Despite the high prevalence of addiction and substance use disorders in the United States, the number of physicians adopting evidence-based substance use disorder interventions in their clinical practice remains low. A team of investigators, including University of Colorado Department of Medicine faculty member Jarratt Pytell, MD, MHS, aimed to find out why.
Through a systematic review of 283 previous studies published between 1960 and 2021, the team found that the most common reasons given by physicians to explain their reluctance were a lack of institutional support, knowledge, skill, and cognitive capacity.
The resulting research article, "Physician Reluctance to Intervene in Addiction," was published July 17 in the JAMA Network Open, and it was highlighted in a National Institutes of Health news release. The study was funded by the National Institute on Drug Abuse.
"We have a lot of evidence-based interventions that are not being delivered by physicians. We wanted to understand what factors make physicians reluctant to address addiction in their clinics," says Pytell, an internal medicine and addiction medicine physician and assistant professor in the CU Division of General Internal Medicine. "Across the board, a lack of institutional support was the most commonly cited reason in the studies we reviewed."
We recently spoke with Pytell to discuss this research, its findings, and what he thinks needs to change to improve patient care for people with addiction and substance use disorders.
This interview has been edited for length and clarity.
Can you explain why this research was needed?
There is a huge disconnect between the number of people who would benefit from addiction treatment and the number of people who are actually treated. The motivation of this research was to comprehensively look at why that gap exists by looking at what previous research has found that explains physicians' reluctance to intervene.
Examples of evidence-based interventions that physicians can incorporate into their clinic include screening for substance use disorders, giving referrals to treatment, and offering behavioral therapies and pharmacotherapies for nicotine, alcohol, and opioid use disorders. Other harm reduction approaches include co-prescribing naloxone — a medication that can reverse an opioid overdose — providing fentanyl test strips, and participating in syringe service programs.
We know what works. This systematic review shows where the barriers are to delivering these interventions.
The systematic review covered articles from 1960 through 2021. Why was 1960 the starting point?
We wanted to look back as far as possible, and one of the first studies we could find on this topic was in 1960. Although we looked back to the 1960s, about 97% of the studies we reviewed had been published in the year 2000 or later, so most of the literature was relatively new.
The research team you were a part of was unique. Can you share more about who was a part of the team?
It was an ideal group, as it included researchers at the National Institute on Drug Abuse, clinicians and investigators at other institutions, as well as people who have lived experience using drugs. In research, we too often forget to include what the patient experiences, and so it was important to have someone with lived experience on the team — and to make sure they felt valued and comfortable sharing their thoughts. They were actively involved in all stages of this research process.
This inclusive team makes our research more impactful because we're thinking about who we're writing for. We're not just writing for other clinicians and researchers, but for our patients and more generally for people who use drugs. That's what sets this paper apart from many others.
Based on the analysis, the most frequently reported reason for physicians' reluctance to address substance use and addiction in their clinical practice was a lack of "institutional support." Can you explain what that means?
Institutional support encompasses a lot. For example, it means having access to multidisciplinary teams and the ability to access the right referral network. A doctor might not ask their patient about drug and alcohol use if they don't know how to help the patient afterward or where they should send them afterward.
Ultimately, institutional support refers to something that the institution helps clinicians do in terms of giving them the time, space, and resources to help patients with addiction and substance use disorders. It's a broad definition, but it encompasses all those elements.
The other top reasons physicians reported were insufficient skills and a lack of knowledge. When you saw those results, what were your takeaways?
Typically, if physicians were not taught how to incorporate these interventions during their training, then they have few opportunities to acquire those skills later, particularly if they are in a busy primary care practice.
However, I am optimistic that the tides are turning in terms of the exposure to this during training. The CU Internal Medicine Residency Program has a wonderful training environment for addiction medicine, as well as access to addiction medicine specialists and clinics, so I think our residents will enter the workforce ready to intervene in addiction.
An issue is that most care in the U.S. is not delivered by new doctors, but rather physicians who've already been practicing. So, how do we support those clinicians when they need to acquire new skills? That's a hard question. Right now, all physicians are required to complete a one-time, eight-hour training, but that is not the sort of sustained support and education physicians need. I think it goes back to the need for institutional support and an investment to get physicians the opportunities to gain a new skill.
The research article touched on the influence that stigma can have on delivering care. For instance, about 66% of the studies your team analyzed cited negative social influences or beliefs about public and community acceptance of addiction care as reasons for physicians' reluctance to intervene. How much of a barrier do you think stigma continues to be?
Stigma is a really important factor and a big issue. When clinicians have highly stigmatized views toward patients who use drugs and alcohol, they are more likely to treat the patients differently and developing a therapeutic alliance is often more difficult. Many patients don't continue seeing their physician if they do not feel like there is a good relationship there.
Something I found interesting was that some physicians worried that bringing up these topics would ruin the relationship they have with their patients by making patients feel judged. This is more of an example of social stigma, as opposed to an interpersonal stigma. It highlights our need to have standardized, non-stigmatizing assessments that are part of routine care for all patients, no matter who they are or what they are seeing their doctor for, to normalize the discussion around drug and alcohol use in outpatient and inpatient settings.
What were your main takeaways from this research? Based on what you found, what changes would you like to see to improve patient care?
As a primary care physician, I know that simply asking primary care physicians to do more without giving them the resources, systems, training, and education they need will not work. To me, this research shows we need more investment in general medical settings and primary care. There needs to be an investment in workforce development to get more counselors, more peer recovery coaches, and more physicians in training exposed to addiction medicine.
It's really hard to help a person recover from their substance use disorder if they are experiencing homelessness, have trouble accessing transportation, or face food insecurity — all of which are elements of the social determinants of health.
If we're going to help treat substance use disorders, we have to take a more expansive view of what treatment is and think about factors such as housing, nutrition, and transportation as part of treatment. When a patient is not having their basic needs met, it is really hard for them to enter into treatment or recovery. If a primary care physician is seeing a patient who needs help with education, employment, or housing, then simply prescribing a medication isn't going to address those issues.
We need our institutions, including the health care systems, to advocate for our patients at the state and federal level, because if we're going to help people improve and reach sustained recovery, then I think that we, as an institution, must focus on all of those social determinants of health.
What do you think are the next steps for research on this topic?
Personally, I think we should take this systematic review — which increased our understanding of what the barriers are for physicians — and use an implementation science lens to figure out how to bring more evidence-based practices into general medical settings like primary care.
For our local research group, we're going to focus on figuring out how to address these barriers that have been described so we can show how we can bridge this gap of addiction treatment in primary care and other general medical settings.
