Medical training to effectively support patients who use substances across practice settings: a scoping review of recommended competencies
DOI:
https://doi.org/10.36834/cmej.75973Abstract
Background: The responsibility for addressing the healthcare needs of PWUS is the responsibility of all physicians. Within the healthcare system, research consistently reveals inequitable experiences in healthcare with people who use substances (PWUS) reporting stigmatization, marginalization, and a lack of compassion.
Objectives: The aim of this scoping review was to find and describe competencies being taught, developed, and fostered within medical education and then to provide recommendations to improve care for this population of patients.
Results: Nineteen articles were included. Recommended knowledge competencies tend to promote understanding neurophysiological changes caused by substances, alongside knowing how to evaluate of ‘risky’ behaviours. Commonly recommended skills relate to the screening and management of substance use disorders. Recommended attitude competencies include identifying personal bias and establishing a patient-centered culture among practice teams. The disease model of addiction informed all papers, with no acknowledgement of potential beneficial or non-problematic experiences of substance use. To enhance knowledge-type competencies, medical education programs are advised to include addiction specialists as educators and prevent stigmatization through the hidden curriculum.
Conclusion: To reduce experiences of stigmatization and marginalization among patients who use illicit substances and to improve quality of care, knowledge, skills, and attitudes competencies can be more effectively taught in medical education programs.
References
Statistics Canada. Alcohol and drug use in Canada, 2019 2021 Available from: https://www150.statcan.gc.ca/n1/daily-quotidien/211220/dq211220c-eng.pdf [Accessed on Jan 25, 2024].
Government of Canada. Substance use spectrum 2023 Available from: https://www.canada.ca/en/health-canada/services/substance-use/about-substance-use.html. [Accessed on Feb 25, 2024].
Touesnard N, Patten S, McCrindle J, et al. Hear us, see us, respect us: respecting the expertise of people who use drugs (3.0). Zenodo 2021. https://doi.org/10.5281/zenodo.5514066
McNeil R, Small W, Wood E, Kerr T. Hospitals as a “risk environment”: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med 2014 Mar; 105:59–66. https://doi.org/10.1016/j.socscimed.2014.01.010 DOI: https://doi.org/10.1016/j.socscimed.2014.01.010
Velez CM, Nicolaidis C, Korthuis PT, Englander H. “It’s been an experience, a life learning experience”: a qualitative study of hospitalized patients with substance use disorders. J Gen Intern Med. 2017 Mar; 32(3):296–303. https://doi.org/10.1007/s11606-016-3919-4 DOI: https://doi.org/10.1007/s11606-016-3919-4
Strike C, Robinson S, Guta A, Tan DH, O’Leary B, Cooper C, et al. Illicit drug use while admitted to hospital: Patient and health care provider perspectives. PloS One. 2020;15(3):e0229713. https://doi.org/10.1371/journal.pone.0229713 DOI: https://doi.org/10.1371/journal.pone.0229713
Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users. J Gen Intern Med. 2002 May; 17(5):327–33. https://doi.org/10.1046/j.1525-1497.2002.10625.x DOI: https://doi.org/10.1007/s11606-002-0034-5
British Columbia Center on Substance Use. A guideline for the clinical management of opioid use disorder. 2017. Available from: http://www.bccsu.ca/care-guidance-publications/. [Accessed on Jan 25, 2024].
British Columbia Center on Substance Use. Provincial guideline for the clinical management of high-risk drinking and alcohol use disorder. 2019 Available from: https://www.bccsu.ca/clinical-care-guidance/. [Accessed on Jan 25, 2024].
Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care. Can Fam Physician. 2019 May; 65(5):321–30.
Spithoff S, Kahan M. Primary care management of alcohol use disorder and at-risk drinking: Part 1: screening and assessment. Can Fam Physician Med Fam Can. 2015 Jun; 61(6):509–14.
