Assessment of opioid knowledge and attitudes among senior medical students in Taiwan’s pain education curriculum: A cross-sectional questionnaire survey

Abstract

Introduction

While the opioid crisis has been a significant concern in North America, Taiwan has not encountered a similar crisis. This study investigated medical students’ perceptions of opioid therapy for chronic pain management in Taiwan.

Methods

A cross-sectional questionnaire survey was conducted among third- and fourth-year medical students who had completed an 18-hour pain medicine curriculum, in comparison with those who did not take the course in Mar 2022 and May 2023. The survey assessed their knowledge, attitude, and perceptions of the opioid crisis in the United States and Taiwan.

Results

In total, 135 (88.2%) of 153 senior medical students who had completed the curriculum responded to the survey. They exhibited a better understanding of opioids (P < 0.001) and held a more negative attitude toward opioid use (P = 0.011) compared with 105 students who did not take the course. Additionally, out of 240 respondents, 177 (73.8%) acknowledged the ongoing opioid crisis in the United States, while only 70 (29.2%) disagreed with the notion of an ongoing opioid crisis in Taiwan. Furthermore, 90% of all students expressed agreement with the need for further education on chronic pain management after graduation.

Conclusion

Among senior medical students in Taiwan, those who completed an elective pain medicine curriculum demonstrated enhanced knowledge of opioids, a more cautious attitude toward opioid use, and a willingness to receive further education on chronic pain management. Over 70% of students remained uncertain or incorrectly believed that there was an opioid crisis in Taiwan.

Introduction

The opioid crisis and the revised definition of pain in 2020

In the National Health Interview Survey in the United States, more than one in five adults reported experiencing chronic pain [1]. This increased the focus on pain as the fifth vital sign since 1996 and led to a surge in the overprescription of opioids for both inpatients and outpatients, consequently elevating the risks of opioid addiction and misuse [2]. Over the past two decades, the opioid epidemic, marked by considerable overdose deaths from illicit opioids, has emerged as a global public health issue. In particular, drug overdose deaths, primarily driven by illicit synthetic fentanyl and, to a lesser extent, prescription opioids, have been extensively documented in the USA and Canada [3], leading to what is now known as the ‘opioid crisis’ in 2016 [4]. Additionally, significant increases in opioid prescriptions, particularly for oxycodone, have been reported in Europe [5, 6]. The International Association for the Study of Pain revised the definition of pain in 2020 as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [7] for the first time since 1979. This revision was aimed at better conveying the nuanced and complex nature of pain. In response to the challenges posed by the opioid crisis and the evolving understanding of pain, the following measures have been emphasized: safe opioid prescription, perioperative multimodal analgesia, and multidisciplinary chronic pain management. These principles are not only integrated into resident training and clinical practice for physicians but are also included in the upstream pain medicine education for medical students [2].

International pain medicine education in medical schools

Chronic pain management was historically overlooked in medical education, representing a significant omission [8]. Prior to 2010, only 80% of U.S. medical schools mandated one or more pain-related sessions, with a mean of approximately 11 h dedicated to pain content [9]. A review of the literature revealed that international pain medicine education in medical schools was often integrated into anesthesia or pharmacology courses. Moreover, student competency in pain medicine education was typically assessed using written examinations rather than clinical competency assessments [10,11,12]. Additionally, the training provided to medical students, residents, and fellows in the management of chronic pain tended to focus predominantly on opioids, with comparatively less attention to nonopioid medications and nonpharmacological approaches [2]. Therefore, substance use disorder was added to four domains of pain curricula in most U.S. medical schools in 2017 [13], namely the nature of pain, pain assessment and measurement, pain management, and the context of pain and substance use disorder. This was done to enhance medical graduates’ understanding of these topics and to minimize potential inappropriate prescription of opioids.

Pain medicine curriculum in Taiwanese medical schools

In Taiwan, pain medicine education in medical schools is primarily distributed across the curricula of anesthesia, oncology, rehabilitation, and other related fields. To the best of our knowledge, the first elective pain medicine curriculum was established by the Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei, Taiwan, in 1995. This curriculum remains the sole program of its kind in Taiwan’s medical schools to date. The latest 18-h curriculum, designed for senior medical students, offers a comprehensive overview of the multidisciplinary specialties involved in both acute and chronic pain management (Appendix).

