Addictions and Recovery

In the previous blog, pertaining to the incidence of alcoholism and substance abuse among medical students, I mentioned that my original intent was to find out what medical students learn about alcoholism and drug misuse in their medical school curriculum. The problem was that I keyed in a phrase into the Google search box that led me to articles pertaining to alcoholism and substance misuse among medical students.

Oops.

In this blog, I discuss the subject that I had originally intended, “What do medical students and residents learn about alcoholism and substance misuse?”

I. My initial point of reference in writing this blog

My initial point of reference regarding what medical students learn about addiction medicine was a conversation I had in the early 1990’s with an alum who had become an emergency room physician. I posed the question about when and how he learned about the consequences of alcoholism and drug misuse, and he said, “During our rotations”:

Me: How so?

Him: When we would see someone in the emergency room who was in a car wreck, we could suspect that alcohol was involved. Then, as we would examine other patients, we would see accompanying patterns of alcohol or drug misuse, as with diabetes, hypertension, elevated triglycerides in blood.

II. One physician’s learning the distinction between didactic (book) learning and real-life situations

Op-Med is a collection of original articles contributed by Doximity members. In 2021,Saaquib Bakhsh, MD, wrote an article entitled Liars, Alcoholics, and Malingerers: Medicine’s Hidden Curriculum in which he learned the distinction between the book learning of the first two years of medical school as opposed to the real-life situations he learned during his rotations in subsequent years (https://opmed.doximity.com/articles/liars-alcoholics-and-malingerers-medicine-s-hidden-curriculum).

He describes a conversation he had with his attending regarding a patient, in which he had just finished taking a thorough history and physical examination (H&P) as a third-year medical student and was presenting the patient to his attending. When he got to the pertinent social history, he relayed the patient’s self-reported alcohol intake of three beers a day. 

“Double it,” said my attending. (Emphasis mine.)

He explains that the attending statement’s “double it” — exemplified an early introduction to the “hidden curriculum” of medicine for him. The first lesson was simple: whatever alcohol intake a patient admits to, double it. This could be to account for patients being unable to truly estimate their daily drinking from memory, an inherent embarrassment to admitting their true habit, or from an intentional withholding of information for reasons unknown. But it also signaled to him that subjective claims made by a patient should almost always be questioned, and, unfortunately, his later experiences validated the lesson. This was a stark difference from the approach to the patient encounter we were taught in medical school, which emphasized listening intently to patients’ long-winded histories — and believing them. In transitioning from training to practice, trainees must unlearn many idealistic behaviors, as the real world requires practical and applicable skills.

III. The Society of Teachers in Family Medicine (STFM) National Addiction Curriculum

Sokol, et. al. (2023) state that most physicians do not feel adequately trained to diagnose and treat addiction. In fact, a 2015 study found that, among the 49% family medicine residency programs that responded, only 28.6% had an addiction medicine curriculum and most graduates did not seek additional addictions training.

Furthermore, in a report published in April, 2024 by the Substance Abuse and Mental Health Services Administration (SAMHSA), the following is stated: “Currently, there are no required curriculum standards within medical schools for SUD/addiction The Liaison Committee on Medical Education (LCME), which accredits all U.S. allopathic medical schools, currently only requires that each school include “behavioral subjects” in its medical curricula, but there is no specific mention of requirements for SUD training. Key words in SUD training such as “addiction,” “substance,” and “drug,” are absent from the 2023-2024 LCME standards (Liaison Committee on Medical Education, 2022). The Commission on
Osteopathic College Accreditation Administration (COCA) standards now mirror many aspects of the LCME.

Despite the dim assessment by SAMHSA, The Society of Teachers in Family Medicine (STFM) saw a need, so from 2018 to 2020, the STFM Addiction Collaborative created a Family Medicine National Addiction Curriculum using the Delphi method (surveying their panel of experts) to identify learning objectives and create the following 12 associated learning modules:

• Addiction as a Chronic Disease
• Screening, Brief Intervention, and Referral to Treatment (SBIRT)
• Taking a Substance Use Disorder (SUD)
• History Safe Prescribing of Opioids
• General Opioid Use Disorder (OUD)
• Inpatient Management of OUD
• OUD in Pregnancy
• Tobacco Use Disorder (TUD)
• Alcohol Use Disorder (AUD)
• Inpatient Management of AUD
• Urine Drug Screen (UDS)
• Interpretation Health Equity, Vulnerable Populations, and Addiction

Assessment of the Curriculum showed the following:

1. There were changes in Residents and Faculty’s knowledge: Both residents and faculty felt that their knowledge base around pain/addiction topics had increased;
2. There were changes in Resident and Faculty attitudes: Participants described how their attitudes toward patients who struggle with SUDs and their role in helping these patients. (Ed. note: I consider it relevant here to include a passage here from Dr. William D. Silkworth, who wrote “The Doctor’s Opinion”, which appears at the beginning of “Alcoholics Anonymous”, the “Big Book” for people following the 12-step program by that name, written 80 years ago: “What with our ultra-modern standards, our scientific approach to everything, we are perhaps not well equipped to apply the powers of good that lie outside our synthetic knowledge…Though the aggregate of recoveries resulting from psychiatric effort is considerable, we physicians must admit we have made little impression upon the problem as a whole. Many types do not respond to the ordinary psychological approach.“
3. There were changes in Resident and Faculty behaviors and practices: Residents and faculty describe increased engagement, providing more frequent screenings; once SUDs were identified, they offered more in-depth conversations and counseling with patients about treatment options, such as helping patients get to the appropriate level of care and offering medications. They also demonstrated increased competence around communication skills among patients with SUDs, especially around motivational interviewing. They made greater efforts to use destigmatizing language among patients with SUDs, and finally, residents and faculty reported that the curriculum helped facilitate increased interdisciplinary collaborative approaches, in which family physicians worked with other health providers, e.g. psychologists, psychiatrists, social workers and nurses, both in teaching about and providing care to patients with SUDs
4. Residents and faculty recommended the content to be evidence-based and relevant and important to their clinical work. They also appreciated the Structure and format of the curriculum, especially the flipped-classroom approach. All of the components of the curriculum were valued.

P.S.:

SAMHSA (2024). CORE CURRICULUM ELEMENTS ON
SUBSTANCE USE DISORDER FOR EARLY ACADEMIC CAREER: MEDICAL AND HEALTH PROFESSIONS EDUCATION PROGRAMS. https://www.samhsa.gov/sites/default/files/core-curriculum-report-final.pdf

Sokol, R.; Ahern, J.; Pleman, B.; Rizzo, P.; Walker, A.T.; Wang, K.; Martin, M.P. (2023) An Evaluation of STFM’s National Addiction Curriculum. Family Medicine 55(6):362-366. doi: 10.22454/FamMed.2023.340020