Stockley D, Egan R, Van Wylick R, et al. A systems approach for institutional CBME adoption at Queen’s University. Med Teach. 2020 Aug; 42(8):916–21. https://doi.org/10.1080/0142159X.2020.1767768 DOI: https://doi.org/10.1080/0142159X.2020.1767768
Lane DS, Ross V. The importance of defining physicians’ competencies: Lessons from preventive medicine. Acad Med. 1994 Dec; 69(12):972. https://doi.org/10.1097/00001888-199412000-00010 DOI: https://doi.org/10.1097/00001888-199412000-00010
Dagnone D, Stockley D, Flynn L, et al. Delivering on the promise of competency based medical education – an institutional approach. Can Med Educ J. 2019 Mar 13; 10(1):e28–38. https://doi.org/10.36834/cmej.43303 DOI: https://doi.org/10.36834/cmej.43303
Dagnone JD, Chan MK, Meschino D, et al. Living in a world of change: Bridging the gap from competency-based medical education theory to practice in Canada. Acad Med J Assoc Am Med Coll. 2020 Nov; 95(11):1643–6. https://doi.org/10.1097/ACM.0000000000003216 DOI: https://doi.org/10.1097/ACM.0000000000003216
Morris-Williams Z, Monrouxe L, Grant A, Edwards A. Teaching postgraduates about managing drug and alcohol misuse. BMJ. 2012 Sep 4; 345:e5816. https://doi.org/10.1136/bmj.e5816 DOI: https://doi.org/10.1136/bmj.e5816
Royal College of Physicians and Surgeons of Canada. About CanMEDS. Available from: https://www.royalcollege.ca/content/rcpsc/ca/en/canmeds/about-canmeds.html [Accessed on Oct 26, 2023].
Kidd JD, Smith JL, Hu MC, et al. Medical student attitudes toward substance use disorders before and after a skills-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) curriculum. Adv Med Educ Pract. 2020 Jun 30; 11:455–61. https://doi.org/10.2147/AMEP.S251391 DOI: https://doi.org/10.2147/AMEP.S251391
Tricco AC, Lillie E, Zarin Wet al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018 Oct; 169(7):467–73. https://doi.org/10.7326/M18-0850 DOI: https://doi.org/10.7326/M18-0850
Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. Natl Med J India. 2019; 32(1):32–7. https://doi.org/10.4103/0970-258X.272115 DOI: https://doi.org/10.4103/0970-258X.272115
Ayu AP, el-Guebaly N, Schellekens A, et al. Core addiction medicine competencies for doctors: an international consultation on training. Subst Abuse. 2017; 38(4):483–7. https://doi.org/10.1080/08897077.2017.1355868 DOI: https://doi.org/10.1080/08897077.2017.1355868
Ayu AP, Schellekens AFA, Iskandar S, Pinxten L, De Jong CAJ. Effectiveness and organization of addiction medicine training across the globe. Eur Addict Res. 2015; 21(5):223–39. https://doi.org/10.1159/000381671 DOI: https://doi.org/10.1159/000381671
Ashburn MA, Levine RL. Pennsylvania State core competencies for education on opioids and addiction. Pain Med Malden Mass. 2017 Oct 1; 18(10):1890–4. https://doi.org/10.1093/pm/pnw348 DOI: https://doi.org/10.1093/pm/pnw348
Koh JJ, Paterson QS, Ong M, Martin LJ, Woods RA, Dong K. Addressing the opioid crisis in the era of competency-based medical education: recommendations for emergency department interventions. CJEM. 2019 Jul; 21(4):452–4. https://doi.org/10.1017/cem.2019.20 DOI: https://doi.org/10.1017/cem.2019.20
Servis M, Fishman SM, Wallace MS, et al. Responding to the opioid epidemic: Educational competencies for pain and substance use disorder from the medical schools of the University of California. Pain Med Malden Mass. 2021 Feb 4; 22(1):60–6. https://doi.org/10.1093/pm/pnaa399 DOI: https://doi.org/10.1093/pm/pnaa399
Wallace PM, Warrier S, Kahn MJ, Welsh C, Fischer M. Developing an opioid curriculum for medical students: A consensus report from a national symposium. Subst Abuse. 2020; 41(4):425–31. https://doi.org/10.1080/08897077.2019.1635971 DOI: https://doi.org/10.1080/08897077.2019.1635971
Antman KH, Berman HA, Flotte TR, Flier J, Dimitri DM, Bharel M. Developing core competencies for the prevention and management of prescription drug misuse: a medical education collaboration in Massachusetts. Acad Med. 2016 Oct; 91(10):1348. https://doi.org/10.1097/ACM.0000000000001347 DOI: https://doi.org/10.1097/ACM.0000000000001347
Lande RG, Wyatt SA, Przekop PR. Addiction medicine: a model osteopathic medical school curriculum. J Am Osteopath Assoc. 2010 Mar; 110(3):127–32.
