuing prescribing when necessary, motivational interviewing, neurobiology
of addiction; screening and diagnosis; withdrawal management; pharmacotherapy for
opioid and alcohol use disorders; opioid overdose prevention and management; physi-
cian addiction; and working with challenging patients. Lecture, resident reports, and
panels of recovering patients were used to deliver the curricula for these studies. Both
of the studies measuring confidence used researcher- developed measures, and both
reported significantly increased confidence in the ability to treat opioid use disorder.
Impact of interventions on attitudes. Two studies included assessment of changes
in attitudes regarding work with patients with OUD. Didactic training, small interac-
tive group learning, and clinical rotations were the means employed for training. Top-
ics covered in training included harm reduction (i.e., safer injection, identification of
overdose, and use of naloxone), as well as managing co-occurring OUD and chronic
pain. The studies examined attitudes regarding work with chronic pain patients as well
as attitudes regarding prescribing naloxone for overdose reversal. Attitudes in both
categories improved significantly in both studies.
Impact of interventions on practice behavior. Four studies examined change in
prescribing practices. One used electronic health record extractions, two used self-
reported changes in practice, and the third used a simulated patient encounter as
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 35

outcome measures. The studies used Internet- delivered training, didactics, interactive
learning, clinical experiences, and small group learning to administer training. The top-
ics covered included motivational interviewing, harm reduction, treating co-occurring
chronic pain and OUD treatment, and effective overdose management. Outcomes were
measured differently across all studies rendering synthesis of the findings impossible.
The management of overdose was measured through simulated patient encounters and
included a comparison group. Those in the treatment group preformed significantly
better than those in the comparator. Retention of patients in buprenorphine treatment
was assessed for medical residents and compared with attendings in the second study,
and there was no significant difference in the two groups. The proportion of residents
self- reporting prescribing naloxone to reverse opioid overdose rose significantly from
pre- to post- test in the third study. In the fourth study, self- reported safe- opioid prescrib-
ing and monitoring did not increase from pre- to post- test. Finally, resident prescribing
of naloxone increased significantly from pre- to post- test in the final study measuring
practice behaviors. Further, the increases noted among residents in this study was not
seen in a faculty group comparator.

Discussion
Several studies have been conducted examining the outcomes of medical resident train-
ing to treat opioid use disorder. There are significantly fewer incorporating medical
students in the study samples, perhaps indicating that this treatment is perceived to be
more aligned with the specialized training provided in residency. However, opioid use
disorder is widespread, and likely all physicians will encounter a number of patients
facing this disorder throughout their career, and the knowledge and requisite skill to
identify, refer, and/or treat this disorder should be given more attention in medical
school training.
Four studies examined change in resident prescribing behavior and one examined
resident performance with a simulated patient. These measures are more proximal
to actual physician performance in the field, whereas the knowledge, attitudinal, and
confidence measures used in the other studies are less likely to be linked to actual
changes in physician behavior post- graduation and post- residency. To understand
the impact of opioid use disorder treatment training on physician behavior, studies
that incorporate longitudinal measurement of physician behavior in practice as well
as patient outcomes are desperately needed.
The trainings offered ranged in content, along a continuum from harm reduction,
including overdose reversal, to medication- assisted treatment and managing complex
OUD (e.g., co-occurring chronic pain and OUD). Further, all of the trainings indicated
some positive effect on knowledge, attitudes, confidence and/or practice behaviors
regarding the aspect of OUD treatment covered. However, many aspects of OUD
treatment were not addressed in any of the studies reviewed. For example, motiva-
tional interviewing was the only psychosocial intervention covered, and none of the
trainings gave an overview of treatment options (e.g., outpatient, intensive outpatient,
residential) nor the American Society of Addiction Medicine’s (ASAM) criteria for
treatment placement. Buprenorphine- assisted treatment was specifically addressed in
36 Opioid use training in medical school

training, but no studies addressed methadone or naltrexone-assisted treatment. More

