1. Faculty Development in Addiction Medicine: A Family Practice Residency – Private Foundation Partnership Ken Saffier, MD Contra Costa Regional Medical Center FMR, Martinez, CA Steve Eickelberg, MD, and Gail Jara, BA Medical Education and Research Foundation for the Treatment of Alcoholism and Other Drug Dependencies

2. Learning Objectives By the end of this seminar, learners will be able to: 1. Identify the obstacles that often interfere with teaching about substance use disorders. 2. Learn how private foundation support can facilitate faculty development. 3. Describe curricular elements that can improve faculty and residents’ recognition, treatment, and referral of patients with substance use disorders.

3. Missed Opportunities CASA STUDY CASA STUDY 650 PCP’s + 500 patients in CD treatment 650 PCP’s + 500 patients in CD treatment 54% said “PCP DID NOTHING” 11% said “PCP KNEW & DID NOTHING” 32% of PCP’s Screen for Substance Use Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.org www.casacolumbia.org

4. Missed Opportunities: Dx 9 in 10 US physicians fail to spot substance abuse in adult patients. 4 out of 10 miss the diagnosis in teens CASA, 2000, Missed Opportunity CASA, 2000, Missed Opportunity

5. MD’s Most Likely To Diagnose Adult’s Substance Abuse Family practitioner Felt most prepared to diagnose SA Strong believer in tx effectiveness Received CME training in past 5 yrs. Received SA training in medical school Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.org Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.orgwww.casacolumbia.org

6. Patients’ Experience: 55% of PCP’s prescribed drugs that could be dangerous could be dangerous 30% of patients: ”PHYSICIAN KNEW ABOUT PATIENT’S ADDICTION AND STILL PRESCRIBED PSYCHOACTIVE SUBSTANCES.” 75% of PCP’s not involved in TX decision Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.org Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.orgwww.casacolumbia.org

8. Barriers to Implementing Substance Abuse Curriculum in Resident Education Negative attitudes Lack of faculty development and expertise Competition for curricular time Lack of funding, financial pressures Lack of treatment resources Lack of adequate training settings

9. Negative Attitudes AngerAvoidanceDiscouragementFatalismFrustrationFutilityHelplessnessJudgmental

10. Barriers to Implementing Substance Abuse Curriculum in Resident Education Negative Attitudes –Personal/family –Professional –Institutional –Societal/cultural

11. Key Personal Experiences Family of Origin Other relationships WorkProfessional

12. Barriers to Implementing Substance Abuse Curriculum in Resident Education Negative Attitudes –Personal –Professional –Institutional –Societal

13. Factors Contributing to Negative Attitudes Limited positive work/professional experiences Past experiences with difficult patients w/o positive mentoring or role models Overexposure to chronic, relapsing patients Lack of treatment resources Lack of positive training, educational settings Narrow view of professional responsibility Only managing w/d, OD, med complications

14. Barriers to Implementing Substance Abuse Curriculum in Resident Education Negative Attitudes –Personal –Professional –Institutional –Societal

15. Factors Contributing to Negative Attitudes Negative societal attitudes and stereotypes Alcoholics and addicts are the dregs of society. They cause incredible harm to their families and society. Why should we help them? They deserve the self destructiveness they get. Why bother? Treatment doesn’t work. They don’t want to get better. Criminalizing addictive disease

16. Consequences of Negative Attitudes and Behaviors At-risk persons not recognized & screened Affected persons not diagnosed & treated Denial of existence of SA problems

17. Consequences of Negative Attitudes and Behaviors Enabling hi-risk behavior (prescriptions, social support rather than treatment, etc.) Punitive management Patronizing Nagging behavior

18. Barriers to Implementing Substance Abuse Curriculum in Resident Education: A National Survey Most common perceived barriers: (1997 national survey) Lack of time 63% Lack of faculty expertise 33% Lack of institutional support 21% Lack of training sites 21% (n= 309/448 programs) (n= 309/448 programs) Isaacson, J.H., et. al., A National Survey of Training in Substance Use Disorders in Residency Programs, J Stud. Alcohol, 61: 912- 915, 2000

19. Overcoming the Barriers Maintaining and developing positive attitudes: –Clinical experiences (with positive outcomes) –Supervision by expert role model –Ongoing access to addiction medicine consultant throughout training

