Doctors Are Poorly Trained About Addiction and Recovery

Addiction? What addiction?

Most medical schools and residency programs place little emphasis on educating future physicians about addiction. A survey conducted by the Center on Addiction and Substance Abuse at Columbia University (CASA) revealed that physicians are poorly trained to recognize and treat addictive disorders. (1)

CASA surveyed nine-hundred and seventy-nine U.S. physicians, from all age groups, practice settings, and specialties. Only nineteen percent of these physicians said they had been trained in medical school to identify diversion of prescribed drugs. Diversion means that the drug was not taken by the patient for whom it was prescribed. Almost forty percent had been trained to identify prescription drug abuse or addiction, but of those, most received only a few hours of training during four years of medical school. More shocking, only fifty-five percent of the surveyed doctors said they were taught how to prescribe controlled drugs. Of those, most had less than a few hours of training. This survey indicates that medical schools need to critically evaluate their teaching priorities.  

Distressingly, my own experience mirrors this study’s findings. My medical school, Ohio State University, did a better job than most. We had a classroom section about alcoholism, and were asked to go to an Alcoholics Anonymous meeting, to become familiar with how meetings work. But I don’t remember any instruction about how to prescribe controlled substances or how to identify drug diversion.

Is it possible that I’ve forgotten I had such a course? Well, yes. But if I can still remember the tediously boring Krebs cycle, then surely I would have remembered something juicier and more practical, like how to prescribe potentially addicting drugs. Similarly, less than half of the surveyed doctors recalled any training in medical school in the management of pain, and of those that did, most had less than a few hours of training.

Residency training programs did a little better. Of the surveyed doctors, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

This last finding is appalling, because it means that thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Could it be true that nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs? Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

Could it be that many of these physicians were in residencies or specialties that had no need to prescribe such drugs? No. The participating doctors were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study reveals a hard truth: medical training programs in the U.S. are doing a poor job of teaching future doctors about two diseases that causes much disability and suffering: pain and addiction. (1)

 I remember how poorly we treated patients addicted to prescription medications when I was in my Internal Medicine residency program. By the time we identified a person as addicted to opioids or benzodiazepines, their disease was fairly well established. It didn’t take a genius to detect addiction. They were the patients with thick charts, in the emergency room frequently, loudly proclaiming their pain and demanding to be medicated. Overall, the residents were angry and disgusted with such people, and treated them with thinly veiled contempt. We regarded them more as criminals than patients. We mimicked the attitudes of our attending physicians. Sadly, I did no better than the rest of my group, and often made jokes at the expense of patients who were suffering in a way and to a degree I was unable to perceive. I had a tightly closed mind and made assumptions that these were bad people, wasting my time.

Heroin addicts were not well treated. I recall a discussion with our attending physician concerning an intravenous heroin user, re-admitted to the hospital. Six months earlier, he was hospitalized for treatment of endocarditis (infected heart valve). Ultimately his aortic heart valve was removed and replaced with a mechanical valve. He recovered and left the hospital, but returned several months later, with an infected mechanical valve, because he had continued to inject heroin. We discussed the ethics of refusing to replace the valve a second time, because we felt it was futile.

I didn’t know any better at the time. We could have started him on methadone in the hospital, stabilized his cravings, and then referred him to the methadone clinic when he left the hospital. Instead, I think we had a social worker ask him if he wanted to go away somewhere for treatment, he said no, and that was the end of that. Small wonder he continued to use heroin.

At a minimum, the attending physician should have known that addiction is a disease, not a moral failing, and that it is treatable. The attending physician should have known how to treat heroin addiction, and how to convey this information to the residents he taught. Instead, we were debating whether to treat a man whose care we had mismanaged. Fortunately, he did get a second heart valve and was able to leave the hospital. I have no further knowledge of his outcome.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients, for whom they had prescribed such drugs. (2).

From this data, it’s clear physicians are poorly educated about the disease of addiction at the level of medical school and residency. Even when they do diagnose addiction, are they aware of the treatment facilities in their area? Patients should be referred to treatment centers who can manage their addictions. If patients are addicted to opioids, medications like methadone and buprenorphine can be a tremendous help.

  1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org

2. Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and

Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org

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8 responses to this post.

  1. Really some physicians are poorly educated about the disease of addiction at the earliest stage.

    Reply

  2. Posted by Chachi on March 3, 2011 at 2:35 am

    what do you think about the current state of awareness re: addiction as a disease among physicians and other medical providers? What more can we do as professionals in the addictions field to help with this?

    Reply

    • Great question.
      I think most physicians and other health providers are clueless about what addiction is and how to treat it, unless they have been addicted themselves or have had family or friends with the disease.