research on training in these areas is needed.
Finally, the high rate of OUD coupled with the associated high rates of opioid over-
dose indicate the need for more holistic training addressing multiple aspects of OUD
treatment from harm reduction and overdose reversal to medication- assisted treatment.
Training at the medical school level should be enhanced through a broader introduction
to all aspects of the OUD treatment continuum. Residency training could then focus
on discipline-specific OUD treatment training. Kunins et al.30 is the best example of a
resident training curriculum tailored to a particular discipline of medicine. Primary
care physicians are perfectly positioned to add buprenorphine- assisted treatment and
psychosocial intervention to their practice, and to use a BupED training curriculum
focused on those skills. The other curricula could be enhanced in this way as well and
could be more effective if the specialized residency training were supported by a broad
introduction in medical school.
Limitations. The limitations noted in this review provide directions for further
research. We conducted an exhaustive search of training for medical school students
and residents, but other disciplines such and physicians’ assistant and nursing student
training were not included. We chose this approach to highlight interventions particular
to physician training because the other potential prescribers must still be supervised
by physicians, and because we intended the findings to be useful to medical school
educators particularly. Other reviews specific to other disciplines as well as reviews
that include multiple disciplines are needed.
Another limitation arose in the heterogeneity of study samples, interventions, topics,
and outcome measures, which precluded quantitative analysis. As addiction medicine
training becomes a more standard part of medical education, standard competencies
for all addiction medicine should be developed. Along with this, measures of compe-
tency could also be standardized to strengthen training across all medical schools and
offer data that can be assessed via meta- analysis. Patient-level outcomes, while used in
one study (buprenorphine treatment retention), were not used in the six other studies
although these measures are the most proximal to the desired outcome of improved
OUD patient care. Finally, the rigor of the studies conducted fell within the low to
moderate range, and as such the current evidence for effectiveness is questionable.
Studies using standardized measures and experimental designs are needed to provide
a more solid foundation of findings upon which to understand the outcomes of OUD
treatment training in medical school.

Acknowledgments
This work was supported by a grant from the Health Resources and Services Administra-
tion of the U.S. Department of Health and Human Services (HHS) under grant number
UH1HP30348 entitled Academic Units for Primary Care Training and Enhancement.
This information or content and conclusions are those of the author and should not be
construed as the official position or policy of, nor should any endorsements be inferred
by HRSA, HHS, or the U.S. Government.
There are no conflicts of interest to report.
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 37

Appendix
Example of search strategy applied in some databases

PubMed
(((((((“medical education”) OR “continuing medical education”) OR “undergraduate
medical education”) OR “medical education curriculum”)) OR (((((((education, medi-
cal) OR graduate medical education) OR education, graduate medical) OR education,
continuing medical) OR medical education, continuing) OR medical education,
undergraduate) OR education, undergraduate medical))) AND ((((((((((((((opioid
related disorders) OR morphine dependence) OR heroin dependence) OR opium
dependence) OR opiate substitution treatment) OR opioid substitution treatment) OR
opioid substitution therapy) OR opioid replacement therapy) OR medication assisted
treatment of opioid) OR opioid medication assisted treatment) OR analgesics, opioid)
OR opioid analgesics)) OR ((((((((((((opioids) OR partial opioid agonists) OR opioid
partial agonists) OR opioid-related disorders) OR addiction, opioid) OR opioid addic-
tion) OR opioid dependence) OR dependence, opioid) OR analgesics, non-narcotic)
OR nonopioid analgesics) OR analgesics, nonopioid) OR non-opioid analgesics))

PsycINFO
(“medical education” OR “graduate medical education” OR “continuing medical educa-
tion” OR “undergraduate medical education” OR “medical education curriculum”) AND
((“Opioid Related Disorders” OR “Morphine dependence” OR “Heroin dependence”
OR “Opium dependence” OR “Opiate Substitution Treatment” OR “Opioid Substitu-
tion Treatment” OR “Opioid Substitution Therapy” OR “Opioid Replacement Therapy”
OR “Medication Assisted Treatment of Opioid” OR “Opioid Medication Assisted
Treatment”) OR (“Opioid Analgesics” OR “Opioids” OR “Partial Opioid Agonists” OR
“Opioid Partial Agonists” OR “Opioid-Related Disorders” OR “Opioid Addiction” OR
“Opioid Dependence” OR “Analgesics, Non-Narcotic” OR “Nonopioid Analgesics” OR
“Non-opioid Analgesics”))

