Whether they like it or not, physicians need to realize that addiction will show up in their practice. One out of eight people suffer from alcohol use disorder, but only 15 percent of those ever receive treatment, largely because the problem goes unrecognized until it’s too late. The opioid crisis, likewise, has underscored that addiction doesn’t discriminate on the basis of sex, age, race, religion, income level, education level, or ZIP code.
In addition, the opioid crisis brought to light the issue that many of the medications we use to treat illnesses, mental health disorders and pain are themselves drugs of abuse. In addition, many of these drugs have not been tested for long-term use yet are routinely prescribed for years on end. Sadly, many physicians don’t recognize the signs and symptoms of substance use disorder or how to treat it.
The truth is most doctors had only a few hours of training in addiction medicine during medical school, compared to the months they might have spent learning about heart disease or cancer. In addition, many physicians aren’t trained or are reticent to discuss substance use and mental health issues with their patients.
We’ve seen the medical community mobilize in reaction to the over-prescribing of opioids with education designed to teach them how to prescribe them responsibly. We need to take that a step further and educate physicians how to identify at-risk behavior and refer to a specialist for assessment, as they would with any other disease. Other best practices physicians can adopt include:
- Learn to recognize the signs of addiction and withdrawal. At the simplest level, physicians should know the definition of substance use disorder and the severity index associated with it.
- Keep withdrawal in the differential diagnosis. Patients are not always forthcoming about the medications, dosages and supplements they may be consuming to manage pain or a co-occurring disorder.
- Treat the person and not the symptom. When someone comes in complaining of a particular issue -- such as insomnia, anxiety, or chronic pain -- take a moment to consider the bigger picture. What medications are they taking? Do these medications have side effects that might be causing the symptom? Is there something else going on -- grief or loss -- that may be manifesting as pain or illness.
- Make a habit of having an honest dialogue with your patients. It’s important to create a safe space with your patients, one where they feel safe talking about what is going on with their lives. Demonstrate that they’re not going to be judged. A practice of talking openly will make a huge difference in empowering patients to be transparent about their lives and concerns.
- Do a thorough review of all prescriptions and supplements with the patient. Consider whether any prescriptions the patient is currently taking may be causing the symptoms. See if a change in the current medications might resolve the issue before prescribing something to address the latest complaint. For example, a patient taking an opioid will often exhibit anxiety, a form of inter-dose withdrawal. Prescribing a benzodiazepine to such a patient to address their anxiety is a recipe for disaster. Instead, look for ways to address the underlying cause, which is the long-term use of an opioid.
- Screen everyone for at-risk behaviors. You can’t make assumptions. Just because someone is affluent, professional, or denies drinking alcohol, doesn’t mean they aren’t at risk for addiction. Screen everyone, as that helps cut through assumptions and, since everyone is screened, overcomes the stigma of “even being asked” about risky behaviors. Become familiar with SBIRT -- Screening, Brief Intervention and Referral to Treatment -- and use it consistently with all patients to screen, intervene, and refer if necessary.
- Know when a referral is needed, and know what referral is appropriate. Addiction is a complex, chronic illness that can be managed through a lifetime of care. Unfortunately, primary care physicians are no more equipped to treat addiction than they are to treat cancer. Patients suffering from substance use disorder should be referred to the appropriate specialist. The American Society of Addiction Medicine (ASAM) Placement Criteria is an easy-to-follow and objective guide to where a patient is within the treatment continuum. All 50 states recently accepted the ASAM criteria for treatment placement, and physicians should know how to use it.
These steps are a good start for individual physicians, but the medical community as a whole also needs to better support doctors in addressing addiction. One key element is better training, both for those in medical school and for those already practicing medicine.
I was recently appointed Chair of the Physician-In-Training Committee of the American Society of Addiction Medicine (ASAM). Our committee is working with the Substance Abuse and Mental Health Services Administration (SAMHSA) and medical schools to develop a set of core competencies in addiction medicine that medical students need to master before they graduate.
The goal is not to dictate curriculum to the medical schools. Instead, we are working on one key question: What should every doctor know about addiction medicine when they graduate from medical school? It is up to the medical schools to integrate the core competencies into their curricula.
Beyond better training in medical school, we need more residencies and Addiction Medicine Fellowships. And, once we have defined the core competencies, they should become part of continuing education requirements for all practicing doctors.
I often compare our response to today’s addiction crisis to the way we dealt with human immunodeficiency virus (HIV). There was a tremendous amount of stigma and bias surrounding HIV in those early years. Doctors would claim that HIV wasn’t something they saw in their practice. Then, as a society, we decided it was important to universally screen patients, even those who may not have previously been considered high-risk. This destigmatized screening and increased access to treatment. Screen, test, treat. Ultimately, that will be our goal in addiction medicine as well. Screen everybody—young and old—stratify to determine the appropriate response and refer to treatment. Addiction is everywhere and affects everyone. By screening everybody, we eliminate the bias and start to remove the stigma.
As doctors, we do a great job screening for prostate cancer and breast cancer. But, substance use disorder is killing more people than those cancers and therefore deserves equal attention. We must screen for substance use disorder with the same universal sense of urgency. Our primary care physicians should be as attentive to the warning signs of addiction as they are to other preventable and treatable diseases. I’m encouraged to see the medical community taking these important steps that I believe will save many lives.
The Drive for Substantive Change in Addiction Treatment
By Dr. Joseph Garbely