Jonathan Goodman can recall most of the lectures he's attended at the Stanford University School of Medicine. He can recite detailed instructions given more than a year ago about how to conduct a physical.
But at the end of his second year, the 27-year-old M.D.-Ph.D. student could not remember any class dedicated to addiction medicine. Then he recalled skipping class months earlier. Reviewing his syllabus, he realized he had missed the sole lecture dedicated to that topic.
"I wasn't tested on it," Goodman said, with a note of surprise.
Americans are overdosing at epidemic rates on opioids such as heroin and prescribed painkillers, and the nation's doctors are inadequately prepared to help, according to some public health experts. They say the shortfall begins in medical school.
A report in 2012 by the National Center on Addiction and Substance Abuse revealed that medical schools devoted little time to teaching addiction medicine -- only a few hours over four years. Since then, the number of Americans overdosing from prescribed opioids has surpassed 14,000 per year, quadrupling from 1999 to 2014.
Schools have been so slow to change that some medical students, like the ones at Harvard University, have started conducting their own training on how to buy and administer drugs that reverse the effects of an overdose, according to Kelly Thibert, the national president of the American Medical Student Association. The students organized to educate themselves about these medications because it was not part of the school's curriculum.
Now, Stanford's medical school may offer an example of what faculty-driven change can look like.
The school began retooling its curriculum after the director of its addiction medicine fellowship, Dr. Anna Lembke, expressed concern about its meager offerings in that field.
Lectures on addiction will no longer be folded into the psychiatry series as a side note, but instead will be presented as a separate unit, relevant to future doctors in any subspecialty, Lembke said. And that training will continue when the students leave the classrooms for clinical rotations.
"We're at the very bottom of a very long uphill road," said Lembke, who gave the lecture Goodman missed.
Medical faculties have traditionally eschewed teaching about addiction, in part because many physicians viewed the subject as a personal vice, not a disease. Some consider it difficult - sometimes impossible - to treat in a medical setting.
"Clearly, if you've got an addiction, you've been making a lot of bad choices," said Dr. Joe Gerstein, a retired clinical assistant professor at Harvard Medical School and founding president of SMART Recovery, which emphasizes positive thinking to help people beat addiction. "I've spent 30 years in the medical community," Gerstein said, "and I don't know of any disease where you can get up in the morning and say, 'That's it.'"
Those who advocate medical treatment for addiction say it can no longer be an afterthought in medical education. Because the current opioid epidemic is largely linked to prescribed opioid painkillers, many doctors are being forced to grapple with addiction in their practices. In March, the American Board of Medical Specialties officially recognized addiction medicine as a subspecialty.
The onus now is on medical schools to change, said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.)
In a March report, the foundation cited inadequate medical school training as one of the challenges in treating patients addicted to opioids.
But many medical schools resist outside direction with regard to their curriculum. Pfeifer noted that more than 60 medical schools signed a pledge, issued in February by the Obama Administration, promising to teach their students about responsible opioid prescription. However, several prestigious medical schools, including Harvard and Stanford, did not sign the pledge.
"I think that people don't like to be told what to do," Pfeifer said. Opting out of such pledges, she added, lets their curriculum fall through the cracks. "If there's no accountability, nobody on the outside can say, 'you promised to do this.'"
Stanford and Harvard signed an alternative, nonbinding statement issued by the Association of American Medical Colleges that acknowledges the role of medical schools in treating the epidemic. As recently as April, however, Lembke had been unaware of concrete plans to change Stanford's curriculum.
But in late spring, she met with the dean of the medical school about bolstering education in addiction medicine. Working with fellow faculty members, Lembke is drawing up plans to expand the teaching of addiction medicine from the lone lecture she gives on opioids each year to a series of lectures.
She said she will recommend that doctors suggest alternate treatments, such as acupuncture or massage, before prescribing opioids.
Lembke is also seeking approval from the Accreditation Council of Graduate Medical Education to accept medical residents -- doctors getting specialized training -- into her addiction medicine fellowship. Before addiction medicine became an official subspecialty, fellowship programs devoted to it could not be ACGME accredited and could not apply for the additional funding available to accredited programs.
Lembke's colleague Jordan Newmark, who directs education in Stanford's pain division, is seeking to increase opioid training for medical students in their third and fourth years. He plans to ask actors to portray patients with opioid addictions in clinical training sessions.
Some challenges remain, even if training at medical schools dramatically improves, said Emily Feinstein, director of health law and policy at the National Center on Addiction and Substance Abuse. As of 2013, she noted, only 1,200 of the roughly 1 million active physicians in the United States had pursued a certificate in addiction medicine -- the highest level of training available prior to the topic's designation as a subspecialty.
One of the challenges is getting doctors interested in the field, Feinstein said, citing low insurance reimbursement rates as a deterrent to young physicians. "And the patients can be difficult to work with," she added. "Addiction is a disease that affects your brain ... and can make people angry."
Goodman, the Stanford medical student, believes his peers are generally disinclined to blame patients in most branches of medicine. "Going into the mechanisms of addiction on the brain" could help students view it as a disease rather than a choice, he said.
Lembke agreed, saying it's best to reach doctors at the start of their careers, before they've established a practice and get set in their ways.