A Response to the Physician Shortage in Addiction Medicine
Part Three: Medical School Curriculum

Evidence-based strategies, when implemented by a large percentage of physicians, can leverage their effectiveness which is especially crucial in the context of a physician shortage. The addiction epidemic is a complex issue. It involves an array of substances that affect users in various ways and to varying degrees. Consequently, a range of strategies needs to be made available to address all the treatment options needed by those who suffer from substance use disorders. This blog will explore two of the main strategies that have been employed in the fight against substance use and abuse. 

 

According to the 2021 World Drug Report from the United Nations Office on Drugs and Crime (UNODC), approximately 275 million people used drugs worldwide in the previous year.  In the United States, 22 million people are estimated to suffer from active substance use disorders (SUDs) (Moore, 2021). However, in 2017 in the US, it was estimated that only about 19% of persons who needed treatment for a substance use disorder received it (Facts About Addiction, 2022). Substance use disorders typically “occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home” (SAMHSA, 2022).


A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University found that quite often, addiction is perceived as a lack of willpower and a reason for humiliation and avoidance (CASA, 2012), as opposed to seeing it as a disease that requires treatment. However, the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institutes of Health (NIH) all describe addiction or SUD as a disease because it causes long-term changes to the brain and is similar to other diseases in that it must be continuously managed (American Addiction Centers, 2022). Treatment for SUDs varies and depends on the substance being abused, the level of care needed, the patient’s mental health, and what the patient can afford (Underwood, 2020). While there are ongoing debates about the best approach to treating alcohol misuse and abuse, the most common treatments for other SUDs include medically assisted detox, behavior therapy, 12-step programs, and medications.

One of the most commonly used treatment options, particularly for tobacco use disorders and alcohol abuse, is abstinence-based recovery. Abstinence-based recovery has been used for centuries, even before addiction was deemed a disease. This approach to treatment and recovery expects patients to completely stop the use of alcohol and other drugs as part of the treatment process. This is based on the idea that there is no “safe” amount of drinking or drug use for those in recovery, and so both the goal and the treatment process focus on zero consumption of the addictive substance (Fierro, 2019). 

 

While this approach may appear to be an excellent one, quite often, abstinence-based programs tend to be a rigid, one-size-fits-all, with no individualization to meet specific needs. Abstinence-based programs may also lack tolerance for relapse which can result in treatment being denied to someone who desperately needs it (Fierro, 2019; Tatarsky, 2002; Stone, 1989). Excluding individuals who fail to remain abstinent has ethical drawbacks and can be seen as paradoxical because abstinence is not consistent with the accepted disease model of addiction (Lee 2015). 

 

Conversely, a more inclusive, balanced, and evidence-informed approach to treatment can be beneficial to those suffering from substance use disorders, as seen in programs such as “reducing to quit” or “preloading” in the case of tobacco.  Harm reduction “emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social wellbeing of those served, and offer low-threshold options for accessing substance use disorder treatment and other health care services” (SAMHSA, 2022). This approach, therefore, accepts that persons with SUDs require as much help as possible and utilizes a comprehensive and individualized approach to prevention, treatment, and recovery.

Harm reduction can assist in preventing drug overdoses, death, and overall misuse, thus reducing the burden of disease in public health. Some of the strategies include:

 

  • Education, counseling, and referral to treatment
  • Distribution of medications such as naloxone
  • Reduction in infectious disease transmission among drug users
  • An integrated approach that includes co-location of services to ensure care
  • Reduction of stigma
  • Using those with lived experiences of recovery to promote hope and healing

Interestingly, harm reduction became popular in the 1980s in Europe at a time when the HIV epidemic was a severe issue and resulted in the development of needle exchange programs which helped to reduce the spread of HIV among drug users. According to Fierro (2019), harm reduction is preferred by many patients as an alternative to abstinence-based programs as it provides a safer space for healing. However, the approach has been criticized for being too reliant on individuals being honest about their drug use and for not preventing persons from using substances entirely. Nevertheless, it can be argued that safer drug use, controlled use, and abstinence together work as effective strategies for harm reduction (Denning & Little, 2011).

 

Key stakeholders in the US fight against the addiction epidemic also approve of harm reduction strategies as the answer to the epidemic. For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded 25 grants for its Harm Reduction grant program. This funding, authorized by the American Rescue Plan, will help increase access to a range of community harm reduction services and support harm reduction service providers as they work to help prevent overdose deaths and reduce health risks often associated with drug use. SAMHSA plans to make $10 million available between 2022 and 2025 (SAMHSA, 2022).

 

While abstinence may be a necessary recovery component for some individuals with SUDs, research indicates that it is not essential for all, and positive changes in functioning and well-being often are more fundamental elements. However, even when interventions such as “reducing to quit” are used, the ultimate aim for tobacco users is total abstinence. Healthcare delivery has evolved to become more holistic and to better integrate substance use prevention and treatment into various aspects of the health system. This has been accomplished by expanding targeted substance use programs and specialty addiction medicine providers.

However, limited resources still exist for such targeted programs and specialty providers, and the availability and accessibility of such programs and providers are limited. In addition, general healthcare providers, who are also positioned to prevent and treat SUDs, lack the necessary resources and education to be able to effectively fill this role in the health system. Treatment of substance use disorders requires both specialty services and integrated services through general healthcare delivery. Both of these areas, therefore, require further efforts to improve access to treatment and prevention services and to improve SUD outcomes.  

 

Addiction Training for Health Professionals (ATHP) is a program at the Frank Foundation that recognizes the gap between needs and resources. The program’s goal is to train physicians in evidence-based and standardized care interventions, including Medication Assisted Therapy and Harm Reduction Strategies to improve outcomes for those experiencing substance use disorders. The program’s primary aim is to maximize the number of physicians receiving addiction training and improve health systems through education related to clinical practice, research, policy, and public health. This will create systems that support physicians as they work to prevent and treat SUDs.

In our next blog, we highlight ATHP’s response to a shortage of physicians and in particular those specialized in Addiction Medicine through the provision of a complete medical school curriculum. Stay tuned!

Visit our website at https://athp.nextgenu.org/ for more information on the work of the Addiction Training for Health Professionals program.

Sherry Joseph, Dr. Brandon Maser, and Dr. Glenda Niles

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