C. Web Of Science
1. ALL FIELDS: (“medical education”) OR ALL FIELDS: (“graduate medical education”)
OR ALL FIELDS: (“continuing medical education”) OR ALL FIELDS:(“undergraduate
medical education”)  OR  ALL FIELDS:  (“medical education curriculum”) 2. ALL
FIELDS: (“Opioid Related Disorders”) OR ALL FIELDS: (“Morphine dependence”) OR
ALL FIELDS: (“Heroin dependence”) OR ALL FIELDS: (“Opium dependence”) OR
ALL FIELDS: (“Opiate Substitution Treatment”) OR ALL FIELDS: (“Opioid Substitu-
tion Treatment”) OR ALL FIELDS: (“Opioid Substitution Therapy”) OR ALL FIELDS:
(“Opioid Replacement Therapy”) OR ALL FIELDS: (“Medication Assisted Treatment
of Opioid”) OR ALL FIELDS: (“Opioid Medication Assisted Treatment”) 3. ALL
FIELDS: (“Opioid Analgesics”) OR ALL FIELDS: (Opioids) OR ALL FIELDS: (“Partial
Opioid Agonists”) OR ALL FIELDS: (“Opioid Partial Agonists”) OR ALL FIELDS:
(“Opioid-Related Disorders”) OR ALL FIELDS: (“Opioid Addiction”) OR ALL FIELDS:
(“Opioid Dependence”) OR ALL FIELDS: (“Analgesics, Non-Narcotic”) OR ALL
38 Opioid use training in medical school

FIELDS: (“Nonopioid Analgesics”) OR ALL FIELDS: (“Non-opioid Analgesics”) 4. #3

OR #2 5. #4 AND #1

OVID
(“Medical education” or “Graduate medical education” or “Continuing medical educa-
tion” or “Undergraduate medical education” or “Medical education curriculum”).af.
2..(“Opioid Related Disorders” or “Morphine dependence” or “Heroin dependence” or
“Opium dependence” or “Opiate Substitution Treatment” or “Opioid Substitution Treat-
ment” or “Opioid Substitution Therapy” or “Opioid Replacement Therapy” or “Medica-
tion Assisted Treatment Of Opioid” or “Opioid Medication Assisted Treatment”).af.
3...(“Opioid Analgesics” or “Opioids” or “Partial Opioid Agonists” or “Opioid Partial
Agonists” or “Opioid-Related Disorders” or “Opioid Addiction” or “Opioid Dependence”
or “Analgesics, Non-Narcotic” or “Nonopioid Analgesics” or “Non-opioid Analgesics”).
af. 4...2 or 3 5..1 and 4

CINAHL
(((((TX “Opioid Analgesics” OR TX Opioids OR TX “Partial Opioid Agonists” OR TX
“Opioid Partial Agonists” OR TX “Opioid-Related Disorders” OR TX “Opioid Addiction”
OR TX “Opioid Dependence” OR TX “Analgesics, Non-Narcotic” OR TX “Nonopioid
Analgesics” OR TX “Non-opioid Analgesics”) AND (S2 OR S3)) AND (S1 AND S4) 

ERIC (ProQuest version)

(“medical education” OR “graduate medical education” OR “continuing medical educa-
tion” OR “undergraduate medical education” OR “medical education curriculum”) AND
((“Opioid Related Disorders” OR “Morphine dependence” OR “Heroin dependence”
OR “Opium dependence” OR “Opiate Substitution Treatment” OR “Opioid Substitu-
tion Treatment” OR “Opioid Substitution Therapy” OR “Opioid Replacement Therapy”
OR “Medication Assisted Treatment Of Opioid” OR “Opioid Medication Assisted
Treatment”) OR (“Opioid Analgesics” OR “Opioids” OR “Partial Opioid Agonists” OR
“Opioid Partial Agonists” OR “Opioid-Related Disorders” OR “Opioid Addiction” OR
“Opioid Dependence” OR “Analgesics, Non-Narcotic” OR “Nonopioid Analgesics” OR
“Non-opioid Analgesics”))