De Jong C, Luycks L, Delicat JW. The master in addiction medicine program in the Netherlands. Subst Abuse. 2011 Apr; 32(2):108–14. https://doi.org/10.1080/08897077.2011.555713 DOI: https://doi.org/10.1080/08897077.2011.555713
Jackson AH, Alford DP, Dubé CE, Saitz R. Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design. BMC Med Educ. 2010 Mar 15; 10(1):22. https://doi.org/10.1186/1472-6920-10-22 DOI: https://doi.org/10.1186/1472-6920-10-22
O’Connor PG, Nyquist JG, McLellan AT. Integrating addiction medicine into graduate medical education in primary care: the time has come. Ann Intern Med. 2011 Jan 4; 154(1):56–9. https://doi.org/10.7326/0003-4819-154-1-201101040-00008 DOI: https://doi.org/10.7326/0003-4819-154-1-201101040-00008
Pinxten WJL, De Jong C, Hidayat T, et al. Developing a competence-based addiction medicine curriculum in Indonesia: the training needs assessment. Subst Abuse. 2011 Apr; 32(2):101–7. https://doi.org/10.1080/08897077.2011.555710 DOI: https://doi.org/10.1080/08897077.2011.555710
Schwartz AC, Frank A, Welsh JW, Blankenship K, DeJong SM. Addictions training in general psychiatry training programs: current gaps and barriers. Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2018 Oct; 42(5):642–7. https://doi.org/10.1007/s40596-018-0950-2 DOI: https://doi.org/10.1007/s40596-018-0950-2
Seale JP, Shellenberger S, Clark DC. Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum. BMC Med Educ. 2010 May 11; 10(1):33. https://doi.org/10.1186/1472-6920-10-33 DOI: https://doi.org/10.1186/1472-6920-10-33
Truncali A, Silva K, Stickney I, Johnson M, Holt CT. An asynchronous curriculum to address substance use disorder training needs for medical and surgical residents. J Public Health Manag Pract JPHMP. 2021 Jun 1; 27(Suppl 3):S168–73. https://doi.org/10.1097/PHH.0000000000001305 DOI: https://doi.org/10.1097/PHH.0000000000001305
Rasyidi E, Wilkins JN, Danovitch I. Training the next generation of providers in addiction medicine. Psychiatr Clin North Am. 2012 Jun; 35(2):461–80. https://doi.org/10.1016/j.psc.2012.04.001 DOI: https://doi.org/10.1016/j.psc.2012.04.001
Rutkowski BA. Specific disciplines addressing substance use: AMERSA in the 21st century. Subst Abuse. 2019; 40(4):392–5. https://doi.org/10.1080/08897077.2019.1686726 DOI: https://doi.org/10.1080/08897077.2019.1686726
Scalese RJ, Obeso VT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med. 2008 Jan; 23 Suppl 1(Suppl 1):46–9. https://doi.org/10.1007/s11606-007-0283-4 DOI: https://doi.org/10.1007/s11606-007-0283-4
Pauly BB, McCall J, Browne AJ, Parker J, Mollison A. Toward cultural safety: nurse and patient perceptions of illicit substance use in a hospitalized setting. ANS Adv Nurs Sci. 2015; 38(2):121–35. https://doi.org/10.1097/ANS.0000000000000070 DOI: https://doi.org/10.1097/ANS.0000000000000070
Ti L, Ti L. Leaving the hospital against medical advice among people who use illicit drugs: a systematic review. Am J Public Health. 2015 Dec; 105(12):e53-59. https://doi.org/10.2105/AJPH.2015.302885 DOI: https://doi.org/10.2105/AJPH.2015.302885
