Harm reduction in undergraduate and graduate medical education: a systematic scoping review

Abstract

Background: Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration.

Methods: PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation.

Results: Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles.

Conclusions: Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

Keywords: Graduate medical education; Harm reduction; Opioid use disorder; Substance use; Undergraduate medical education.

Fig. 1

PRISMA flow diagram of the literature search, screening, and selection process conducted in November 2021

Fig. 2

The Harm Reduction Educational Spectrum (HRES) Framework. (The HRES Framework developed by the authors describes how the discrete content topics found during a scoping review of 19 distinct harm reduction curricula taught in undergraduate and graduate medical education programs in the United States + Canada build upon one another and ultimately require an understanding of Harm Reduction Principles for full progression. Completed in Nov 2021.)

Fig. 3

Results of educational content analysis and application of Harm Reduction Education Spectrum (HRES) framework. (The discrete content topics included in the educational content of 19 distinct harm reduction curricula and how many times each of those topics arose across programs are presented un-bolded. These topics have been organized into the HRES framework which was developed by the authors with the themes identified during analysis to summarize the topics found during the scoping review. Content topics that were not explicitly reported by any programs but are additional topics that our authors believe should be included in a robust harm reduction education are presented in bold.)