The goals of this study

In this study, we assessed the opioid knowledge, attitudes toward opioid therapy for chronic pain, and perceptions regarding opioid crisis of medical students who have either completed or not completed this pain medicine curriculum in Taiwan.

Methods

Participants

This questionnaire survey study was approved by Tri-Service General Hospital Institutional Review Board (TSGHIRB-A202105015), and the requirement for written informed consent was waived. In this study, third- and fourth-grade medical students who were enrolled in the elective 18-h pain medicine curriculum (as detailed in the appendix) were included and surveyed in March 2022 and May 2023. Additionally, a comparison survey was conducted involving senior students who had not undergone the pain medicine curriculum.

Study instrument

The questionnaire used in this study was adapted from the Taiwan Physician’s Prescribing Opioid Survey conducted in traditional Chinese [14], and it was also based on other similar surveys [15, 16]. The questionnaire was designed to evaluate various aspects including the characteristics of students, their knowledge of opioid pharmacology, their attitudes toward the use of long-term opioid medications for chronic pain [15, 17], and their perceptions of the opioid crisis in both the United States and Taiwan.

Data analysis

All statistical analyses were performed using SPSS version 22 (IBM, Armonk, NY, USA). Demographic data are presented as numbers (%) or means (standard deviations). The total number of correct responses in the assessment of opioid knowledge is presented as mean ± SD and was analyzed using either Student’s t test or the Mann–Whitney U test. The categorical responses to statements about opioid knowledge and attitudes were “strongly agree,” “agree,” “uncertain,” “disagree,” or “strongly disagree.” Categorical variables were estimated using the chi-square test or Fisher’s exact test. In all cases, a P value of < 0.05 was considered statistically significant.

Results

Among the 153 students who had received the elective pain medicine curriculum, 135 (88.2%) completed the questionnaires, compared to another 105 students who did not take the course (Table 1). A higher percentage of students who received the course reported being familiar with Taiwan’s narcotic regulations (48.9% vs. 16.2%, P < 0.001) and had ever learned pain assessment scales (76.3% vs. 45.6%, P < 0.001).

Table 1 Demographic data

Table 2 presents the rates of correct responses related to opioid knowledge. Students who received the curriculum provided more correct responses than those who did not take the course (62.1% ± 19.9% vs. 48.1% ± 20.8%, P < 0.001) (Fig. 1). Moreover, a higher number of students who completed the curriculum correctly responded to the statement, “One-quarter of patients on long-term opioids may experience addiction or struggle with it.” (80.0% vs. 46.7%, P < 0.001).

Table 2 Knowledge of prescribing long-term opioids for patients with chronic noncancer pain

Fig. 1

Senior medical students who had completed the pain curriculum exhibited a better understanding of opioids and held a more negative attitude toward chronic opioid use compared with those who did not take the course

As presented in Table 3, the overall attitudes toward opioid use for chronic pain management were more negative among students who received the curriculum (65.7 ± 25.1% vs. 57.0 ± 27.1%, P = 0.011), including agreement with the statement, “Requiring additional opioid analgesics is indicative of a patient becoming addicted,” (81.5% vs. 68.6%, P = 0.020). Up to 84.6% and 54.6% of all students expressed agreement with the statements, “Opioids can have many side effects” and “Relieving the side effects of opioids is not easy,” respectively, with no between-group differences.

Table 3 Attitudes regarding long-term use of opioids

Table 4 indicates that 73.8% of 240 respondents were aware of the ongoing opioid crisis in the United States, whereas only 29.2% of all students disagreed with a current opioid crisis in Taiwan. Low percentages of all students perceived adequate education related to chronic pain pathophysiology (40.4%) and opioid use (45.4%) in this medical school. Most students were in agreement with the need for increasing education on chronic pain management in the medical school (87.4% vs. 63.8%, P < 0.001) and after graduation (91.9% vs. 87.6%, P = 0.278).

