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When a San Diego mother asked her family doctor for help with the anxiety she’d been experiencing over her teenage son’s struggles with drugs, she received some unsolicited advice.
“He told me to urine test my son and if he came up positive, to throw him out of the house,” she said. “There was no talk of treatment for him. No compassion.”
Fortunately, the mother had already arranged behavioral therapy and psychiatric care for her teen that was helping him deal with his substance use and the issues behind it, “but it made me wonder what kind of damage my doctor was doing to other people who came to him with addiction problems.”
Sadly, her experience is far from unique. Aside from those who specialize in addiction medicine or addiction psychiatry, doctors are required to undergo little to no training in addiction medicine, meaning those on the front lines of patient care are often poorly poised to recognize, prevent or treat substance abuse problems or connect patients with specialty treatment.
In a 2012 study that looked at the gap between the science and the practice of addiction medicine, the National Center on Addiction and Substance Abuse (the Center) analyzed the board certification exam requirements of several key medical specialties and found that addiction was hardly mentioned. Exam requirements for family medicine, for example, touch on addictive substances only as a possible subtopic in an optional sports medicine subspecialty.
Unfamiliarity Breeds Contempt
That lack of knowledge can lead to a fundamental misunderstanding of the nature of addiction, which a growing body of research now makes clear is a complex disease that can change brain structure and damage a person’s ability to make good decisions and control impulses. While a cure remains elusive, addiction can be managed and recovery achieved.
If a doctor is unfamiliar with the mechanisms of addiction, he or she is more likely to blame substance users for their situation and view them as weak, manipulative, indulgent or unmotivated rather than ill. That mindset, which patients often pick up on and which can push them deeper into shame and denial, contributes to suboptimal care and poor outcomes.
Megan O’Grady, PhD, research scientist and associate director of health services research for the Center, confirmed the damage that can be done. “Research shows that poor training in the care of patients with addiction relates to low confidence among physicians in their ability or competence to treat such patients, negative attitudes toward patients with addiction, pessimism about the effectiveness of treatment, and low rates of implementation of evidence-based practices related to screening, brief interventions and treatment.”
In addition, because addiction care only recently became a required part of most health insurance policies — thanks to the combined effect of the Affordable Care Act and parity laws — and because it has traditionally been treated outside of mainstream medicine, many doctors still hold on to the misconception that addiction treatment shouldn’t be part of routine care.
That stance is made even more troubling by the fact that close to half the people who responded to a national survey said that if someone close to them needed help with a substance use problem, they’d turn first to a health care professional. For well over a quarter of the respondents, that professional would be their primary care physician.
An Addiction Epidemic
Ignorance about the realities of addiction not only means missing opportunities to solve problems, it can create them.
We now know, for example, that one of the key drivers of the nation’s current opioid addiction epidemic, was the pharmaceutical industry’s aggressive (and sometimes fraudulent) marketing of prescription painkillers that began in the 1990s to doctors whose lack of addiction training left them vulnerable to sales pitches.
The doctors, who were increasingly coming under pressure by a changing medical industry to limit time spent with patients, were happy to believe, as were their patients, that opioid painkillers represented a safe and easy treatment for pain. The result was massive overprescribing of what was discovered to be highly addictive and dangerous opioid drugs (we have 5% of the world’s population and use almost all of its painkiller supply) and an addiction epidemic that is now helping drive a turn to that other opioid — heroin.
Overdose deaths have now become the leading cause of accidental death in the U.S., meaning getting up to speed on preventing, recognizing and treating addiction is crucial at every level of medical care.
Getting Educated
There has already been some movement in that regard. A protocol called SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment, has been incorporated into primary care settings as a way to identify substance use problems in patients and get them care. But it hasn’t lived up to its promise. Two recent studies concluded that it didn’t decrease drug use or increase commitments to treatment, although some argue that the lack of positive data points more to the difficulty in measuring such success than it does in any shortcomings in the program.
But clearly, much more is needed, and the nation is starting to respond.
The Centers for Disease Control and Prevention, for example, recently released guidelines for physicians which spell out a much more conservative approach to prescribing opioids, and a U.S. Food and Drug Administration advisory panel in May voted that opioid training should be mandatory for physicians.
The White House has also thrown its weight behind the effort to educate physicians, particularly as it relates to the ongoing opioid use epidemic. A total of $1.1 billion has been earmarked to improve opioid addiction treatment, including doubling the number of doctors trained to prescribe buprenorphine, a drug that has shown to be effective in helping people reduce or quit opioid use.
In conjunction with the White House initiative, more than 60 medical schools announced that, beginning in the fall 2016 school year, they would require their students to undergo prescriber education.
In its 2012 study on addiction medicine, the National Center on Addiction and Substance Abuse pulled together a long and comprehensive list of recommendations for improving addiction care within the medical system. Among them were ensuring that core clinical competencies — things such as learning how addictions develop, about the co-occurring conditions that often go along with them, and how drug and alcohol problems can be recognized, prevented, treated and managed — become required components of all medical school training, licensing exams and certification programs, and that physicians be incentivized to incorporate screening and treatment into their practices.
Implementing such recommendations, Dr. O’Grady said, “will go a long way toward closing the gap between physicians’ perceptions about addiction and the evidence regarding its causes and consequences, and will help to improve physicians’ attitudes regarding their ability and duty to help patients with substance use problems.”
Finding Addiction Help
Although research shows that general physicians often hold substance users in low regard and view them with fear, distrust and anger, the good news in the same study is that learning about how addiction works, coming to realize treatment can be effective, and spending time around those with substance use disorders boosts levels of regard for those patients, and that improves care and results. Education, then, is both worth the effort and a must.
Until such education becomes standard practice, however, it’s wise not to assume your primary care doctor will have the knowledge, the experience or the willingness to help you or a loved one with a substance use issue if the need arrives.
It’s important to ask questions along these lines:
- Do you have any formal training in assessing people with drug and alcohol problems?
- Are you familiar with the referral and drug treatment process?
- Are you comfortable working with people with drug addictions or alcoholism?
If the answers are no, it’s time to seek out someone trained in addiction medicine who will be up to speed on the realities of the illness and on the latest advances in evidence-based treatment practices.
Addiction is a complex illness and one that takes hard work and persistence to overcome. Navigating the road to recovery becomes much easier with a guide who not only knows the way but is committed to taking the journey with you.
David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. As CMO of Elements Behavioral Health, he oversees a network of addiction treatment centers led by addiction psychiatrists and board certified addictionologists. These programs include Promises luxury rehab in California and COPAC addiction rehab in Mississippi.
