Prescription for Improved Treatment System Must Include Physicians

Education, training, and infrastructure-development would go a long way towards getting doctors to screen their patients for addiction and to advocate for treatment and recovery, according to physicians who took part in Join Together's inaugural Demand Treatment Institute.

But it will also take another kind of motivation to rouse doctors from their current apathy: money.

Like other members of society, many doctors are biased against people with addictions. In conservative communities, attitudes may reflect commonly held beliefs about the fundamental nature of addiction being moral, not medical. Other physicians find the evidence supporting the disease concept of addiction unconvincing. And many simply believe that alcohol and other drug abuse is not treatable.

In Boise, Idaho, for instance, there are “heavy moral overtones” to treating addiction that must be overcome before doctors can be educated about screening patients or making referrals, says Mike Mercy, M.D., medical director and chair of the Department of Emergency Medicine at St. Alphonsus Medical Center.

“We're trying to show doctors that in our own minds we have a prejudicial picture of people with addictions,” he says. “We want them to understand that this a community problem and to understand the extent of the untreated addiction problem. That's the only way to get leaders to understand that it's a disease like diabetes or cancer.”

While methamphetamine gets most of the media attention in Boise, Mercy believes that educating people about the pervasive abuse of alcohol and the similarities between legal and illegal drugs is the best way to get physicians and others to overcome their biases. “Data is the key to convincing people that [the addiction patient] is the person who lives down the street, or who works next to you, or your father,” he says. “If we can convince them that it's a problem throughout the fabric of the community, there will be more incentive to ante up some money and put together some programs to treat people.”

Even when doctors embrace the disease concept, doubts often linger about the efficacy of addiction treatment and the prospects for long-term recovery. “We've wasted too much time and effort on things that don't help,” said Jennifer Smith, M.D., a general internist at Cook County Hospital in Chicago. “We've made too many referrals of people who don't want to go, and that's very demoralizing; it makes providers cynical and not respectful of treatment.” Because of the perceived intractability of addiction and the inadequacies of the treatment system, Mercy says, “Doctors have trained themselves to overlook drug problems and just deal with the complications.”

Better screening, along with empirical evidence on outcomes, would certainly improve treatment's image in the general medical community. But doctors like Smith, who gained valuable perspective on addiction and recovery while working in a Salvation Army community health center, can also provide invaluable peer-to-peer testimonials. “I feel that addiction is something that every general internist should have knowledge of,” she said. People with addiction problems “are an incredibly rewarding group of people to work with,” adds Smith. “It's very challenging, and there are some painfully sad stories, but there's also a lot of really wonderful changes. It's exciting to see someone go from being completely miserable to being in recovery.”

“Doctors and nurses are dying to do a better job,” stresses Smith. “They do not want to see the same patients coming back over and over again with the same problems. As much as they do have negative attitudes and stigma, on the other hand they are self-selected to want to help people do better.”

Even doctors with the best intentions are often hamstrung in their attempts to assist patients, however, because they lack the training and tools to do so. To address this problem, the Chicago/Cook County Demand Treatment plan includes teaching doctors at five area medical schools about addiction technology, screening, and assessment.

Smith, who instructs other doctors on how to screen patients, says primary-care physicians need to know what kind of assessment is appropriate in their setting, where patients can be sent for more help, and what some of the options are for the two-thirds of patients with addiction problems who say they don't want to go to a treatment program.

Smith is especially high on the use of motivational interviewing as a brief-intervention technique for addictions, which she says has been embraced by the addiction field and mainstream medicine alike. Many doctors already use motivational interviewing to address such problems as asthma and diabetes, she points out. “The degree to which I can identify skills that doctors already have and use in another context, and apply them to substance abuse, makes it less scary,” Smith says.

When speaking to doctors, Smith also stresses the similarities between addiction screening and the widely accepted stop-smoking interventions conducted by physicians. “We need to move doctors from hopelessness to strategy,” she says.

Under Boise's Demand Treatment initiative, city agencies plan to develop a standard intake procedure that will include screening for addiction, and local hospitals will help design a system to document treatment referrals. Unfortunately, emergency-room physicians in Boise often see no point in screening people for alcohol or other drug problems, because there is no referral system in place, and few treatment programs available, says Mercy. “There are lots of people coming through my ER who need help, and I have no way to help them,” he says. “The infrastructure doesn't exist.”

Part of the Boise Demand Treatment project will be to advocate for more accessible treatment services. But Mercy argues that most physicians won't really get behind treatment until health insurers start to take it seriously. “Physicians have abdicated their role in caring for this disease partly because they don't get reimbursed for it,” he says. “If reimbursement rates go up, more doctors will be interested in treatment. Insurers don't like to pay for things that are preventable and have a high relapse rate, so it may have to be mandated by government.”

Physicians can be a tremendous asset in the fight to win parity coverage for addiction treatment, the doctors who spoke with Join Together agree.

For example, Ken Thompson, M.D., an associate professor of psychiatry at the University of Pittsburgh School of Medicine, is not only involved with the Pittsburgh/Allegheny County Demand Treatment project, but has also been a member of the Coalition for Leadership, Education and Advocacy for Recovery (CLEAR) for the past decade. “When doctors do use their bully pulpit, people will listen to them,” says Thompson. Unfortunately, he adds, “There isn't a lot of physician leadership on community health issues, and psychiatrists are among the most reticent. We're notorious for being listeners, not talkers.”

On the other hand, Thompson says, the issue of managed care has brought many physicians out of their shell, and he believes initiatives like Physician Leadership on National Drug Policy can help focus practitioner attention on addiction treatment. “We have to engage the doctors out there who don't think it's their issue,” he says. Adds Mercy, “Demand Treatment should be a rallying call, especially for primary-care doctors and the psychiatry field.”

Doctors have a unique capacity to help reframe the debate over addiction treatment, points out Smith. “Physicians speaking about addiction as a medical problem is very powerful,” she says. “In debates like spending money on treatment rather than prison, for a real transition to take place we need the medical community to come on board. The treatment field can't do it alone.”

Original feature article, Join Together Online (www.jointogether.org), April 26, 2001.

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