20. Medical Education & Research Foundation For The Treatment of Alcoholism and Other Drug Dependencies M E R F 575 Market Street, Suite 2125 San Francisco, CA 94105 Medical Education & Research Foundation For The Treatment of Alcoholism and Other Drug Dependencies M E R F 575 Market Street, Suite 2125 San Francisco, CA 94105

21. M E R F 1988 Created MISSION STATEMENT MISSION STATEMENT PREVENT THE HARM BEING DONE PREVENT THE HARM BEING DONE TO PATIENTS BY PHYSICIANS WHO TO PATIENTS BY PHYSICIANS WHO LACK THE KNOWLEDGE, SKILL AND LACK THE KNOWLEDGE, SKILL AND TRAINING TO RECOGNIZE AND TRAINING TO RECOGNIZE AND TREAT ADDICTION TREAT ADDICTION

22. M E R F Private Donations Focus on improving identification and care of patients with substance use problems Educate –Medical Educators –Residents –Medical Students

23. M E R F W H Y ?

24. M E R F Deficient Medical Education about Deficient Medical Education about Substance Use Substance Use Unacceptably low rates of identifying Unacceptably low rates of identifying persons with substance use problems persons with substance use problems Difficulties creating space in Medical Difficulties creating space in Medical School and Residency Curriculum School and Residency Curriculum Committed to overcome Deficiencies, Committed to overcome Deficiencies, Improve identification and Improve Improve identification and Improve patient care patient care

25. M E R F Missed Opportunities – Northern CA Missed Opportunities – Northern CA 627 Alcohol Dependent & Problem Drinkers 926 Consec. Admissions to CD Treatment Interviewed one year later 2/3 ≥ 1 MEDICAL VISITS w/in last year Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July 2003 Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July 2003

26. M E R F PROBLEM DRINKERS -- VISITS TO MD PROBLEM DRINKERS -- VISITS TO MD 65 % had a medical visit in the past year. 65 % had a medical visit in the past year. < 25% had drinking problem addressed. < 25% had drinking problem addressed. Weisner & Matzger; Alc: Clin. Exp. Res., 2003

27. M E R F DSM-IV ALCOHOL DEPENDENT 62% -- Alcohol use NOT addressed during medical visit during medical visit PROBLEM DRINKERS W/O DEPENDENCE 84% -- Alcohol use NOT addressed during medical visit during medical visit Weisner, C. & Matzger, H., Alcoholism: Clin. Exp. Res., July 2003 Weisner, C. & Matzger, H., Alcoholism: Clin. Exp. Res., July 2003

28. M E R F 20 years Organized Medicine Recognizes 20 years Organized Medicine Recognizes Need to Increase Medical Education to Need to Increase Medical Education to Improve DETECTION & TREATMENT Improve DETECTION & TREATMENT NIAAA NIAAA Institute of Medicine Institute of Medicine AMA AMA APA APA AAFP AAFP

29. M E R F 20 YEARS WITHOUT CHANGE 20 YEARS WITHOUT CHANGE No Changes: –Screening Rate or # of Pt’s screened –Recognition/Diagnosis Rate –Number of Patients Discharged with a Diagnosis of Alcoholism –Number of Patients Receiving Psych. or Addiction Consultation Mayo Clinic Proceedings 2001 Mayo Clinic Proceedings 2001

30. M E R F QUALITY OF HEALTH CARE DELIVERED QUALITY OF HEALTH CARE DELIVERED TO ADULTS IN THE UNITED STATES TO ADULTS IN THE UNITED STATES McGlynn, et. al., NEJM, June 2003 McGlynn, et. al., NEJM, June 2003 54% of Recommended/Standard care is delivered for 25 common conditions delivered for 25 common conditions High - 79% - Senile Cataracts Medium - 53% - Asthma Lowest - 10% - Alcohol Dependence

31. M E R F OPPORTUNITIES

32. PRIMARY CARE PRIMARY CARE OUTPATIENT CLINIC VISITS OUTPATIENT CLINIC VISITS > 20% of Patients Seen Exceed NIAAA Alcohol Consumption Guidelines Consumption Guidelines 2 – 9% Prevalence of Alcohol Dependence NIAAA, July 2005 NIAAA, July 2005 9 – 35% Prevalence of Harmful Drinking Fiellien, et. Al., Ann. Int. Med., 2000 Fiellien, et. Al., Ann. Int. Med., 2000

