Filling the substance use treatment gap requires better education and research training

While education is unlikely the ultimate filling for the substance use treatment gap, it is one that can be hardly overlooked and underestimated.

Many medical programs likely do little in the way of introducing students to the scientific evidence underlying addictions treatment, and emerging physicians have difficulty implementing best evidence.

This is a serious concern in light of the urgent need for improved addictions care, and highlights even further the necessity of expanding interdisciplinary education in evidence-based addictions treatment.

How was the study done

In the last half decade, there has been an explosion of new evidence for the treatment of substance use disorders (SUDs), including the emergence of new opioid agonists, pharmaceuticals for the treatment of alcohol use disorder, a continuum of available treatment services.1,2 Overall, addiction is increasingly being recognized as a medically-relevant field, and its biological basis has been further illuminated.1 At the same time, there remain areas in evidence for SUD treatment, aptly referred to by O’Connor et al. as “The addiction treatment gap”.3 Nevertheless, only one in ten individuals with SUD enrol in treatment in the United States.1 Furthermore, differences in the efficacy of long and brief interventions are still quite unclear,4 and the effectiveness of some therapies, such as those for stimulant use disorder, remains largely unexplored.

However, the limitations of addiction medicine arguably go beyond simply missing evidence. Evidence-based treatments which do exist have a marked lack of implementation in practice, as documented by less than half of Americans with opioid use disorder received medication-assisted treatment in 2013.5 Brief interventions with minimal evidence or physician involvement continue to dominate the integration of SUD treatment into North American primary care settings,6 and specialized training is often not provided to the healthcare providers who see patients with SUDs the most, such as emergency physicians or family physicians.7 8 Thus, despite a cultural shift towards greater integration of addictions care into general medical settings, gaps in physician knowledge remain large, both due to a dearth of high quality evidence and minimal knowledge of emerging research.

Part of the solution to these issues has been the expansion of addiction medicine training programs, wherein physicians specialize in this discipline through participation in a structured, accredited fellowship. Many of these fellowships also provide the opportunity to learn about research, including training in evaluating scientific articles, presenting at conferences, and conducting independent studies.

To evaluate the state of medical training in addictions throughout early medical education (i.e., medical school and residency), as well as the current implementation of best practices in treatment settings, we interviewed 45 early-career physicians, social workers, nurses, and 17 medical students participating in training in addiction medicine, between April 2015 – June 2017. These interviews were part of a larger, novel evaluation of addiction medicine research training (NEAR) study, and examined participants’ experiences of working in addiction medicine as well as their feelings on the quality of addictions education in medical curricula. Ethics approval was obtained by the Research Ethics Board at Providence Healthcare Research Institute, University of British Columbia.

All interviews were conducted by a trained interviewer or study authors (JK, LG) and transcribed by a trained staff member. All interviews were then analyzed for common themes by the lead author, first through open coding, and then a second time through axial coding.10,11 Data were analyzed inductively for concepts and patterns in medical students’ experiences using qualitative data analysis software, NVivo 11.4.3.

Results: Filling the substance use treatment gap

Limitations of early medical education. Overall, our analyses suggested six broad areas of improvement for early medical training in addiction medicine: (1) Time devotion, (2) A need for more structured addictions training, (3) Insufficient hands-on clinical training and skill development, (4) Lack of patient-centeredness and empathy in the training environment, (5) Insufficient implementation of evidence-based medicine, and (6) Prevailing stigmas toward addiction medicine.

Fellows overwhelmingly reported that the medical school and residency has insufficiently trained them in addiction medicine.

Interviews illuminated two areas in particular that fellows believed warranted greater attention in medical curricula: the underlying causes of SUDs, and the scientific evidence underlying SUD treatment.

In addition to describing the shortcomings of earlier medical education, fellows highlighted the difficulty of staying informed about new treatments in addiction medicine, and the challenges physicians face when trying to implement new evidence.

Discussion and conclusion

Together, these findings have a number of important implications for future changes to medical curricula. First, our interviews suggest that many medical training programs lack adequate education in addictions treatment. Most every fellow we interviewed highlighted large gaps in the education they received in addictions throughout both medical school and residency – some reporting the absence of even the most basic training. Second, many fellows reported receiving minimal training in the evaluation of novel research in addictions, and in the incorporation of this research into practice. This was compounded by reports that fellows wished to have improved research skills following residency, however, since this was a study of physicians actively seeking out research experience, the generalizability of this implication is questionable.

Nevertheless, fellows overwhelmingly reported feeling inadequately prepared to keep up-to-date on novel evidence following medical school and residency, suggesting that many medical programs do little in the way of providing students with these skills. Finally, many of the physicians who practice evidence-based addictions medicine reported facing opposition from other health providers, suggesting that best evidence continues to face significant stigma in practice.

In a field so rapidly evolving and still limited in implementation, it is critical that medical curricula educate future healthcare providers in evidence-based addiction medicine. However, education in this context cannot be limited to current treatment options – it must emphasize the importance of staying on top of new evidence, and working together to implement that evidence in treatment settings. Only then can we perhaps start to really narrow the addiction treatment gap.

Cited study: Klimas, J., Gorfinkel, L. R., Hamilton, M. A., Lail, M., Krupchanka, D., Cullen, W., Wood, E., & Fairbairn, N. (2022). Early Career Training in Addiction Medicine: A Qualitative Study with Health Professions Trainees Following a Specialized Training Program in a Canadian Setting. Substance Use and Misuse, 1-8. https://doi.org/10.1080/10826084.2022.2137815 

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References

 

  1. Day E. Facing addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health U.S. Department of Health and Human Services, Office of the Surgeon General. Washington, DC, USA: U.S. Department of Health and Human Services, 2016 382 pp. Online (grey literature): https://addiction.surgeongeneral.gov/. Drug Alcohol Rev. 2018;37(2):283-284.

  2. Bisaga A, Mannelli P, Sullivan MA, et al. Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies. Am J Addict. 2018;27(3):177-187.

  3. O’Connor PG, Sokol RJ, D’Onofrio G. Addiction medicine: the birth of a new discipline. JAMA Intern Med. 2014;174(11):1717-1718.

  4. Kaner EF, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2:CD004148.

  5. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies–tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063-2066.

  6. Knudsen HK, Abraham AJ, Roman PM. Adoption and implementation of medications in addiction treatment programs. J Addict Med. 2011;5(1):21-27.

  7. US Burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA : the journal of the American Medical Association. 2013;310(6):591-608.

  8. O’Toole TP, Pollini RA, Ford DE, Bigelow G. The health encounter as a treatable moment for homeless substance-using adults: The role of homelessness, health seeking behavior, readiness for behavior change and motivation for treatment. Addictive Behaviors. 2008;33(9):1239-1243.

  9. Klimas J, McNeil R, Ahamad K, et al. Two birds with one stone: experiences of combining clinical and research training in addiction medicine. BMC Med Educ. 2017;17(1):22.

  10. Strauss AL, Corbin JM. Basics of qualitative research : grounded theory procedures and techniques. Newbury Park, Calif.: Sage Publications; 1990.

  11. Braun V, and Victoria Clarke. Using thematic analysis in psychology. Qualitative research in psychology 2006;3(2):77-101.

 

Note. The first draft of this summary was written in April 2018 by Lauren Gorfinkel MPH, MD (Candidate)