As a third-year medical student, Ally Fuher has learned many skills that have taken weeks or even months to master. But just this past August, in a session that lasted 45 minutes, Fuher mastered yet another skill, one that she believes could give her the power to save — directly or indirectly — thousands of lives.
The skill that Fuher learned, along with some 240 of her University of Minnesota Medical School classmates from the Minneapolis and Duluth campuses, was how to administer naloxone, a lifesaving drug that blocks or reverses the effects of opioid overdose. She left the course with something she calls an “incredibly useful life skill,” and her very own naloxone kit.
Giving someone naloxone is fairly simple, Fuher said, so the course devoted less time to skill building and more to general education about the opioid epidemic, including information about how ordinary people can access the kits. “It was cool to learn how to administer naloxone, and to be in a position to tell people how easy it is to get it,” she added.
Fuher left the training so convinced of the kits’ usefulness that she’s decided to take hers with her wherever she goes.
“I always have it in my backpack,” she said. “Or I throw it in my soccer bag.”
The training course emphasized just how high the odds were that the med students would one day put their kits to use, Fuher said. The message wasn’t lost on her.
“I’m from north Minneapolis, Brooklyn Park. I know several people in my high school class that have overdosed since we graduated. It is something that is very real for our generation.”
She recalled an incident from the not-so-distant past: “When I was in high school, I had an experience where someone had taken too many pills. I walked up on the situation. I didn’t know what to do other than call for help. Now, if I came in contact with something like that, I can act on it and do something in addition to calling for help. It feels a lot more reassuring to have this empowerment, to have this tool in your back pocket that you can use and feel confident using.”
The naloxone training course was a first for the U of M, and likely the first ever at any medical school nationwide, said Charles Reznikoff, M.D., University of Minnesota Medical School assistant professor of medicine and one the course’s staunchest advocates. A former board member and current prescriber education lead for the Steve Rummler Hope Network, a Twin Cities-based nonprofit dedicated to advancing education about opioid addiction and overdose deaths, Reznikoff helped organize and lead the course. Part of his annual donation to Rummler funded the purchase of the naloxone kits provided to the class of med school students.
“While other medical schools may do trainings,” Reznikoff said, “I have never heard of a med school anywhere that has incorporated a training for the entire class and provided the kits. That’s where we stand out.”
Anne Pereira, M.D., MPH, assistant dean for curriculum and an associate professor of medicine at the medical school, added that the U’s increased focus on educating future physicians about the impact of the opioid epidemic meant that holding the course made perfect sense.
“A couple of years ago we recognized that we needed to get more education around opioid prescribing and the opioid epidemic to our students,” she said. “It wasn’t a central part of our curriculum before then. This new course is an important extension of that change, and, to our knowledge, we are one of the first med schools anywhere to be taking this aggressive approach.”
An increased emphasis on opioid education required significant change at the med school. The impetus for this shift came in part, Pereira said, through political interest.
“We were getting some interest in this from legislators on the state and federal level,” she said. “We were getting the message that we needed to start teaching about opioids.” There was also internal pressure to realign the school’s focus, Pereira added: “All of that external conversation made us look at our curriculum and say, ‘We recognize that this needs to be a more prominent part to our curriculum.’”
But it isn’t a simple task to make changes in the way medical students are taught at the university.
“Our curriculum is already full,” Pereira explained. “We don’t just have space to shove more information at students. It’s not like we have empty blocks of time.” Then curriculum planners realized that they could build some of this new emphasis into the med school’s new “Becoming a Doctor” course that is scheduled during students’ third and fourth years of training.
“It is a course that is required for all students,” Pereira said. “It’s a week in August and a week in January. Students have been in a clinical environment and are now coming back to the medical school to reflect on the experience. The ‘Becoming a Doctor’ course created substantial space that we hadn’t had previously in the curriculum. We saw it as an opportunity.”
With his deep knowledge of the opioid crisis born out of his involvement with The Steve Rummler Hope Network, Reznikoff seemed like the ideal person to lead part of this effort. Pereira said that she and her curriculum colleagues asked if he’d be willing to take it on.
“We said, ‘We need help developing curriculum around how do you have difficult conversations with patients who are coming in wanting opioid medication and for whom you don’t feel these medications are appropriate,’” she said. “We also said that we need to come up with a way to do some education around naloxone.”
While he was happy to lead students in courses focusing on communication around opioid prescribing practices, Reznikoff was most excited about the naloxone part of the program.
“There are so many things that need teaching and there are only so many hours’ worth of curriculum,” Reznikoff said. “You could add 20 hours of curriculum and it still wouldn’t be enough to cover this topic.” But the naloxone course had a distinct appeal: “Why naloxone? It is a single, discreet, understandable thing. It is an achievable goal, a box we can check off.”
