Survey of doctors' fears of patient opioid use shows gap in addiction education
Nearly a decade into the opioid epidemic and in the shadow of the COVID-19 pandemic, physicians in America seem to remain uncertain about how to identify and treat patients with addiction disorders, a new survey shows.
Quest Diagnostics recently released its latest Health Trends report, Drug Misuse in America 2021: Physician Perspectives and Diagnostic Insights on the Drug Crisis and COVID-19, conducted by the Harris Poll, which reveals physicians' worries and fears about recognizing addiction and affects of the pandemic on people who use drugs.
The doctors' responses show a troubling, yet unsurprising, lack of understanding about opioid use disorder, addiction specialists say.
"Most physicians cannot recognize early signs of drug misuse by their patient," said Dr. Roberto Soria, chief medical officer of the Crossroads Center, a methadone clinic in Corryville. "But not just in the pandemic."
The survey, for which Quest Diagnostics partnered with the nonprofit Partnership to End Addiction in New York City, included these key findings:
Nearly 80% of physicians fear patients will turn to illicit fentanyl if they cannot get a prescription medication.
Almost 70% of physicians fear that they missed signs of drug misuse or use disorders in one or more of their patients during the pandemic.
3 in 4 believe that telehealth limits the ability to detect drug misuse.
78% say they want more information on how to monitor for prescription drug addiction.
"Despite the availability of effective screening, intervention and treatment options for opioid misuse and opioid use disorder, health care professionals continue to feel ill-equipped to manage this enormous and growing problem within their clinical practices," said Linda Richter, vice president of prevention research and analysis at the Partnership to End Addiction.
The survey results come as the United States faces a record high number of overdose deaths. The federal Centers for Disease Control and Prevention last month released a provisional count of 100,306 drug overdose deaths from May 2020 to April 2021. The new record follows a previous record 93,000 overdose deaths in 2020, indicating that the pandemic has exacerbated the epidemic.
The Quest survey follows U.S. Drug Enforcement Administration reports of a staggering increase in illicit fentanyl, including pressed pills that are prescription opioid look-alikes. Fentanyl is a powerful synthetic opioid that has been identified as the primary killer through overdose.
The research, Quest says, "reveals that physicians need comprehensive resources to identify risk, combat drug misuse and care for suffering patients."
Doctors missing understanding of addiction, prescribing
"They need to know how to manage patients’ pain more safely, how to talk confidently and compassionately with patients about the risks of opioid misuse," Richter said, "and know how to intervene early with those at risk to keep prescription opioid misuse from leading to a problem with illicit opioids, including fentanyl."
Soria said the survey reveals a clear lack of understanding of substance use disorders. For example, he said, "If a patient obtains fentanyl because they did not get an Rx, they had a problem to begin with. And this is addressed by better physician education in identifying the patients at risk for developing or exhibiting addictive behaviors."
Dr. Mina "Mike" Kalfas, an addiction specialist with Journey Recovery in Crestview Hills, said the physicians' fears are unsurprising. The message for the past 10 to 15 years has been to limit opioid prescribing, he said, but many doctors have adopted blanket nonprescribing as a result.
"The general answer wasn't (learning) how to prescribe safely," Kalfas said. "It was, 'I am just not going to prescribe at all.' "
Kalfas said alternative methods – from prescribed ibuprofen to physical therapy – should be the first line of treatment for pain. But he added, "There should be a vetting process and ability to prescribe for the people with extraordinary circumstances and suffering horrific pain conditions." And physicians should understand it, as well as whether someone is addicted to pain medication.
Question-answer tool can help doctors assess for addiction
The survey indicates an insecurity about the use of telehealth, a practice that has soared during the pandemic, in identifying people with substance use risks. Cincinnati-area doctors agreed it isn't a perfect system, but say that a consultation by phone or internet still can raise red flags.
"In person, I might notice their arms. I might notice their behavior, notice them fidgeting," Kalfas said. But, he added, there are oral assessments for opioid misuse that are available to all physicians and can help identify at-risk patients.
One widely used assessment comes from the American Society of Addiction Medicine. It's a continuum of questions that uses "research-quality questions … to generate a comprehensive patient report which includes a recommended level of care determination." The organization of addiction specialists says the tool lets clinicians and nonclinicians assess patients with addictive, substance-related and co-occurring conditions through computer-guided, structured interviews.
Dr. Kevin Hartman, a primary care provider with Mercy Health Physicians in Fairfield and chief medical officer of Bon Secours Mercy Health's physician group, had this response to the telehealth dilemma: "In my opinion, this is reflective of learning how to effectively deliver care through a new modality rather than an inherent limitation of telehealth."
How were signs of addiction missed during pandemic?
People who use drugs themselves said the coronavirus pandemic hurt their mental health, "including by exacerbating use of alcohol or drugs … in the past year," the 2020 National Survey on Drug Use and Health, released in October, shows.
Hartman said that, at the beginning of the pandemic, all eyes were on the COVID-19 impact itself.
"As a primary care provider, the concern over missed signs of drug misuse or substance use disorders is a reminder to me of what all physicians learn in medical school: We should not make assumptions about our patients, and it is important to ask open-ended questions in a nonjudgmental manner," Hartman said.
Med students have more education, but more needs to be done
The cry for more substance-use disorder training for medical students has not gone unheard.
"There has been more of an attempt to improve medical education around substance use disorders," Richter said, "but … it’s not nearly enough in terms of its scope and reach yet."
Kalfas has seen more interest among students to follow an addiction-specialist track, he said, but also an increased awareness that any physician should be able to recognize signs of addiction and direct patients to appropriate care.
Even so, the addiction specialists said it is clear that physicians need more help in their own practices.
"My best recommendation," Soria said, "is to educate, educate."
This article originally appeared on Cincinnati Enquirer: Quest survey: Physicians remain uncertain in addiction education
