Off the record: addictions in medical schools
“If it’s not recorded, it didn’t happen.”
– An old saying
We wanted to find out how much teaching on addiction get on medical students. In 2011, our colleagues Sarah O’Brien and Professor Cullen searched PubMed (online database of medical papers) for published literature on training of undergraduate medical students in addiction
There is currently no documentation of drug addiction teaching sessions in Irish medical schools.
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| photocredit: mrmediatraining.com |
We looked at other medical databases and we also searched websites of all 6 medical schools in Ireland. We have searched the literature published after October 2009.
We found nothing in the medical databases. Schools’ homepages did not mention addiction either.
A telephone survey may provide a more accurate representation of how addiction medicine education is incorporated into the medical school curricula.
Substance use disorders are a worldwide problem, and have become a major health concern in Ireland particularly.
In their new position paper on addiction, the Irish Medical Organisation recognized the lacking education and called for “appropriate training of all physicians in treatment of addiction” (Irish Medical Organisation, 2015). Although the science behind addiction treatment has discovered new treatments for addiction, the medical doctors don’t know about them, mainly because they get no training on addiction. As a result, they feel unprepared to treat people with addiction who receive inadequate care.
To cite this article: Mitch Wilson, Walter Cullen, Christine Goodair & Jan Klimas (2016): Off the record: Substance-related disorders in the undergraduate medical curricula in Ireland. Journal of Substance Use, DOI: 10.3109/14659891.2015.1112853
What do persons on methadone in primary care think about alcohol screening?
Enhancing alcohol screening and brief intervention among people receiving opioid agonist treatment: Qualitative study in primary care
New Paper Out Now
Although very common, excessive drinking by people who also use other drugs is rarely studied by scientists. The purpose of this study was to find out patient’s and clinicians’ opinions about addressing this issue. All of them took part in a study called PINTA – Psychosocial interventions for problem alcohol use among problem drug users.
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| photocredit: emerald |
Doctors reported obstacles to addressing heavy drinking and overlooking and underestimating this problem in this population.
Patients revealed that their drinking was rarely spoken about and feared that their methadone would be withheld.
Read the full article in the latest issue of the Drugs and Alcohol Today: http://www.emeraldinsight.com/loi/dat
See also my previous posts about the PINTA study:
New paper out now: Psychosocial Interventions for Alcohol use among problem drug users
2014
Beg, steel or borrow: getting physicians to recruit patients in clinical trials
Addiction Medicine Education for Healthcare Improvement Initiatives: New Paper out Now
2013
Honor pot: testing doctors’ drug counselling skills in a new pilot study in Ireland
Fidelity questions
Why Empirically Supported Psychosocial Treatments Are Important for Drug Users? New research project
XXV Annual Meeting & Canadian Scientific Conference 2015 CSAM – SMCA (#WhatTheFentanyl #abhealth)
What is the future of addiction medicine? What is the future addiction specialist going to look like? Nobody knows what the future is going to look like, but the delegates of the 25th CSAM annual conference imagined answers to these questions in Banff, Alberta at the Banff Centre on Tunnel Mountain. As a first comer to the conference, I had a lot to learn and a lot to write down. Read more below.
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| photocredit: csam-smca.org |
Seven high-profile experts explored trends at home and abroad and the scientific topics impacting the future of addiction treatment delivery in their keynote plenaries.
1. Prescription Abuse (Dr. Roger Weiss)
Dr Weiss updated he delegates on the progress of the Prescription Opioid Addiction Treatment Study (POATS). The outcomes of the first phase of the trial were disastrously low, in contrast with the buprenorphine that was 7 times more effective after 4 weeks. Who did well? If you’d ever been in a treatment, or used not-as-prescribed prescription opioids, or the OxyContin was your most frequently used opioid – that was a bad sign. Older people did better. Interestingly, depression was also a good sign. What initiates the addiction is not necessarily what maintains the addiction.