SCOPUS
( ( ALL ( “medical education” ) OR ALL ( “graduate medical education” ) OR ALL
( “continuing medical education” ) OR ALL ( “undergraduate medical education” )
OR ALL ( “medical education curriculum” ) ) ) AND ( ( ( ALL ( “Opioid Related
Disorders” ) OR ALL ( “Morphine dependence” ) OR ALL ( “Heroin dependence” )
OR ALL ( “Opium dependence” ) OR ALL ( “Opiate Substitution Treatment” ) OR
ALL ( “Opioid Substitution Treatment” ) OR ALL ( “Opioid Substitution Therapy” )
OR ALL ( “Opioid Replacement Therapy” ) OR ALL ( “Medication Assisted Treat-
ment Of Opioid” ) OR ALL ( “Opioid Medication Assisted Treatment” ) ) ) OR
( ( ALL ( “Opioid Analgesics” ) OR ALL ( opioids ) OR ALL ( “Partial Opioid Ago-
nists” ) OR ALL ( “Opioid Partial Agonists” ) OR ALL ( “Opioid-Related Disorders”
) OR ALL ( “Opioid Addiction” ) OR ALL ( “Opioid Dependence” ) OR ALL (
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 39

“Analgesics, Non-Narcotic” ) OR ALL ( “Nonopioid Analgesics” ) OR ALL ( “Non-

opioid Analgesics” ) ) ) )

References
1. Centers for Disease Control and Prevention (CDC). Drug Overdose Deaths. Atlanta,
GA: CDC, 2020. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths
.html.
2. Association for Safe International Road Travel (ASIRT). Road safety facts. Potomac,
MD: ASIRT, 2020. Available at: https://www.asirt.org/safe- travel/road- safety- facts/.
3. Center for Behavioral Health Statistics and Quality. Results from the 2017 National
Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2018. Available at: https://www.samhsa
.gov/ data/ sites/ default/ files/ cbhsq- reports/ NSDUHDetailedTabs2017/ NSDUH
DetailedTabs2017.pdf.
4. Rettig RA, Yarmolinsky A, eds. Institute of Medicine (US) Committee of Federal
Regulation of Methadone Treatment. Washington, DC: National Academies Press,
1995.
5. Fullerton CA, Kim M, Thomas CP, et al. Medication- assisted treatment with metha-
done: assessing the evidence. Psychiatr Serv. 2014 Feb 1;65(2):146–57.
https://doi.org/10.1176/appi.ps.201300235
PMid:24248468
6. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution
treatment: systematic review and meta- analysis of cohort studies. BMJ. 2017 Apr
26;357:j1550.
https://doi.org/10.1136/bmj.j1550
PMid:28446428
7. Woody G, Bruce D, Korthuis PT, et  al. HIV risk reduction with buprenorphine-
naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic
Syndr. 2014 Jul 1;66(3):288–93.
https://doi.org/10.1097/QAI.0000000000000165
PMid:24751432
8. Nolan S, Lima VD, Fairbairn N, et al. The impact of methadone maintenance therapy
on hepatitis C incidence among illicit drug users. 2014 Dec;109(12):2053–9. Epub
2014 Aug 14.
https://doi.org/10.1111/add.12682
PMid:25041346
9. Carrieri P, Vilotitch A, Nordmann S, et  al. Decrease in self- reported offences and
incarceration rates during methadone treatment: a comparison between patients
switching from buprenorphine to methadone and maintenance treatment incident
users. Int J Drug Policy. 2017 Jan;39:86–91.
https://doi.org/10.1016/j.drugpo.2016.08.005
PMid:27770695
10. Fei JTB, Yee A, Habil MHB, et al. Effectiveness of methadone maintenance therapy
and improvement in quality of life following a decade of implementation. J Subst
Abuse Treat. 2016 Oct;69:50–6.
https://doi.org/10.1016/j.jsat.2016.07.006
PMid:27568510
11. Gunderson EW, Coffin PO, Chang N, et al. The interface between substance abuse
40 Opioid use training in medical school

