Volume 4, Issue 2

All Roads Lead to Rome:
Furthering Physician Involvement in the Care of Patients with Substance Use Disorders

John Sellinger, PhD
Steve Martino, PhD
Yale University School of Medicine
Department of Psychiatry


Acknowledgments: The authors are supported by the Veterans Affairs Connecticut Healthcare System and the Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center (MIRECC).  In addition, Dr. Martino receives additional support from the US National Institute on Drug Abuse grants (DA027194, DA034243). The views expressed in this article are those of the authors and do not represent the views of the VA or NIDA.

Getting physicians to embrace direct involvement in the assessment and management of their patients’ substance use disorders remains a challenge to the field.  It is widely acknowledged that most patients with active substance use disorders do not receive treatment for these conditions, and they are more likely to present to medical settings than they are to specialty substance abuse treatment programs. This situation has created a well-recognized opportunity for physician-driven screening and brief interventions for substance abuse in the United States healthcare system. 

Unfortunately, many patients continue to report that their physicians do not inquire about their use of substances, let alone intervene or treat them for risky or more serious patterns of use.  Moreover, many physicians state that they continue to be ill-prepared to identify and treat substance abuse problems.  It seems as if we have a very long road to travel to further physician involvement in the care of patients with substance use disorders. 

As the age-old adage states, all roads lead to Rome.  We propose that better integrating physician involvement in the care of patients with substance use disorders will require the use of multiple strategies.  Below we detail several options in the areas of education, training, and reducing workload burden, all of which should increase physicians’ addiction medicine practice.

Education
In many instances physicians do not screen or treat their patients who have substance use disorders because they have not been educated about addiction medicine in medical school, residencies, or thereafter. This dearth of education has been due in part to the absence of an addiction medicine subspecialty for primary care physicians, even though there are over 9,000 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that train over 120,00 residents per year. Fortunately, the American Board of Addiction Medicine (ABAM) has now accredited 19 fellowship programs to train physicians in addiction medicine.  The programs have resulted in over 3000 physicians being certified in addiction medicine by ABAM.  We need more ABAM-supported addiction fellowship programs to build a physician workforce that has the requisite knowledge to treat patients who have substance use disorders.

In addition, the American Society of Addiction Medicine (ASAM) is a professional society of physicians who are dedicated to promoting the appropriate role of physicians in the care of patients with substance use disorders.  ASAM provides educational resources, online learning, and live courses to help physicians develop expertise in addiction medicine, as well as to maintain their ABAM certification.  ASAM provides a professional home for like-minded physicians to share resources and expertise and to train one another in a myriad of addiction topics likely to arise during patient encounters (e.g., use of buprenorphine, detoxification, addiction risk assessment within pain management, and how to screen patients for substance misuse, briefly intervene and refer them to treatment).  Medical facilities should consider paying for their physicians’ ASAM memberships and provide them with performance incentives (e.g., bonuses) to complete ABAM certification.

Another strategy for educating physicians is to create mini-residencies for physicians at facilities that have built-in addiction medicine expertise.  Mini-residencies are brief intensive learning experiences for primary care providers to enhance their knowledge and expertise in a particular topic or disease state. For example, VA Connecticut Healthcare System has been selected to become a site for a chronic pain mini-residency in which out-of-state primary care providers visit the facility for a three-day training provided by local experts in pain medicine.  Subsequently, the local experts go to the physician trainees’ sites to monitor their implementation and to train them in becoming trainers for other primary care providers in their network. This format might work well as a strategy to train physicians in substance abuse screening, brief intervention, and the use addiction medication treatments, including understanding medication abuse and ways to work with patients who have misused or become addicted to their prescription drugs.

Training
As suggested by the mini-residency approach, education needs to be complemented by active efforts to train physicians at their worksites.  Didactics alone are not sufficient for skill development to occur or for addiction medicine skills to transfer and be sustained in real world clinical settings.  Fortunately, physicians are very accustomed to being trained using an apprenticeship model. Commonly referred to as see one, do one, the instructor explains the theory and techniques of a practice and demonstrates it in a simulated scenario (e.g., manikin) or directly with patients. Subsequently, the physician trainee practices the approach under the direct observation and supervision of an expert physician who provides live performance feedback and coaching to improve the technique. Eventually, the physician trainees will “teach one” to others when they have mastered the practice. This form of learning on the job has been a modus operandi in medical education for centuries, with the ultimate aim being to have physicians implement the targeted procedure proficiently with their patients.