Table 4 Perceptions of the opioid crisis and chronic pain education

Discussion

Major findings

This comparison questionnaire survey demonstrated that senior medical students who received the unique 18-h pain medicine curriculum, the only one of its kind in Taiwan’s medical schools, exhibited enhanced awareness of the ongoing opioid crisis in the United States. However, over 70% of students were either uncertain about or incorrectly believed that an opioid crisis existed in Taiwan. Furthermore, students who completed this curriculum demonstrated greater familiarity with Taiwan’s narcotic regulations, possessed a higher level of knowledge of opioids, and held a more negative attitude toward opioid use. Moreover, the majority of students agreed with receiving more education on chronic pain management in the medical school and after graduation.

Pain medicine curriculum in the current medical school

In 2018, the International Association for the Study of Pain recognized a Global Year for Excellence in Pain Education. This initiative encompassed four domains: public and government education, patient education, professional education, and pain education research [18]. Moreover, a review of the international pain education literature spanning 25 years revealed that prelicensure students in health professions often have inadequate knowledge, skills, attitudes, or beliefs about pain, as well as a well-documented gap between knowledge and practice competencies in pain [11]. Similar to the curricula in international medical schools [11], pain medicine education in Taiwan is largely integrated into anesthesia, rehabilitation, or pharmacology courses. In the present study, we revealed that the only elective pain medicine curriculum was offered at the National Defense Medical Center, Taipei, Taiwan since 1995. This curriculum, spanning 18 h (as detailed in the appendix), encompasses 10 specialties: pain, anesthesia, neurology, neurosurgery, psychiatry, rehabilitation, general surgery, radiology, oncology, and gynecology. It was designed to align with the four domains of pain curricula in most U.S. medical schools in 2017: the nature of pain, pain assessment and measurement, pain management, and the context of pain and substance use disorder [13]. The 3rd- or 4th-year students who undertook this curriculum had more correct responses to statements about opioid knowledge and exhibited a more cautious attitude toward opioid use and side effects compared with those who did not take the course. For example, a meta-analysis conducted in 2010 indicated that signs of opioid addiction or abuse were reported in only 0.27% of participants who received at least 6 months of opioid treatment [19]. By contrast, the 2016 CDC guideline suggested that up to one-quarter of patients on long-term opioids may experience addiction or struggle with it [20]. Consequently, students who completed the latest curriculum in the current study responded correctly to this statement (80.0% vs. 46.7%, P < 0.001). The primary goal of this course was to provide students with the most up-to-date evidence, enabling them to interpret study outcomes and relate them with real-world data. It also considers sociocultural differences to equip medical students in Taiwan with a thorough understanding of pain management and opioid use.

Drug overdose deaths involving illicit and prescription opioids in the United States

In the ongoing overdose epidemic, drug overdose deaths in the United States have increasingly involved illicitly manufactured fentanyl, methamphetamine, and cocaine [21]. In contrast, overdose deaths involving prescription opioids have gradually decreased, from 17,029 (24.2%) of 70,237 deaths in 2017 to 14,716 (13.6%) of 107,941 deaths in 2022 [22]. A pivotal moment in this crisis occurred with the introduction of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain [20] and the subsequent declaration of a national public health emergency in 2017. These events prompted significant preventive measures, including heightened physician awareness, new regulatory policies, and shifts in public perception regarding pain management. However, a confluence of factors—including forced tapering or stoppage of opioid prescriptions to medically needed patients, the COVID-19 pandemic, reduced access to interventional techniques, and the increased availability of illicit synthetic opioids—has led patients to seek remedies on their own [3]. In response to these challenges, the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain was introduced to address the misinterpretation and misapplication of the previous guideline. This updated guideline offers 12 evidence-based practice recommendations designed to assist health-care professionals in making informed decisions regarding the initiation, dosage selection, treatment duration, and risk assessment when curbing long-term opioid prescriptions for pain [23].

