An Artistic Active-Learning Approach to Teaching a Substance Use Disorder Elective Course

INTRODUCTION

Substance use disorder (SUD) and substance misuse are the source of a public health crisis in the United States.¹ Opioid use disorder (OUD), a chronic illness manifested through the use of illicit opioids and misuse of prescription pain medications, fuels this nationwide epidemic. Opioid use disorder currently afflicts an estimated two million Americans, resulting in over 46,802 deaths from drug overdose in 2018.² The healthcare costs of illicit drug use and prescription opioid misuse approach $37 billion annually.³ The opioid epidemic has revealed numerous missed opportunities where pharmacists’ clinical skills could have been used to screen and assess patient disease risk, manage pain medications, make clinical interventions, coordinate care, promote harm reduction strategies, and provide rescue naloxone.^4-8 As frontline community healthcare providers equipped with extensive drug knowledge, pharmacists are uniquely positioned to access, treat, and educate underserved rural and urban populations who are at increased risk for poor health outcomes and medication misuse.^5,6

The education of future pharmacists in SUD is critical to prepare them to work with SUD patients. A 2015 survey on SUD content in US pharmacy programs revealed that most responding programs provided two hours of SUD in therapeutics, but fell short of the suggested content and hourly curricular recommendations from the American Association of Colleges of Pharmacy (AACP)’s Special Committee on SUD and Pharmacy Education.⁹ Additionally, programs should meet the 2018 pharmacy core competencies for SUD education set forth by the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA).⁸ An SUD elective with an interactive-learning approach is one method of offering SUD content using a variety of teaching approaches as recommended by AACP and which also meets AMERSA’s core competencies.

We describe a novel, creative format for an SUD elective course for Doctor of Pharmacy (PharmD) students that featured activities and assignments that combined SUD content with visual, linguistic, and performing arts forms. Artistic methods including acting, screenwriting, choreography, dancing, painting, drawing, movie reviews, book reports, journal reflections, create-your-own-adventure storytelling, speech writing, examination writing, policy writing, and creative thinking in an “escape room” gaming environment were used to engage students with SUD content. Although the dance activity for this course was reported in a paper published in 2017, the entire course has not been previously described in the literature. A literature search revealed descriptions of individual activities used in pharmacy courses that included either dance, movie reviews, book reports, or film-making, as well as one course that used an escape room format, but we did not identify an elective pharmacy course that encompassed all of these.^10-14 This elective course was intended to assist students in achieving AACP’s core entrustable professional activity (EPA) domains, including patient care provider (ie, information collection and analysis, care plan creation and implementation, patient education), interprofessional team member (ie, understanding of team member roles), population health promotor (ie, screening and patient assessment, appropriate medication use), and information master (ie, education of patients and colleagues).¹⁵ The course was also intended to bolster student attainment of several elements of the Accreditation Council for Pharmacy Education (ACPE) Standards 2016.¹⁶

METHODS

Beginning in 2013, a two-credit hour elective course on SUD and misused substances was developed for third professional year (P3) pharmacy students enrolled in the PharmD curriculum at the University of South Florida (USF) College of Pharmacy. Having P3 standing was a prerequisite for the course, which included two hours of pharmacotherapeutics on SUD. The format for weekly class sessions was one hour of lecture on a drug topic delivered by the course coordinator, followed by either a one-hour artistic, collaborative, active-learning activity or a one-hour lecture by a guest speaker, after which students would compose a reflection. Course activities were designed and speakers selected with the goal of engaging students’ attention each week by having them participate in a different method of artistic expression or listen to and speak with a field expert. For the following three class sessions, the entire two hours was devoted to a single activity involving the entire class: the in-class 12-step program meeting, the in-class Mechanism of Action Rave Dance, and the final project presentations. For the following four class sessions, the entire two hours was devoted to one or more guest speakers, including a patient in recovery, law enforcement officer, psychiatric clinical pharmacist, Florida Professionals Resource Network (PRN) medical director, a drug court expert, etc.

Guest speakers were recruited from the community through professional connections. Guests chose the format of their hour-long discussion. Most speakers (about 75%) used a PowerPoint presentation and engaged in interactive discussion with students, while the remainder (about 25%) spoke without visual aids. No pre- or post-lecture assessments were administered, but students completed a reflection paper that had to include some of the factual information given as well as their personal opinion about the speaker’s presentation and the topic.

Hour-long traditional lectures on major drug topics were created and presented by the instructor. Students’ knowledge of drug lecture material was assessed through two Quiz Myself assignments (Table 1).

There were seven in-class activities. Students wrote a paper analyzing marijuana legalization for medical and recreational use and wrote reflections on guest speaker talks. The details of each activity, the paper, and guest speaker reflections are described in Table 1. The escape room activity was evaluated in 2016. Thirty-five students were given a 22-question pre-lecture, pre-activity, and post-activity test to evaluate their learning during the activity versus their learning after lecture.

