A new study has identified the top reasons why some physicians may be reluctant to intervene in addiction. The comprehensive review, pulling 283 studies published on this topic within the last 61 years, showed that "institutional environment" was the reason most frequently reported in these studies. "Institutional environment" refers to factors like lack of support from a physician's institution or employer; insufficient resources, such as staff and training; challenges in organizational culture; and competing demands. This reason was cited in 81% of the studies reviewed, followed by insufficient skill (74%), lack of cognitive capacity to manage a certain level of care (74%), and inadequate knowledge (72%).
Around 66% of studies cited negative social influences - or beliefs about public and community acceptance of addiction care - while 56% of studies cited fear of harming the patient-physician relationship as deterrents for physicians to intervene in addiction. These may represent the manifestation of stigma associated with substance use disorder, the authors say. Reimbursement concerns for the cost of delivering addiction interventions were also observed.
The study's findings point to the need for institution-wide changes to improve the adoption of evidence-based substance use disorder treatment practices among physicians. These changes include increasing organizational support, leadership and staff buy-in, and education and training. The study, published in JAMA Network Open, was led and funded by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health.
"People with substance use disorders must be able to access compassionate and evidence-based care at any touchpoint they have with a health care provider," said Nora D. Volkow, M.D., Director of NIDA. "To make that vision a reality, clinicians across all medical disciplines need greater training, resources, and support in caring for people with addiction, so that they feel prepared to proactively offer prevention, screening, treatment, harm reduction, and other tools that can help save lives."
Despite effective interventions for treating substance use disorders, including medications and behavioral therapies, adoption of these practices remains low and demand exceeds treatment capacity. In 2022, nearly 49 million people in the U.S. had at least one substance use disorder, though only around a quarter (13 million people) received treatment in the past year. More than 9 million adults needed treatment for opioid use disorder in 2022, but fewer than half (around 46%) received any form of treatment, and only 25% received medications for opioid use disorder. Although recent federal policy changes have reduced barriers to addiction treatment, helping to boost the number of prescribers of the opioid use disorder medication buprenorphine, for example, this has not yet translated into more patients receiving treatment.
To better understand factors limiting treatment access, researchers reviewed studies from 1960 to 2021 focusing on physician-described barriers to adopting evidence-based practices for addiction. The researchers pulled studies from within this 61-year time period to ensure data collection was comprehensive, though they note approximately 97% of studies were published in 2000 or later, with the number of studies increasing over time. Analyzed studies - most of which reported survey data - were taken from various science literature databases, and data included feedback from 66,732 physicians, primarily in general practice, internal medicine, and family medicine. Alcohol, nicotine, and opioids were the most often studied substances, and screening and treatment were the most often studied interventions.
The study also examined factors that facilitate physician intervention in addiction, and suggests potential benefits of community outreach efforts, educational materials for patients and families, and public health campaigns that promote non-stigmatizing language.
The researchers conducted this study using standard systematic review protocols. They note that many of the studies did not use or report best practices in survey development and there was inconsistency in terminology and reporting. A future direction for this field should therefore focus on development of high-quality studies that address these limitations, the authors say.
"Developing new addiction treatments is crucial, but it is equally important to rigorously study how to implement these treatments so that they make it into the doctor's office and reach the people who need them," said NIDA Deputy Director Wilson M. Compton, M.D., a senior author on the study. "Survey results have helped us better understand the treatment landscape, so the next step is to test ways to change behavior and attitudes around providing addiction treatment, in order to break down barriers to the addiction care that people seek."
As treatment practices evolve over time, the authors also recommend future studies closely examine the role of stigma on limiting treatment implementation, as well as explore the unintended impacts of increased physician intervention, such as strain on the physician-patient relationship, less opportunity for the physician to meet the patient's other healthcare needs due to focus on addiction, and the possibility of the patients facing stigmatizing interactions with other healthcare providers due to wider documentation of their substance use disorder diagnosis.