Hamovitch EK, Choy-Brown M, Stanhope V. Person-Ccentered care and the therapeutic alliance. Community Ment Health J. 2018 Oct; 54(7):951–8. https://doi.org/10.1007/s10597-018-0295-z DOI: https://doi.org/10.1007/s10597-018-0295-z
Shippee ND, Domecq Garces JP, Prutsky Lopez GJ, et al. Patient and service user engagement in research: a systematic review and synthesized framework. Health Expect Int J Public Particip Health Care Health Policy. 2015 Oct; 18(5):1151–66. https://doi.org/10.1111/hex.12090 DOI: https://doi.org/10.1111/hex.12090
Canadian Medical Association, Canadian Nurses Association. Principles to guide health care transformation in Canada. 2011 Available from: https://policybase.cma.ca/link/policy10218. [Accessed on Jan 25, 2024].
Bacchi C. Drug problematizations and politics: Deploying a poststructural analytic strategy. Contemp Drug Probl. 2018 Mar 1; 45(1):3–14. https://doi.org/10.1177/0091450917748760 DOI: https://doi.org/10.1177/0091450917748760
Kiepek N, Van de Ven K, Dunn M, Forlini C. Seeking legitimacy for broad understandings of substance use. Int J Drug Policy. 2019 Nov; 73:58–63. https://doi.org/10.1016/j.drugpo.2019.07.014 DOI: https://doi.org/10.1016/j.drugpo.2019.07.014
Councillor Swanson. Council member’s motion: 4 Decriminalizing poverty and supporting community-led safety initiatives. 2020. Available from https://council.vancouver.ca/20200707/documents/b4.pdf. [Accessed on Feb 16, 2024].
Culberson JW. Alcohol use in the elderly: Beyond the CAGE. Part 1 of 2: prevalence and patterns of problem drinking. Geriatrics. 2006 Oct; 61(10):23–7.
d’Angelo LC, Savulich G, Sahakian BJ. Lifestyle use of drugs by healthy people for enhancing cognition, creativity, motivation and pleasure. Br J Pharmacol. 2017 Oct; 174(19):3257–67. https://doi.org/10.1111/bph.13813 DOI: https://doi.org/10.1111/bph.13813
Reiff-Hekking S, Ockene JK, Hurley TG, Reed GW. Brief physician and nurse practitioner–delivered counseling for high-risk drinking. J Gen Intern Med. 2005 Jan; 20(1):7–13. https://doi.org/10.1111/j.1525-1497.2005.21240.x DOI: https://doi.org/10.1111/j.1525-1497.2005.21240.x
Kiepek N, Beagan B, Ausman C, Patten S. “A reward for surviving the day”: Women professionals’ substance use to enhance performance. Perform Enhanc Health. 2022; 10(2):100220. https://doi.org/10.1016/j.peh.2022.100220 DOI: https://doi.org/10.1016/j.peh.2022.100220
Kiepek N, Ausman C. “You are you, but you are also your profession”: nebulous boundaries of personal substance use. Contemp Drug Problems. 2023; 50(1):63-84. https://doi.org/10.1177/00914509221132301 DOI: https://doi.org/10.1177/00914509221132301
Cape G, Hannah A, Sellman D. A longitudinal evaluation of medical student knowledge, skills and attitudes to alcohol and drugs. Addict Abingdon Engl. 2006 Jun; 101(6):841–9. https://doi.org/10.1111/j.1360-0443.2006.01476.x DOI: https://doi.org/10.1111/j.1360-0443.2006.01476.x
