All hands on deck: The urgent need for improved education in addiction medicine
Canada has an issue with addictions.
The opioid crisis has claimed the lives of over 13,000 Canadians since 2016 and has caused the average life expectancy of Canadians to decrease for the first time in recent memory. Alcohol use is related to an average of seven in-hospital deaths daily, and rates of alcohol-related hospitalizations are increasing. Nicotine is responsible for killing 37,000 Canadians yearly, and is the most important cause of premature death in Canada.
Despite these sobering facts, there is reason to be hopeful. Effective therapies for opioid use disorder, alcohol use disorder, and nicotine use disorder exist. Suboxone (buprenorphine/naltrexone) and methadone have been repeatedly shown to reduce mortality, improve adherence to treatment, and reduce rates of criminality. Anti-craving medications, such as naltrexone, have shown significant increases in rates of abstinence and marked reductions in return to heavy alcohol use. Medications such as varenicline, bupropion, and nicotine replacement therapy are far more effective compared to placebo for smoking cessation.
But many health care professionals are unfamiliar with how to prescribe these life-saving medications and care for patients who take them. Why?
One potential reason is that the treatment of substance use disorders has not traditionally been included as a routine part of medical education, leading to an undeniable gap in knowledge. This is because, historically, substance use disorders were seen as a moral issue rather than a medical one. A survey of family physicians in Ontario demonstrated concerning numbers: out of 119 respondents, only four physicians felt comfortable prescribing pharmacotherapies for alcohol and opioid use disorder, and the overwhelming barrier identified was a lack of knowledge.
Thankfully, times are changing, and there is a growing appreciation for the role that health care workers can play in the treatment of substance use disorders. The Royal College of Physicians and Surgeons of Canada recently recognized Addiction Medicine as an Area of Focused Competency (AFC), placing it alongside other specialities, such as thrombosis medicine, hepatology, and sleep medicine.
Although this is a step in the right direction, this does not mean that the treatment of addiction should be limited to those who have chosen to pursue specialty training. After all, it would be impractical if every patient with a deep vein thrombosis (DVT) needed to be seen by a thrombosis medicine clinic! All health care workers must have some understanding of DVT – even if we are not experts, we know the basics, while complex cases are referred to those with specialist training. It should be no different for addictions.
Today, it is impossible to work in the health care field without encountering patients where knowledge of addiction care would be beneficial. Consider the nurse practitioner treating a patient with recurrent cellulitis from injection drug use, the orthopaedic surgeon, anaesthetist and pharmacist seeing a patient for a planned hip replacement on naltrexone for alcohol use disorder, or the internist discharging a patient with active nicotine use after an admission for a COPD exacerbation. While each should not be expected to be an expert in addictions, all of them must have a baseline level of knowledge to care for their patient.
So how do we ensure that the health care workers of today and tomorrow have these fundamental skills? We argue that there needs to be a multi-faceted, national approach in order to close the knowledge gap.
Second, formal education in all health care fields is paramount. Undergraduate medical schools should include evidence-based addiction teaching. Postgraduate training programs must also integrate topics in addiction medicine into their teaching and offer opportunities to develop skills through rotations and fellowships to interested learners. Opportunities for physicians who are already in practice should likewise be expanded. The creation and expansion of training programs for nurses, nurse practitioners, social workers, and pharmacists – such as the ones offered through the BC Centre for Substance Use – would facilitate and strengthen the interdisciplinary expertise necessary to care for these patients.
Finally, providers with experience and/or dedicated training in addictions medicine should be leveraged to facilitate the dissemination of best practices. For larger centres, the development of interdisciplinary Addiction Medicine Consult Teams should be prioritized, as these can reduce self-reported rates of hospitalization and have been estimated to reduce overall health care expenditures. In smaller centres and rural areas, the creation of robust telehealth networks that allow health care providers to speak with an Addiction Medicine specialist in real-time (such as the British Columbia RACE line, or Alberta’s RAAPID call centre) can help provide support where hiring a dedicated Addiction Medicine specialist may not be feasible. These networks could have the secondary benefit of acting as an education hub for interested health care providers. For example, Ontario’s META: PHI is an interdisciplinary initiative that hosts monthly teleconferenced education sessions led by a variety of healthcare practitioners, and provides a mechanism to discuss and learn from challenging cases.
We can no longer afford to ignore the pressing issue of addictions in Canada – too many people are dying unnecessarily because of a lack of access to evidence-based care. The fundamental principles of addiction medicine are something that all health care workers, regardless of discipline, practice setting or specialty need to become familiar with to help stem the tide.
It’s time for all hands on deck.