and chronic pain management in primary care: a curriculum for medical residents.
Subst Abus. Jul–Sep 2009;30(3):253–60.
https://doi.org/10.1080/08897070903041277
PMid:19591063
12. Ling W, Mooney L, Torrington M. Buprenorphine for opioid addiction. Pain Manag.
2012 Jul;2(4):345–50.
https://doi.org/10.2217/pmt.12.26
PMid:24654720
13. Weinstein ZM, Kim HW, Cheng DM, et  al. Long- term retention in Office Based
Opioid Treatment with buprenorphine. J Subst Abuse Treat. 2017 Mar;74:65–70.
https://doi.org/10.1016/j.jsat.2016.12.010
PMid:28132702
14. D’Onofrio G, Chawarski MC, et al. Emergency department buprenorphine for opioid
dependence with continuation in primary care. outcomes during and after interven-
tion. J Gen Intern Med. 2017 Jun;32(6):660–6. Epub 2017 Feb 13.
https://doi.org/10.1007/s11606-017-3993-2
PMid:28194688
15. Morgan JR, Schackman BR, Weinstein ZM, et  al. Overdose following initiation of
naltrexone and buprenorphine medication treatment for opioid use disorder in a
United States commercially insured cohort. Drug Alcohol Depend. 2019 Jul 1;200:34–
9. Epub 2019 May 3.
https://doi.org/10.1016/j.drugalcdep.2019.02.031
PMid:31082666
16. Metzger DS, Donnell D, Celentano DD, et  al. Expanding substance use treatment
options for HIV prevention with buprenorphine- naloxone: HIV Prevention Trials
Network 058. J Acquir Immune Defic Syndr. 2015 Apr 15;68(5):554–61.
https://doi.org/10.1097/QAI.0000000000000510
PMid:25564105
17. Mauger S, Fraser R, Gill K. Utilizing buprenorphine- naloxone to treat illicit and
prescription- opioid dependence. Neuropsychiatr Dis Treat. 2014 Apr 7;10:587–98.
https://doi.org/10.2147/NDT.S39692
PMid:24741316
18. Wiegand TJ. The new kid on the block—incorporating buprenorphine into a medical
toxicology practice. J Med Toxicol. 2016 Mar;12(1):64–70.
https://doi.org/10.1007/s13181-015-0518-4
PMid:26574020
19. Evans EA, Yoo C, Huang D, et al. Effects of access barriers and medication accept-
ability on buprenorphine- naloxone treatment utilization over 2 years: results from
a multisite randomized trial of adults with opioid use disorder. J Subst Abuse Treat.
2019 Nov;106:19–28. Epub 2019 Aug 7.
https://doi.org/10.1016/j.jsat.2019.08.002
PMid:31540607
20. Mark TL, Parish WJ, Zarkin GA. Association of formulary prior authorization policies
with buprenorphine- naloxone prescriptions and hospital and emergency department
use among medicare beneficiaries. JAMA Netw Open. 2020 Apr 1;3(4):e203132.
https://doi.org/10.1001/jamanetworkopen.2020.3132
PMid:32310285
21. Jarvis BP, Holtyn AF, Subramaniam S, et al. Extended- release injectable naltrexone
for opioid use disorder: a systematic review. Addiction. 2018 Jul;113(7):1188–209.
 Cooper, Ramesh, Juarez, Edgerton, Paul, Tabatabai, et al. 41

