Recently, the Journal of the American Medical Association (JAMA) published an article commenting on the United States Preventive Services Task Force (USPSTF) recommendation for a "drinking check-up" for all adults when they visit their primary care doctors. For those who consume alcohol above recommended limits, the task force advised doctors to “provide ‘brief counseling’ to help patients reduce their drinking.”
The peer-reviewed article, which came a week right before the prime holiday drinking season, is a good start and an initiative to be applauded. Still, it doesn’t go far enough. The problem runs much deeper than the task force’s guidelines are able to suggest. National data shows that one out of seven patients aged 12 and over currently have a substance use disorder, totaling close to 40 million people. It is an epidemic that places demand on physicians to incorporate patient-centered, evidence-based practices to address substance use.
It’s no easy task. The challenge to clinicians has many layers. How do doctors address and treat a disorder that many still do not recognize as a disease? How does the medical community stress the consequences of substance use and the need for clinical concern if many doctors haven’t studied or been trained in the science or practical skills to address these important questions about a patient’s health?
The answer, as it most often does, lies in education. There is an overwhelming need to ensure that each practicing physician, clinician and medical student undergoes training on substance use, addiction and the core communication strategies necessary to engage patients. It should not merely be a goal or a medical education supplement for clinicians to complete this training. It should be viewed as what it really is: a life-saving medical necessity.
That is not hyperbole. First-hand experience reveals it to be an unmet need. As highlighted in the JAMA article, based on research “one in six patients reports having discussed alcohol with their physician." How can we sever to support our patients if our workflows, combined with hesitation, serve as barriers to identify and intervene? It’s why these USPSTF guidelines are so important and can serve as a springboard to where our industry needs to be.
However, empowering clinicians to address the topic and ensuring that they are able to effectively engage patients, are not the same thing.
In our process of implementing a “We Ask Everyone” strategy that encouraged screening for all possible substance use disorders (including opioids and smoking) via our Screening, Brief Intervention and Referral to Treatment (SBIRT) program, we identified gaps in education. Gaps representing key factors leading to what was widespread avoidance and discomfort with the topic of substance use and misuse (both clinicians and patients).
The discomfort of being tasked to universally address substance use with all patients stemmed from a lack of dedicated education and training, plus other factors, such as stigma, driven by conscious and unconscious biases. Yet, we had an opportunity. This prompted a strategic planning that brought the focus from just the clinical arena, to the educational realm -- from a health system to a medical school. The major takeaway? The need to start training early in the health professional’s career to help them frame the topic with a lens of patience, humility and compassion.
In 2014, a two-hour course on alcohol use was offered at the Zucker School of Medicine at Hofstra/Northwell. By 2018, that educational footprint had been expanded to more than 27 dedicated hours of the “Addressing Substance Use” curriculum which includes sessions on communications, evidence-based screening tools, addiction treatment, pain management, quality improvement, patient and family perspectives and overdose prevention training. Elements of this curriculum are now in play for residency education, faculty development and clinical team education.
This undertaking allowed us to reinforce the expansion of clinical care in support of an under-appreciated disease process. The SBIRT program and accompanying educational experiences we developed, allowed us to rethink, reframe and revisit the use of substances in a humanistic and empathetic way. We were able to emphasize that this was a disease process relevant to usual care and that we needed to find ways to support our patient population and communities by enhancing the awareness, skills and comfort of our clinical teams. In plain English, we are changing the way our doctors and clinical teams are practicing medicine.
When speaking of organizational/industry change and the need to identify clear drivers and barriers for the intended change, the educational gap highlighted opportunities where we could educate the clinicians of tomorrow and as a result, our current clinical team members.
This is an important evolution and can serve as a model for expanding guidelines in medical schools, hospitals and clinician’s office throughout the country. By investing and expanding in the education and training that students, residents and other clinical team members receive, we will ensure that they will be better able to provide structured opportunities for our patients to discuss their substance use with us.
Education, serving as a strategic driver for shifting organizational and industry practices, will empower health care professionals to disseminate the empathetic and humanistic approaches necessary to better address substance use as part of usual care.
Sandeep Kapoor, MD, is director of Screening, Brief Intervention and Referral to Treatment (SBIRT) program at Northwell Health and assistant professor of medicine and emergency medicine at the Zucker School of Medicine at Hofstra/Northwell. He is also a member of the Northwell Health Opioid Management Steering Committee, which is charged to collate a community of solutions to address the prevalent opioid epidemic.
This op-ed appeared in The Hill.