After the inaugural course was complete, Pereira and her colleagues polled med students on its effectiveness. The results were mostly positive.
“Two-thirds said they would recommend the session to future students,” Pereira said. “And 75 percent said they felt it supported their learning as a physician. Those are high numbers for med students. They are incredibly discerning consumers.”
How the training works
The course is structured like a workshop, with presenters from outside agencies and a special focus on discussion.
“It wasn’t like a CPR training with a dummy, with 90 percent action and 10 percent knowledge,” Reznikoff said. “This was a lot of information to give them and a lot of question-and-answer, balanced with, ‘Here’s what you do with your hands,’ and, ‘Here is something to look at and take apart.’ It’s a little bit of a lecture, a little bit of a Q & A, a little bit of a hands-on. They can witness a variety of different naloxone kits.”
The hands-on aspect has a particular appeal to med students, Reznikoff added.
“They find this training kind of fun,” he said. “We can geek out, take a closer look and get advanced and talk about rare circumstances and subtle things you can’t talk to the general public about.”
Workshop presenters made a point of helping the med students make connections between the training and their real lives. Part of the med school’s expanded curriculum is an effort to destigmatize addiction, partly through emphasizing how the opioid epidemic impacts nearly every American.
“The presenters at the workshop said, ‘We expect that many people in this room have had or will have experience with someone they know with an opioid-use disorder,’” Pereira said. “Acknowledging how common it is was an effort to destigmatize it.”
Many of the students themselves have personal connections to opioid addiction, Reznikoff said. Planners tried to take this reality into account when they planned the course.
“We start this training with a trigger warning that this may personally impact some people who have lost relatives or friends to opioid overdose,” he said. “It is actually surprising just how many people in medical school have a close relative or associate who has struggled with this.”
Pass it on
Perhaps the most important message that came out of the training goes beyond the basics of how to administer naloxone. Reznikoff hopes that the students will take the knowledge they gained and apply it to their future work as physicians in clinics and hospitals around the country.
“The old, ‘teach a man to fish rather than give the man the fish,’ adage applies here,” he said. “Docs are the people who then go to a primary-care clinic with thousands of patients and take those skills and pass them on to thousands of potential doctors. By training the trainers we have a bigger impact.”
Offering a naloxone training is a good way for the medical school and the university to get positive attention, Reznikoff said. But what’s more important is the message that the trainings spread — that addiction can happen to anybody, and that everyone — med students and regular citizens alike — has the power to make a difference.
“The trainings are trendy, fine, good, achievable,” Reznikoff said. “Here you have a thing that will get everyone’s attention. You can get it done in 45 minutes and it’s memorable. It is also this Trojan horse for an attitude and approach toward addiction that we want students to internalize more generally. That includes the notion that docs can approach this in a certain way, that they can start thinking about addiction and the opioid epidemic and engaging further rather than running from it.”
Fuher said she that before she took the course she didn’t understand just how accessible naloxone is for anyone, not just medical professionals.
“It was surprising for me to learn how easy it is for people to go to the pharmacy and access it,” she said. She also learned that the drug is generally safe and easy to administer.
“Even for a general citizen,” Fuher said, “there’s no downside to administering naloxone. And it is really easy to spot the symptoms of overdose. For us as med students, once we got past the how-to part, we had time to ask questions and learn about how we can tell patients how easy it is, if they have a family member of a friend they are concerned about, to get a kit to have around.”
With its goal of communicating the universality of opioid addition, Pereira said that she hopes the naloxone trainings passed a similar message on to all of the med students who were in attendance. By taking away the mystery surrounding this treatment, and by showing just how simple and accessible it can be, hopefully these future physicians will head into practice prepared to discuss and treat addiction in an open manner. “Once they know how easy it is to administer naloxone,” she said, “the more they will be willing to prescribe it to their patients, and the less stigma they will have around the issue.”
Reznikoff, for his part, likes to return to his Trojan horse analogy. While he’s happy that the training gave some 240 future physicians a lifesaving skill that they may not have learned before, he’ll be even more satisfied if those same students walk away with a more open attitude about addiction and the millions of Americans it has ensnared.
“I didn’t do this naloxone training because I thought this was the single most important thing to learn,” Reznikoff said. “I thought it was the best way to broach the subject of addiction. I think it went well. We got a lot of really important, bigger things communicated by way of a naloxone training, and I’m excited to do it again next year.”
Fuher, who is likely to eventually specialize in internal medicine, said that the training perfectly aligned with her approach to her work.
“I want to be able to empower people,” she said. “I think naloxone is a great example of that. With this knowledge, I can empower people and help them out in terms of their health, whether it be for themselves or if they are concerned about a family member. Being in a position of empowering people is exactly why I’m in medicine.”