2. Marihuana and Anxiety (Dr. Matthew Hill)
Dr Hill introduced the insights from the basic science field. Why people use cannabis? 84% say it helps them relax; to help reduce feelings of stress, tension and anxiety. The endocanabinoids tends to keep the amygdala quiet when it should be quiet. They act as natural regulators of the amygdala. Anxiety may be related to impairment in the endocannabinoid signalling. Dr Hill’s 2014 talk on the same topic has been recorded and posted online.
3. State of the Science for Technology-Based Approaches to Substance Use: Directions for the future (Dr. Sarah E. Lord)
Internet Electronic Therapy was the focus of the first afternoon plenary. Dr Lord described some of the tools that are out there, gave examples of them and validation data. Brief intervention and CBT-4-CBT were among them. The space of phone applications industry is far ahead of the science.
4. Integrative Addiction Medicine (Dr. G. Bunt)
The weather conditions worsened in Banff so much that Dr Bunt slipped and fell down on the way to the lecture hall (see Figure 1).
5. Brain Plasticity and Addiction (Dr. Bryan Kolb)
Dr Kolb kicked off the Saturday conference programme. Brain changes constantly. Anything you learn is going to occur because the brain changes. Play and stress too modify pre-frontal cortex. Interaction of brain and psychoactive drugs keeps fascinating scientists.
6. Clinical considerations for behavioural addictionsin the settings of DSM-5 and ICD-11 (Dr. Marc Potenza). During the first part of this millennium the perspectives on addiction changed, especially the behavioural addictions. How are they different or similar to substance use disorders? Many are strongly associated with behavioural addictions, e.g., heavy alcohol use and gambling. In addition to the high rates of co-occurrence, there are similar clinical courses, similar clinical characteristics, similar biologies and similar treatments for behavioural addictions.
7. The Alberta Addiction & Mental Health Review: Current challenges & lessons learned (Dr. David Swann).
Investment into addiction treatment is only a fraction of the Alberta’s budget – 0.1%. The current government of Alberta isn’t doing evidence-based policy but policing evidence. Racism is alive and well in Alberta. Lack of understanding led to the fiasco of the primary care reform in Alberta. It has an ambiguous direction on harm reduction. Dr Swann concluded his talk with 30 questions for the audience.
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| Figure 1. Banff centre snow |
AMERSA 39th Annual National Conference
November 5th, the national conference of the Association for Medical Education and Research in Addiction – AMERSA 39th – took place in Washington, DC. With 75% of the 225 delegates being new to the conference, the conference dynamics enlivened. As a rather small association with only 1 FTE, it is doing great in attracting so many new delegates. To see what lectures they got to hear, read my notes from the Keynote speeches below.
www.amersa.org
There is no room for prosecutors in the delivery room
Dr Paltrow questioned who gets the rights when it comes to pregnant drug users. While the laws in many US states try to protect the unborn child, in reality it is the judge, the county and the attorney who gets the rights. Is this the protection of the unborn or of the system? Dr Paltrow’s mother smoked during pregnancy:
“Maybe if my mom wasn’t smoking throughout her pregnancy, I might have been a for-profit lawyer.”
To reduce the stigmatisation of pregnant women with substance use disorders, make sure to “use the word use” – not Abuse, neither drug-dependent newborn. If you are asked to drug test when you shouldn’t, it is a moral obligation to do civil disobedience. The medical education should include teaching the risks that clinicians carry when they report pregnant women who use drugs.
What is appropriate counselling?
Dr Carroll posed some really important questions, such as – How do we really get to good long-term outcomes? Is Medical Management (MM approach) that good? The intensity of MM done in trials is probably not scalable in clinical practice. We shouldn’t give up on the research evaluating psychosocial treatments. Let’s give the therapies a fighting chance, shall we? We’ve just gotta find a way to do better as therapists. Many trials report that people do not finish the treatment. We have to reach to underserved and vulnerable populations. We have to realise that people in buprenorphine treatment are different – they don’t seek counselling. CBT (Cognitive Behavioural Therapy) retains people in treatment 3x better than treatment as usual. Usual treatment does not teach people skills.
