A blockbuster review of scientific research concerning physicians and addiction treatment has just been published in JAMA Network Open, and the bottom line is that a shocking number of physicians say they do not have the education or training to treat patients showing signs of substance use disorder.

Shocking? How big is that number? The systemic review involved 283 articles collecting data from 66,732 physicians. The researchers, including the National Institute on Drug Abuse, the National Survivors Union, and the National Library of Medicine looked at the instances where treatment was not offered for substance use disorders and found:

• 81% of the time physicians said it was due to the “institutional environment”
• 74% of the time physicians said they lacked the knowledge to treat drug addiction
• 71% of the time physicians said they lack the skills to treat drug addiction

Which begs the question: What are they teaching in medical schools if someone can get an M.D. in America and not know how to treat addiction?

The main reason for “physician reluctance to intervene in addiction,” according to the researchers, is the lack of institutional support. This includes such things as the lack of insurance coverage and the reluctance of healthcare facilities to treat those who cannot pay for services. Clearly, there are market forces at work to resist costs that will not be reimbursed, but for nearly three-quarters of these doctors to say they lack the skills and knowledge to treat addiction is remarkable.

The result of this intentional ignorance is that screenings for substance use disorders are not done and referrals for treatment are not made. Patients descend into crippling addiction without receiving treatment that should have slowed or stopped the decline. A mere 6.3% of those with a past-year substance use disorder diagnosis received treatment in 2021, according to the review.

Institutional Impediments to Addiction Treatment

The review found that the “institutional environment” was the leading reason for the lack of physician intervention. The list of issues can be read in reverse to see the gauntlet of obstacles faced by substance abusers confronting the medical system:

• lack of trained staff
• lack of resources
• reluctance to accept addiction patients
• lack of clinical backup
• concerns over liability
• concerns over violating regulations
• record-keeping
• confidentiality
• need to get prior authorization
• medications not available in a pharmacy
• mental health programs won’t accept patients with substance use disorders
• Medicaid reimbursement is inadequate

Wow, that’s some list. It paints a picture of a safety net medical system that is paper thin for those at the low end of the income/insurance spectrum. Half the items on the list are because the U.S. doesn’t really have nationalized medical care for the poor with no paperwork, in-and-out service as Canada, the U.K., and many other countries have. Instead, each time the patient faces a bewildering amount of paperwork, authorization, waiting, drug shortages, and physicians determined not to understand how addiction treatment works. The bottom line, say the researchers:

Physician reimbursement was viewed as insufficient to cover both the staff time necessary to intervene in addiction and the expense of additional staff training.

Physician Impediments to Addiction Treatment

Many physicians prefer to remain unaware of their patients’ risky substance use, say the researchers. By and large, they do not inquire about it, they do not know the warning signs to look for, and they are unfamiliar with readily available screening procedures. In defense of the doctors, many of them said they are not counselors and can’t offer the time-consuming care a recovering addict requires. The lack of experience treating substance use disorders leads to a lack of confidence in dealing with addicted patients.

The physicians did better with smoking cessation and alcohol use disorder. When it came to opioid addiction, however, their preference was to provide a “brief intervention” and refer the patient to a treatment program. Even the brief intervention would benefit from physician and staff training with naloxone and less restrictive requirements for the prescription of buprenorphine and methadone.

Many of the recommendations made by the authors sound like wishful thinking:

• breaking down of barriers between addiction services and both medical and mental health care
• commitment by insurers to provide reimbursement that covers the actual cost of providing addiction interventions
• investing in staffing and staff training

A more realistic recommendation from the team is that “physicians need updated information on dosing, pharmacology, and overall efficacy of interventions and medications.” And they do, in the end, recommend better training on addiction treatment in medical schools, in post-graduate programs and in residencies. 

There’s no better place for doctors and students to start than AddictionNews, where we summarize the science of addiction on a daily basis. We can help you find the science you need on anything having to do with behavioral addictions and substance use disorders.

Written by Steve O’Keefe. First published July 23, 2024.

Sources:

“Physician Reluctance to Intervene in Addiction: A Systematic Review,” JAMA Network Open, July 17, 2024.

“Doctors reluctant to treat addiction most commonly report ‘lack of institutional support’ as barrier,” National Institutes of Health News Release, July 17, 2024.

Image Copyright: benzoix.