Kleinman A. The divided self, hidden values, and moral sensibility in medicine. Lancet. 2011 Mar 5; 377(9768):804–5. https://doi.org/10.1016/S0140-6736(11)60295-X DOI: https://doi.org/10.1016/S0140-6736(11)60295-X
Ram A, Chisolm MS. The time is now: Improving substance abuse training in medical schools. Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2016 Jun; 40(3):454–60. https://doi.org/10.1007/s40596-015-0314-0 DOI: https://doi.org/10.1007/s40596-015-0314-0
Lee CS, Abrantes AM, Colby SM, López SR, Jordan TJ. Medical student judgments of adolescents with alcohol use disorders (AUD). Subst Use Misuse. 2008; 43(5):709–21. https://doi.org/10.1080/10826080701202791 DOI: https://doi.org/10.1080/10826080701202791
O’Gara C, Keaney F, Best D, et al. Substance misuse training among psychiatric doctors, psychiatric nurses, medical students and nursing students in a South London psychiatric teaching hospital. Drugs Educ Prev Policy. 2005 Aug 1; 12(4):327–36. https://doi.org/10.1080/09687630500083691 DOI: https://doi.org/10.1080/09687630500083691
Aziz S. Global News. There are growing calls for drug decriminalization. Could it solve Canada’s opioid crisis? 2021 Available from: https://globalnews.ca/news/8359890/drug-decriminalization-opioid-crisis/. [Accessed on Oct 26, 2023].
Zimonjic P. CBC News. Police chiefs call on Ottawa to decriminalize possession of illicit drugs for personal use. 2020 Available from: https://www.cbc.ca/news/politics/chiefs-police-decriminalize-posession-personal-use-1.5643687 [Accessed on Oct 26, 2023].
Toronto Public Health. Exemption request: Request for exemption to the Controlled Drugs and Substances Act to allow for the possession of drugs for personal use in Toronto. 2022 Available from: https://www.toronto.ca/wp-content/uploads/2022/01/943b-TPH-Exemption-Request-Jan-4-2022-FNLAODA.pdf. [Accessed on Oct 26, 2023].
Canadian Association of Chiefs of Police. Decriminalization for simple possession of illicit drugs: exploring impacts on public safety and policing. 2020. Available from: https://www.cacp.ca/index.html?asst_id=2189 [Accessed on Oct 26, 2023].
Government of Alberta. Alberta COVID-19 Opioid response surveillance report Q2 2020. 2020.Available from: https://open.alberta.ca/dataset/f4b74c38-88cb-41ed-aa6f-32db93c7c391/resource/e8c44bab-900a-4af4-905a-8b3ef84ebe5f/download/health-alberta-covid-19-opioid-response-surveillance-report-2020-q2.pdf [Accessed on Oct 26, 2023].
MacDougall L, Smolina K, Otterstatter M, et al. Development and characteristics of the provincial overdose cohort in British Columbia, Canada. PLoS ONE. 2019 Jan 10; 14(1):e0210129. https://doi.org/10.1371/journal.pone.0210129 DOI: https://doi.org/10.1371/journal.pone.0210129
Kiepek N, Jones-Bonofiglio K, Freemantle S, Byerley-Vita M, Quaid K. Exploring care of hospital inpatients with substance involvement. Soc Sci Med. 2021; 281:114071. https://doi.org/10.1016/j.socscimed.2021.114071 DOI: https://doi.org/10.1016/j.socscimed.2021.114071
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