For the required final project, students were given three options: creating original artwork, composing a create-your-own-adventure story, and writing a book report. The option of writing a movie review was added in 2018. If students selected the same movie or book, they gave a group presentation with an overview of the plot and then each student provided individual commentary. The audience (student peers) was encouraged but not required to ask questions because of time constraints. This study was deemed exempt by the USF Institutional Review Board (IRB).

RESULTS

The elective was offered from 2013 through 2019. Initial student enrollment in the class was 22. This grew steadily to 45 students in 2019.

Student perceptions of the course were assessed by the instructor based on student comments on standard university-developed course evaluations and on requested student feedback on the escape room and dance activities. On the standard course evaluations, 122 out of 173 students submitted written comments from 2013 to 2019. Completion of evaluations is mandatory, but comments are not required. Under the question, “Please comment on at least two aspects of the course that you enjoyed and helped you learn,” the most common responses included the interactive activities (76 comments) and the guest speakers (52). Some students stated they loved everything about the class (63), the course was enjoyable and educational (42), they loved the creativity (16), it was a great environment to learn in (8), they looked forward coming to class every week (7), they liked the written assignments (7), and the course reduced semester stress (6). Feedback from the dance rave and escape room activities was similar, with students expressing appreciation for the course having collaborative activities and using creative learning methods. Students did not formally evaluate speakers, although the patient in recovery and the law enforcement officers received consistent praise in student reflections and course evaluations across all years.

Learning was evaluated based on student performance on assignments and activities as assessed by the course coordinator using analytic rubrics. The overall class average was an “A.” The escape room evaluation showed improvement when average pre-lecture (56.7%), post-lecture (85.3%), and post-activity test scores (94.9%) were compared. With the exception of the dance activity, we did not attempt to assess the individual impact of the other course activities; therefore, pre- and post-intervention tests were not conducted specifically on those activities.

DISCUSSION

The design of this SUD elective course, which includes a variety of activities and has an artistic, creative emphasis, continues to be a popular choice for students. The majority (70%) of students who completed the elective course submitted comments and all of the comments were enthusiastic about the course format and delivery. Course enrollment increased and even reached maximum capacity in most years.

Abraham Flexner revolutionized medical education with his 1910 report that emphasized the importance of active learning to promote critical thinking and lifelong learning in students.¹³ Flexner believed “description is no substitute for tactile and visual experience.” The design of this elective course, with its focus on artistic, interactive, expressive, practical activities reinforces Flexner’s vision for education where “[t]he student no longer merely watches, listens, memorizes; he does.”¹³ In their analysis of Flexner’s report on the context of pharmacy education, Crass and Romanelli suggested pharmacy educators “look to other areas of education, namely primary and secondary education, for insights on engaging students in active learning.”¹³ This elective course encompassed primary and secondary education activities, including artwork, physical activity (acting and dancing), creative writing, and writing book reports. The cultural aspects of illicit substance use make the topic of SUD suitable for creative, relatable projects.

This course provides interprofessional interactions with interdisciplinary experts involved in different areas of SUD treatment and the legal aspects of the disease, thus meeting ACPE Standard 11.2 for interprofessional team education and practice. The course curriculum also covers the 10 educational goals and four major content areas recommended by the AACP Special Committee, ie, psychosocial aspects of alcohol and other drug use; pharmacology and toxicology of illicit/misused substances; identification, intervention, and treatment of people with addictive diseases; and legal/ethical issues.^1,16 Students enjoyed hearing guest speakers’ life experiences and learning their practical expertise. Several speakers described the importance of the role of pharmacists in treatment (ie, the patient in recovery, police officers, emergency room physician, clinical pharmacists, community pharmacist, PRN representative, Drug Enforcement Agency Special Agent, etc) which gave the students a holistic, multifaceted perspective on their role and potential interactions within and outside of the profession involving SUD and substance misuse.

Challenges in course implementation included course coordinator time investment to create the games and use of personal funds to enhance the course. Escape room construction cost $500 initially and approximately $250 thereafter. Another challenge is obtaining guest speakers and coordinating their schedules, availability, and handling cancellations. Instructors would also need to follow and become knowledgeable about pop culture and other references familiar to students in order to incorporate those aspects into the class to further engage and connect with students. Additionally, a future study on this course should include further assessment of student knowledge pre- and post-course to determine the exact degree of student learning.

A limitation of the study is that the feedback provided on this elective course represented the perspectives of only those students who were enrolled in the course rather than all students in the PharmD program. Students who chose to enroll in this elective course likely had artistic inclinations and preferred participating in a variety of activities and engaging with a variety of content, and this could have been partially responsible for their positive feedback about the course. Students who did not prefer an artistic approach to learning SUD would likely have enrolled in a different elective course.

CONCLUSION

Students enrolled in an SUD elective designed to engage students in activities using a variety of art forms to teach them about SUD enjoyed the interactive format of the class and had the perception of simultaneously learning and having fun. Pharmacy instructors are encouraged to incorporate memorable creative projects and activities into courses to enhance student learning and increase students’ motivation to engage with the material, their classmates, and other professionals.