Approximately 1 in 10 Canadians describe symptoms consistent with alcohol or illicit drug dependence. Yet, the undergraduate medical education system devotes a total of 12 hours of curricular time to addiction medicine, not a proportionate response to the severity of the problem.
Addictions place a serious burden on the healthcare system, costing Canadians an estimated $39.8 billion in 2002. Despite years of rigorous training, why is it that less than 20% of primary care physicians feel confident identifying a patient with alcohol/drug dependence?
The medical education system does not dedicate sufficient time to addiction medicine: not enough time is spent in class, students are not introduced to effective screening tools, and they are not exposed to addiction patients during their undergraduate career.
Exposure to addiction medicine during undergraduate education is enormously important, because it means all students will be taught before they split into their residencies. Addictions are a reality in every part of the health care system: ER doctors encounter patients who are intoxicated or in withdrawal in the Emergency Department, surgeons encounter addictions when they must manage a post-op patient’s withdrawal, and since so few hospitals have in-patient addictions services, internal medicine and psychiatry often find themselves managing complicated medical detoxifications or maintenance therapies.
Incorporating addiction medicine into the curriculum is difficult as there are many hurdles that need to be overcome. The belief that addictions are a choice and not a disease has resulted in a “bad rep” for suffering patients, despite research that suggests otherwise. The stereotype that an individual with an addiction is a challenging patient with a poor social and medical prognosis is the foundation of what is being taught, resulting in physicians expressing negative views regarding these patients.
In addition, many physicians do not feel competent treating these patients and do not find the work rewarding. Consequently, patients are not screened for addictions, leaving them to suffer alone.
A vicious circle of ignorance and incompetence is created as these physicians teach medical students and mould the students’ views to mirror their own. This is reflected in numerous studies that show students express increasingly negative feelings regarding addiction patients as they progress through medical school.
Finding a solution to this problem is critical as the incidence of mental illnesses is increasing in Canada. Teaching students about effective screening tools and referrals to appropriate services can improve identification and quality of care. It is necessary to not only dedicate an appropriate amount of time, but also to use different forms of teaching methods (small-group discussions, role-play and traditional didactic lectures) to ensure that the allocated time is used in the best possible way and with the greatest impact.
Giving students the opportunity to become familiarized with addiction patients under physician guidance can provide them with an example to follow in their own practice. Gaining exposure by attending Alcoholics Anonymous meetings can allow students to see the non-medical implications of this disease. Furthermore, creating standards regarding addiction medicine curricula can help create congruency across the undergraduate medical education system. Also, remembering that education is not solely about the student but the teacher as well requires the development of programs to teach faculty members about addiction medicine in order to help them revise their negatives attitudes.
Undoubtedly, overcoming the stigma associated with addictions is an uphill battle. However, change must begin immediately to ensure that future generations will receive the full benefits of our Canadian healthcare system. A stronger education system will lead to a culture shift, allowing addiction patients to receive the best possible care, so they do not suffer alone.
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Your article raises valid points on addiction education in medical school. There’s an adage which states, “what you don’t know could kill them/you”. Alcohol is a disease it affects every part of the human body. And with millions of people consuming alcohol we need to know about it’s progression.
Thank-you for this article. I worked in the field of addictions, in community development and consultation, for over 20 years. So few physicians were equipped to deal with addictions in their patients–and yet, of course, so many of their patients had substance use problems. It is not yet even standard practice to screen for substance use problems (there are many short [e.g., four-question] screening tools, reliable and valid, which can be easily incorporated into conversations with patients).
Furthermore, many physicians have been (inadvertently) instrumental in creating substance use problems in their patients through prescribing practices. The most frustrating experiences I had were with such physicians, who, having helped to create a problem of opioid dependence, then refused to engage in such harm reduction practices as methadone maintenance treatment. It was difficult to even attract physicians to professional information sessions on the topic.
%featured%There is a plethora of sound research and clinical evidence available. It should certainly be incorporated into initial, and continuing, medical education.%featured%
Thank-you again.
Thank you so much for your comment, K. Kilburn! I appreciate it!
Fantastic article. As a incoming medical student, I am now motivated to not only advocate for addictions education, but also to search for avenues to further my knowledge in addiction medicine.
Thanks for the comment I.
Awesome post.
Thank you DC for the generous words. I appreciate it!
Medical students are also not exposed to the science of medicine; pathological education has been basically eradicated from medical school in favor of soft-sessions, social work sessions, PBL sessions, and other sessions of dubious value.
The fact of the matter is that numerous social, political, and academic groups clamor to thrust their ideologies upon medical education, leaving the most important part – the medicine – by the wayside.
%featured%I am all for making addiction medicine a more prominent part of medical education, but what will be sacrificed for it? More science? More of the knowledge that underpins the practice of medicine?%featured%
Medicine is both an art and a science. The decades-long fad that claimed medicine could be reduced to science alone was discredited by its own failures. I for one appreciate the renewed focus on the art of medicine.
As for the implication that addiction medicine is somehow soft, ideological, or non-scientific, tell me: how you would manage post-op alcohol withdrawal after an emergency trauma surgery? What medications would you administer and in what does? How about a GHB withdrawal on your internal medicine unit? Would you administer valium, fenobarb or something else? What protocol to follow if/when they seize? What about the obstetrical patient who is stable on methadone? How do you manage her methadone while ensuring a safe pregnancy? How do you treat her baby’s withdrawal symptoms once it’s born? These are scientific questions and they have answers based on the best available evidence, just like the rest of medicine. Moreover, they are questions that are not just relegated to a single specialty. They impact surgery, medicine, obstetrics, paediatrics, psych and family medicine at the very least. And the knowledge of many of these clinicians is currently sorely lacking..
Thank-you for this clear and well-argued reply.
Thank you for this comment! Couldn’t have said it better myself.
Great post, thank you. Yes more education and discussion necessary to help end addiction stigma but the first step must be the acknowledgement that illegal/illicit drugs are not the only ones that cause problems. Prescription drugs such as opioids are molecularly similar to illegal drugs and wreak havoc on the brain’s pleasure/reward system and as such are as dangerous as illegal drugs. Legal does not mean safe. As long as we continue to tell patients that opioids are ‘safe as prescribed’ we help fuel stigma.
Ada, I agree with your comment that illegal drugs are not the only problem. Prescription drugs can be just as dangerous. If 1/10 people are suffering from alcohol or illicit drug dependence, I can only imagine how this number would be impacted if prescription drugs were also taken into account. Thank you for the comment.