Betty Ford Award Plenary Session at the AMERSA 39th Annual National Conference
How AMERSA was saved? When Betty Ford learned in 1985 that the association is near extinction due to only $200 left in the kitty, she offered a $10.000 cheque from the royalties of her new biography and personal account. This year, Dr Caetano received award named after her. His Border project, and two other projects, found how the Mexican Americans and the Puerto Ricans drank much more than the other groups of US Hispanics. Women of this origin drank the most of all national groups in this country.
“No matter what is the dimension of drinking, the diversity is there.”
If you’re in Miami, it’s not gonna be helpful to know the national data. The local authorities need to know.
If you enjoyed reading about this year’s conference, you may like to read my notes from the previous year, 38th meeting in San Francisco, CA, November 4th, 2014.
Doctors sweat to discover traditions of the first nations
Many doctors see addiction as a disease of body only. If overdone, this view can lead to medicalization of addiction. Some may argue that the latest research proves addiction as a chronic brain disease. This view is supported by brain scans of people who used drugs compared to people who didn’t. The scans show a loss of dopamine neurons after heavy methamphetamine use. Although brain’s plasticity allows it to recover, we don’t know how much of this loss is permanent.
While brain researchers may not mean to reduce addiction to a purely medical condition, its psychological, social and spiritual facets get sometimes overlooked. Not only medical students do not get enough education on addiction, what they get is often focused on the biological aspect.
To bridge this gap, in June 2014, a group of eight medical doctors (five doctors in training and three staff) from Canada went on a three day journey to a remote First Nations (i.e. American Indian) community to hear stories of recovery and participate in traditional healing techniques. After the trip, the Director of their addiction training programme (www.addictionmedicinefellowship.org), analysed the group’s experiences using qualitative research techniques and presented* the narratives at conference of the Association for Medical Education and Research in Substance Abuse.
People from the First Nations reservation shared their experience with the power of spiritual recovery tools – sweat lodges (see Figure 1), community round ups, connection to heritage, family support, and elder-guided self-reflection: “…learning came through creating bonds of friendship with people at Alkali Lake. It was through these bonds that the human face…emerge[d] and the real learning started to happen.”
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| Figure 1. Sweat lodge (photocredit: fellowship archive) |
First Nations communities are over-represented among people with substance use disorders in Canada. Having little sense of cultural competency, clinicians can become discouraged when faced with the suffering and despair of those with substance use disorders: “…the most valuable lesson [of the field trip] was in deepening the understanding that the most effective way of being an addiction physician is by humbling ourselves, relinquishing our titles as doctors and getting to know the person behind the addiction.”
The Director encouraged programmes to “find a local community that has tackled the programme and go out to do a field trip and learn from the community members.”
*Text first published at a registration-restricted website: https://www.mariecuriealumni.eu/news/doctors-sweat-discover-traditions-first-nations
Story based on a poster presented at the AMERSA conference November 5th, 2014: Lighting the ember of hope: Integrating field experience and narrative techniques into Addiction Medicine Fellowship training. By Launette Rieb (a,b), MD, MSc, CCFP, FCFP, dip. ABAM; Nitasha Puria (b), MD, CCFP; Marcia Thomson (a), MSc; and Evan Wood (a,c) MD, PhD, ABIM, FRCPC, dip. ABAM
Author affiliations:
a)St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship, Vancouver, B.C., Canada. b)Department of Family Practice, and c)Division of HIV/AIDS, Faculty of Medicine, University of British Columbia, Canada
Association’s for Medical Education and Research in Substance Abuse mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org
Clinical addiction medicine training is a multidisciplinary addiction medicine fellowship that strives for excellence in clinical training, scholarship, research and advocacy and involves medical education to trainees from Psychiatry, Internal Medicine, Family Medicine and Nursing. For more details, click here.