The apprenticeship model within addiction medicine implies that, following a period of education, physicians need to be directly observed as they become more involved in the care of patients with substance use disorders. Observing how physicians ask patients about their use of alcohol and drugs, how they respond to their patients’ answers, and the manner in which they attempt to motivate patients for change when problematic use is evident are all fertile grounds for training.  Providing physicians with performance feedback and coaching them how to further improve their practice, including having the expert model effective communication skills, could go a long way in both facilitating physician learning and fostering their long-term change in practice. 

If logistical issues complicate direct observation of actual patient care, standardized patients, a widely used and reliable clinical skills assessment approach in medical education, might be considered.  Alternatively, confederate patients (i.e., actors posing as patients with substance use disorders) might be scheduled to see physicians who are unaware of their confederate status.  The confederates’ experiences within the session are then used to provide the physicians with feedback. Depending on the addiction medicine skill set being promoted, standardized or confederate patients could be carefully trained to reliably evaluate performance in targeted performance areas.

Training physicians to screen and treat substance-using patients could also be accomplished using a co-visit approach in which the physician sees the patient with an addiction specialist.  The addiction specialist provides direct consultation when a suspected high-risk patient is visiting with the physician.  This approach might be preferred by some physicians who do not have the time to devote to formal training.  Providing physicians with opportunities to witness the benefits of addressing their patients’ substance use problems  might also spur greater interest in learning more about addiction medicine and the impact of substance use disorders on other, more traditional health conditions managed in the primary care setting (e.g., diabetes).

Reducing Workload Burden
Physicians are busy providers with many medical care mandates and clinical guidelines that affect their practice and ability to extend their expertise into new areas such as substance use disorders.  Strategies to promote physician involvement in addiction medicine that minimize burden on physicians’ workload are likely to be most effective.  Use of brief screening tools like the AUDIT C, questions based on NIAAA guidelines for risky drinking, the CAGE, or single item queries about drug use (i.e., “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?) are more likely to be used by physicians than lengthier screening and assessment scales, like the ASSIST.  If more thorough scales are desired, delivering them in computerized and web-based formats and having the results immediately available to physicians for review would make them more acceptable within busy medical practices.  This latter approach was the basis for the NIDAMED website (http://www.drugabuse.gov/nmassist/), giving medical professionals tools and resources to screen their patients for tobacco, alcohol, illicit, and nonmedical prescription drug use using an online screening tool, a companion quick reference guide, and a comprehensive resource guide for clinicians.

Another way to encourage physicians to be more attentive to their patient’s addictive behaviors is to use “warm hand-offs”.  Warm hand-offs involve having the physician literally walk the patient to a non-physician addiction specialist co-located in the medical setting.  These individuals could be nursing staff members, psychologists, social workers, or addiction counselors. The specialist then further assesses and motivates the patient to address his or her substance use problems.  Warm hand-offs require that the specialist is part of the healthcare team, thereby fostering the sense that everyone on the patient’s medical team is working together to promote the patients’ positive health-related behavior change.  This approach also keeps physicians informed about the patient’s substance abuse treatment progress, in contrast to trying to coordinate care with specialty addiction treatment programs where the communication loop between physician and addiction specialist providers is often suboptimal.

Finally, while not all physicians may have an interest in developing their expertise in addiction medicine, some physicians might welcome this opportunity.  Pitching education, training, and implementation to these individuals rather than to physicians en masse collectively reduces burden. These physicians might become “champions” at their primary care clinics or other medical facilities, meaning that they receive advanced education and training in addiction medicine and then become the local experts/consultants for their colleagues around issues related to substance use disorders.  Examples of medical champions abound in the literature for fostering more focused attention on other disease states (e.g., diabetes, hypertension, pain). 

Conclusions
Furthering physician involvement in the identification, assessment, and care of patients with substance use disorders requires the use of multiple strategies.  Promoting physician education and training in addiction medicine and reducing the added burden of implementing addiction medicine practices will increase the chance physicians will more routinely attend to their patients’ addictive behaviors.  Let all these roads lead to Rome.


 




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