Current narcotic regulations for chronic noncancer pain in Taiwan

In response to the opioid crisis in North America, the Taiwan Food and Drug Administration reduced the recommended maximum daily morphine milligram equivalent from 200 to 100 in the narcotic regulation Physician Guidelines on Clinical Use of Narcotics in Chronic Noncancer Pain, which was amended in January 2022 [24]. Each patient with chronic noncancer pain could obtain long-term opioid prescriptions from only one physician at a medical center or regional hospital with a Narcotics Management Committee [24], but not from physicians at local clinics [25]. This stringent narcotic regulation serves to prevent aggressive marketing by pharmaceutical companies and the establishment of ‘pill mills’ in Taiwan [16], which is different from the more common practice of opioid prescription by family medicine specialists in the United States [26]. Moreover, psychiatric evaluations, opioid therapy, and monitoring of aberrant behaviors suggestive of opioid misuse are subject to regular audits by the hospital’s Narcotics Management Committee. Any deviations may lead to the discontinuation of opioid treatment and the submission of the case to the Taiwan Food and Drug Administration. According to the official patient lists, only 114 and 328 registered patients with chronic noncancer pain received chronic opioid therapy in 2001 and 2010, respectively [27, 28], from a total of 67 treating physicians in 2010 in Taiwan [16]. Therefore, the prescription of long-term opioids for managing chronic pain and the subsequent development of an opioid crisis are extremely rare in Taiwan [29], but they are widespread in the United States. In the current study, most medical students were aware of the ongoing opioid crisis in the United States (73.8%), but only 29.2% of all students accurately recognized that an opioid crisis is not an emerging concern in Taiwan. This finding indicates the need for future pain medicine education in Taiwan to be tailored and adjusted on the basis of local evidence, in alignment with the U.S. CDC practice guideline.

Limitations

Three limitations of this study should be addressed. First, the cross-sectional design of the survey may have introduced bias in responses, as it primarily captured the perspectives of participants with a high level of interest and willingness to participate. In this study, we mainly obtained responses from students who had chosen the elective curriculum, potentially skewing the results. A pre- and post-course comparison may provide insights into the actual effectiveness of this curriculum. Second, in Taiwan, most medical students transition directly from high school, and 3rd- and 4th-year students do not begin clerkships until their 5th year. In the current study, students who completed the curriculum demonstrated a better understanding of opioids but exhibited more cautious attitudes toward opioid use compared to those who did not take the course. This curriculum emphasizes multidisciplinary chronic pain management, incorporating the context of the current opioid crisis with significant overdose deaths and the U.S. CDC guidelines for physician awareness and practice. The survey on attitudes and practices among these medical students may primarily reflect their perceptions of knowledge and theoretical concepts rather than practical experiences with opioid use for medically indicated patients with chronic pain. Third, although this questionnaire survey assessed the differences in the characteristics, opioid knowledge, and attitudes of third- and fourth-year medical students without clinical experience, it did not evaluate their clinical competencies. A gap between knowledge and clinical application of that knowledge often exists in in clinical practice during the prelicensure and postgraduate training. To address this gap, innovative e-learning pain education resources could be considered for medical school students [30]. For future studies, the evaluation of educational outcomes should focus on postgraduate practice behaviors and patient outcomes.

Conclusions

This study provided insights into the educational outcomes of the sole pain medicine curriculum offered in Taiwan’s medical schools. Senior medical students who completed the 18-h multidisciplinary curriculum possessed enhanced knowledge of opioids and held a more cautious attitude toward chronic opioid use. However, over 70% of students remained uncertain or held the incorrect belief that an opioid crisis exists in Taiwan, which necessitates more comprehensive pain education that considers both the U.S. CDC guideline and local evidence. This education should be integrated into medical schools and continued after graduation to ensure that health-care professionals are well prepared to address the complexities of pain management and opioid use.

Appendix

The 18-hour elective pain medicine curriculum with 10 specialties

No.	Title	Lecturer specialty
1	Introduction & Pain Mechanism	Pain
2	Postoperative Pain	Anesthesia
3	Pain Management in Pediatric Patient	Anesthesia
4	Pain Assessment	Pain
5	Autonomic Nervous System and Pain	Pain
6	Abdominal Visceral Pain	General Surgery
7	Ultrasound & Musculoskeletal Pain Block	Radiology
8	Cancer Pain	Oncology
9	Pelvic Pain Management	Gynecology
10	Low Back Pain with Spinal Neuromodulation	Neurosurgery
11	Central Pain	Neurology
12	Neuropathic Pain	Pain
13	Psychological & Psychiatric Approach to Pain Diagnosis & Treatment	Psychiatry
14	Rehabilitation & Pain	Rehabilitation
15	Pharmacology of Pain	Pain
16	Ultrasound Guidance for Spine Injection	Pain
17	Chronic Pain with Supraspinal Modulation	Psychiatry
18	Surgical Approaches to Pain Management	Neurosurgery