https://doi.org/10.1111/add.14180
PMid:29396985
22. Makarenko I, Pykalo I, Springer SA, et al. Treating opioid dependence with extended-
release naltrexone (XR-NTX) in Ukraine. Feasibility and three- month outcomes.
J Subst Abuse Treat. 2019 Sep;104:34–41. Epub 2019 May 10.
https://doi.org/10.1016/j.jsat.2019.05.008
PMid:31370983
23. Patel RM, Foote C, Duwye J, et al. Reduction of injection- related risk behaviors after
emergency implementation of a syringe services program during an HIV outbreak.
J Acquir Immune Defic Syndr. 2018 Apr 1;77(4):373–82.
https://doi.org/10.1097/QAI.0000000000001615
PMid:29271829
24. Abdu- Quader AS, Feelmyer J, Modi S, et al. Effectiveness of structural level needle/
syringe programs to reduce HCV and hiv infection among people who inject drugs:
a systematic review. AIDS Behav. 2013 Nov;17(9):2878–92.
https://doi.org/10.1007/s10461-013-0593-y
PMid:23975473
25. Noroozi M, Armoon B, Ghisynd H, et al. Prevelance and risk factors for injection site
skin infections among people who inject drugs (PID) in Tehran. J Cosmet Dermatol.
2019 Feb;18(1):258–62.
https://doi.org/10.1111/jocd.12675
PMid:29781249
26. Roth A, Aumajer BL, Felsher MA, et al. An exploration of factors impacting preex-
posure prophylaxis eligibility and access among syringe exchange users. Sex Transm
Dis. 2018 Apr;45(4):217–21.
https://doi.org/10.1097/OLQ.0000000000000728
PMid:29465703
27. Reed M, Wagner KD, Tran NK, et al. Prevalence and correlates of carrying naloxone
among a community- based sample of opioid- using people who inject drugs. Int J
Drug Policy. 2019 Nov;73:32–5. Epub 2019 Jul 20.
https://doi.org/10.1016/j.drugpo.2019.07.010
PMid:31336291
28. Brown AT, Kolade VO, Staton LJ, et  al. Knowledge of addiction medicine among
internal medicine residents and medical students. Tenn Med. 2013 Mar;106(3):31–3.
29. Kim H, Heverling H, Corderio M, et al. Internet training resulted in improved trainee
performance in a simulated opioid- poisoned patient as measured by checklist. J Med
Toxicol. 2016 Sep;12(3):289–94. Epub 2016 Apr 1.
https://doi.org/10.1007/s13181-016-0544-x
PMid:27037564
30. Kunins HV, Sohler NL, Giovanniello A, et al. A buprenorphine education and train-
ing program for primary care residents: implementation and evaluation. Subst Abus.
2013;34(3):242–7.
https://doi.org/10.1080/08897077.2012.752777
PMid:23844954
31. Monterio K, Dumenco L, Collins S, et al. An interprofessional education workshop
to develop health professional student opioid misuse knowledge, attitudes, and skills.
J Am Pharm Assoc (2003). 2017 Mar–Apr;57(2S):S113–7.
https://doi.org/10.1016/j.japh.2016.12.069
PMid:28159503
42 Opioid use training in medical school

32. Ruff AL, Alford DP, Butler R, et al. Training internal medicine residents to manage
chronic pain and prescription opioid misuse. Subst Abus. Apr–Jun 2017;38(2):200–4.
https://doi.org/10.1080/08897077.2017.1296526
PMid:28394733
33. Taylor JL, Rapoport AB, Rowley CF, et al. An opioid overdose curriculum for medi-
cal residents: Impact on naloxone prescribing, knowledge, and attitudes. Subst Abus.
2018;39(3):371–376. Epub 2018 May 15.
https://doi.org/10.1080/08897077.2018.1439800
PMid:29432074
34. Wakeman SE, Pham- Kanter G, Baggett MV. Medicine resident preparedness to
diagnose and treat substance use disorders: impact of an enhanced curriculum. Subst
Abus. 2015;36(4):427–33. Epub 2014 Sep 25.
https://doi.org/10.1080/08897077.2014.962722
PMid:25257796
35. Maxwell S, Bigg D, Stanczykiewicz K, et  al. Prescribing naloxone to actively
injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis.
2006;25(3):89–96.
https://doi.org/10.1300/J069v25n03_11
PMid:16956873
36. Evans JL, Tsui JI, Hahn JA, et  al. Mortality among young injection drug users in
San Francisco: a 10-year follow-up of the UFO study. Am J Epidemiol. 2012 Feb
15;175(4):302–8. Epub 2012 Jan 6.
https://doi.org/10.1093/aje/kwr318
PMid:22227793
37. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation
of overdose education and nasal naloxone distribution in Massachusetts: interrupted
time series analysis. BMJ. 2013 Jan 30;346:f174.
https://doi.org/10.1136/bmj.f174
PMid:23372174
38. DiClemente CC, Corno CM, Graydon MM, et al. Motivation interviewing, enhance-
ment, and brief interventions over the last decade: a review of reviews of efficacy and
effectiveness. Psychol Addict Behav. 2017 Dec;31(8):862–87.
https://doi.org/10.1037/adb0000318
PMid:29199843
39. Moore BA, Fiellin DA, Cutter CJ, et al. Cognitive behavioral therapy improves treat-
ment outcomes for prescription opioid users in primary- care based buprenorphine
treatment. J Subst Abuse Treat. 2016 Dec;71:54–7.
https://doi.org/10.1016/j.jsat.2016.08.016
PMid:27776678