One of the greatest challenges facing US public health today is addressing the rise of substance use disorders (SUDs). Addiction and overdose, their impact on care practitioners and the community, and how to effectively treat patients are at the forefront of ongoing vigorous debate within the health care sector and extend into society.
During a Featured Plenary at the 2023 ACGME Annual Educational Conference entitled Preparing Learners to Care for Patients and Communities Experiencing Substance Use Disorder, three experts discussed their unique experiences in treating and creating learning environments for physicians and other care practitioners to treat SUD. Moderating the session, ACGME Chief Research, Milestone Development, and Research Officer Eric Holmboe MD, MACP, FRCP asked how we can move forward to provide the education and training to help combat this crisis. He noted that the “overarching goal is a public health approach that informs a minimum standard of competence” that targets all aspects of the health care professions.
The panelists emphasized the magnitude of the impact of SUDs on society. Citing the number of addiction deaths in the US with the most recent year of statistics, Stephen Loyd, MD asked, “107,622, what’s that?” He answered his own question: “It’s a loaded 747 airplane crashing every 36 hours around the clock for a year.”
Charlene M. Dewey, MD, MEd, FACP noted the role of prescribers, as well as the public health care system and community at large, and urged for more focus on the roots and causes of mis-prescribing. “These are generally well-meaning-intentioned physicians,” she noted, arguing that most are simply unprepared to manage this crisis.
The presenters lamented that only one of 10 SUD patients receives care. Jeanette Tetrault, MD, FACP, FASAM asked the audience to imagine that same rate of care for diabetes, heart disease, or cancer.
Pervasive and Damaging Stigma
A key theme surrounded how to avoid stigma when discussing SUDs. “We absolutely cannot talk about quality education unless we address stigma as a barrier to access to care,” said Dr. Tetrault.
“Stigma not only exists in our profession, but exists in our institutions,” warned Dr. Loyd, noting challenges that come from structural stigma. Dr. Dewey reminded the audience to avoid shame or guilt as a tactic to addressing SUDs.
Dr. Tetrault also offered perspective on how stigma is attached to certain SUD treatments. For instance, some argue that methadone is substituting one habit for another, while naloxone may be enabling the use of opioids. “Even these evidence-based treatments carry stigma,” she said.
“Without refining this foundation, we’ll continue to perpetuate a broken treatment system that keeps 90 percent of people out of care,” she concluded.
“One thing we constantly hear is, ‘how come nobody taught us this in residency,’” said Dr. Dewey, discussing the “transformative” remediation course on proper practice developed at the Vanderbilt Center for Professional Health (CPH), which was expanded through an Association of American Medical Colleges grant to provide training to the 10 US states with the highest opioid prescription rates. Under this program, he explained, one person could impact more than one hundred faculty members and one thousand prescribers at a very low cost.
“With available tools, experiences, and knowledge,” Dr. Dewey asked the audience, “why isn’t the proper prescribing of controlled prescription drugs mandated for all trainees?”
Calling SUDs one of the “most pressing issues of our time,” Dr. Tetrault discussed her own experience in weaving SUD treatment into the curriculum at Yale to prepare learners to “compassionately care” for patients and communities. She noted that this curriculum reaches beyond residency, also involving physician assistants, nurses, and addiction psychiatry fellowships. She discussed the relatively new but rapidly growing specialty of addiction medicine, which has been accredited by the ACGME since 2018 and now serves approximately 7,000 patients annually.
The American College of Addiction Medicine, where Dr. Tetrault currently serves as president, boasts 93 accredited fellowship programs and is on track to graduate 600 fellowship-educated physicians this summer. “It’s not enough,” she argued, noting a “huge swath” of the country where addiction medicine fellowships are lacking.
Leaving few dry eyes in the room, Dr. Loyd discussed the journey of two SUD patients: one of his patients and himself. He juxtaposed the difference in care that each received. He noted that physicians with SUD challenges who get help have a 90-95 percent success rate over five years. On the other hand, the help available to him as a physician was not available to others experiencing SUD, like his patient. Many of these patients, he asserted, enter the criminal justice system, warning that we cannot “incarcerate our way out” of this crisis. “[My experience] should be the norm, mine should not be…an exception,” he said.
After leaving his care due to system circumstances, Dr. Loyd’s patient, Brooke, passed away from an overdose.
“Brooke is a system death,” he said as his voice broke, turning to the audience and emphasizing the absolutely critical need for SUD care training. “If your trainees don’t understand,” he said, “you’ll have a high likelihood of [patients] dying.”
Dr. Loyd, now sober, has devoted his practice to caring for those living with SUDs.
And despite the sad outcome of this case and many others, Dr. Loyd reminded the audience of the good this type of work does, and the value of each positive outcome. He optimistically reflected on the most exciting part of this job: “we get to watch people’s lives change.”