      Education needs to start in medical school. In the first two years, usually didactic training, there needs to be a teaching module of at least 4 weeks, and an elective rotation in the clinical years 3 & 4. Residencies must focus on appropriate prescribing of controlled substances as well as recognition and treatment of addiction. We should spend at least as much time educating young doctors about recognition and treatment of drug and alcohol addiction as we do about treating the complications of drug and alcohol addiction. In my residency program, we became proficient at managing acute alcoholic withdrawal and treating terminal cirrhosis. It’s a pity we didn’t learn much about recognizing addiction in its early stages, and referring people for help. We know now that screening and brief intervention, called SBIRT for short, does help. Even a minimal intervention at a critical time has been shown to have a huge impact.

      Doctors in established practice should be encouraged to become educated about how to recognize addiction and refer for help. They also should be taught how to do SBIRT and be paid for this work. Sadly, healthcare payers often pay large sums for procedures (like sclerosis of esophageal varices), but little for screening for disease and intervention in the early stages.

      Believe me, I could bang on about this for some time, but that’s my suggestions in a broad, nonspecific way.

      Reply

  3. For starters Doctors need to learn the difference from “addiction” and “chemical dependance”

    The reality for me is stopping short term use of opiates is nothing. I might have some loose stools for a day or two, maybe my sinuses are stuffy, but that’s about it.

    Addiction starts long before the actual use comes along. Addition is much more than simply using. Addiction is a compulsive behaviour and use of many things, addiction is an activity to take you away from you. Food, sex, drugs (of course), gambling, etc.

    It’s a mess for sure when you have a legitimate issue and are denied treatment because of some A-hole Dr opinion.

    18 years ago I ruptured a disc in my back (L5-S1). It hurt like hell. After a week of prescribed pain pills I went back to what was my primary doc, I was told this;

    “You will get no more pain pills, you need to leave the office now!”

    Man it was WW3, I could barely keep my voice down; “I am not leaving without a MRI order for my back!!!!!”

    The Dr quickly gave me that order, I guess to get me out of the office.

    I did the MRI the next day, took my last Norco (10mg), most of you know those take a long time, difficult with a severe case of sciatica.

    After a long 5 days of consuming alcohol for the pain (man it hurt like hell) I went back to my primary for the MRI reading.

    HA, as she is reading this MRI reading, first her eyes popped wide open, then I had my revenge as I watched her face grow beet fricking red.

    “Oh” she says; “I guess you do have a problem”.

    No kidding!

    4 weeks later I went under the knife and all was repaired and 18 years later all is well.

    I have learned to NOT talk to DR.s about pain issues.

    sourdo

    Reply

  4. Your article certainly supports the need for more training and understanding. The CDC and NIH had far worse numbers for doctors who believed in the disease ideology, and fewer still properly trained in addiction.
    I would like to bring to your attention. The idea that methadone is a solution for heroin addiction is not supported by anyone experienced in heroin recovery.
    As of 2014, from the CDC and NIH, methadone deaths surpass all other opioids combined in the U.S.
    The truth about methadone is not readily available. Methadone has never been predictable. While many patients will have similar results in the beginning of their use, after a few days or weeks individual reactions change dramatically.
    Detoxing a methadone patient is far more difficult and dangerous than medical grade heroin or any other opioid.
    Sadly, we have many in the medical community telling folks they can use this drug long term. Long term use of this drug almost always ends in death.

    Reply

    • Sorry, but you are in error. Actually, both the CDC and NIH support MAT with methadone. I have written many blog posts with the citations for data on which I base this information.

      Reply

      • I am well aware of the “support” the CDC and NIH give to the use of methadone.
        While their own website shows the massive increase in deaths caused by methadone. Death tolls far exceeding that of street heroin.
        We have endless information coming out of Europe showing long term health effects of methadone and disputing this forty year ideology for treatment of addiction with methadone. Sadly, no one has been doing reliable research on this drug until recently.
        We also know from our own record keeping that methadone is very unpredictable in some people.
        The U.S. government is allowing its use for many conditions that have nothing to do with pain management and or heroin withdrawal.
        The controls methadone clinics do not track the deaths or long term problems of patients who “stop showing up for their supply”.
        My extensive personal experience with people, research and evidence is this. Treating heroin addicts with grade heroin, supplying them with pharma grade heroin would save tens of thousands of lives a year. These addicts can become functional members of society while using heroin and many quit on their own.
        Success rates for long term recovery off methadone, are half that of heroin.

      • So…injecting heroin is safer than methadone….
        No.
        Opinion and emotion aren’t facts. Now it’s time for you to cite data showing what you’re saying.
        Where is the “endless information coming out of Europe..?” It’s not in the addiction medicine journals.
        I’m not saying methadone doesn’t have side effects. It does. It doesn’t work for everyone, but it’s allowed many people to function normally, taking one oral dose per day, rather than having to inject heroin multiple times per day. It’s not a perfect drug, but it improves the outcomes and the daily function of people for whom it works.
        There will never be one medication that works for everyone. Some patients refuse methadone, and heroin maintenance (the Vancouver studies come to mind) has been shown to reduce certain risks in those people.

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