33. M E R F 70 % of population sees PCP at least once every 2 years 200 million patient visits to PCP annually Source: CASA(2000) Missed Opportunity Missed Opportunity

34. M E R F ADDRESSING NEED ADDRESSING NEED WITH EDUCATION WITH EDUCATION

35. M E R F FULFILLMENT OF MERF’S MISSION FULFILLMENT OF MERF’S MISSION Scholarships to multi-day addiction medicine educational conferences/workshops –Residents –Residency Educators/Faculty Mentored learning experience Collegial/group learning environment Basic medical science information

36. M E R F Clinical Problem solving -- Discussion Familiarization discussing substance use, abuse, addiction Improve comfort discussing substance use [demystifying]

37. M E R F Collegial Interaction Facilitated Collegial Interaction Facilitated and Encouraged and Encouraged –Conference faculty –Mentors –Fellow attendees and scholarship recipients –Meals –Special Conference Events

38. M E R F TESTIMONIALS TESTIMONIALS

39. M E R F “I found all elements helpful. The lectures were fantastic. I feel my comfort level with ETOH patients has definitely improved.” “I feel like part of the larger body of people in the field of addiction treatment now.” “The conference provided me with much needed information.”

40. M E R F “Interacting with the experts in the field and other residents and the people at MERF was excellent.” “I wish all of the residents in my program could get this education.” “Very informative…contrary to some teaching at my program, the attitude and approach to dealing with SA was refreshing.”

41. M E R F FROM EDUCATORS “The things I learned.…have already changed my practice and the residents’ education.” “My next step is to incorporate this knowledge into curricular and clinical teaching.” “I felt like I walked away with a new toolbox.…..to use in my teaching.”

42. UC Davis FMR Network 8 residencies, over 200 residents Redding to Merced, Sacramento to Martinez Yearly annual retreat for all residents and some faculty Very supportive residency network director

43. Addiction Medicine at UCD FMR Network Programs Two faculty specializing in addiction medicine with a passion for teaching –Active members of the California Society of Addiction Medicine –Goals: To increase and integrate addiction medicine in residency curricula A variety of didactic presentations and clinical rotations Sharing of resources, presentations

44. Addiction Medicine at UCD FMR Network Programs 3 programs send residents to office-based addiction/family medicine practice (Stockton). Yearly report to residency program directors 3 teleconference meetings/yr. of interested faculty to share ideas, resources

45. ADM Learning Objectives To promote positive provider attitudes to increase screening for substance abuse, referrals to treatment, and improved treatment outcomes. To recognize the many manifestations of addictive disease. To illustrate how substance use disorders are treatable with medical and non- medical interventions.

46. Integrating ADM into One FMR – Martinez “Growing” a faculty with ADM expertise –8 MERF scholarship participants –FP, IM, OB/GYN, BM, Peds Faculty Leadership Group –One member - UCSF Faculty Development Fellowship (also a MERF Scholar) – Addiction Medicine Curriculum Project Quarterly Addiction Medicine Noon Conferences – 3 year cycle Problem Based Learning Seminars

47. Integrating ADM into One FMR (More) clinical experiences into R1 Behavior Medicine rotation Pain and Addiction consult clinic Future: Buprenorphine training for all (including more faculty) Future: Develop, reinforce and document ADM skills on all rotations with our growing ADM faculty.

48. What Do Faculty Want and Need? Survey of Participants Ways to teach –a compassionate approach to SA –Stages of change and motivational interviewing How to teach interviewing skills for addiction issues in time limited primary care settings. Dedicated session for residency faculty addressing effective teaching strategies including role modeling, didactic teaching.

49. Faculty (cont’d): Motivating residents to get interested in addiction medicine as an integral part of caring for poor populations. How to approach teaching residents who have little experience with SA – overcoming stereotypes of SA’s. Learn more about the biological aspects of addiction

50. Faculty (cont’d): PPT presentations that go beyond just information Innovative teaching methods Teaching approaches other than lectures to maintain interest. Good teaching aids: videos, cd’s, dvd’s

51. Faculty (cont’d): How to prevent cynicism amongst residents. Outside speakers, including recovering alcoholic’s testimony Collegial support and other faculty willing to help Scarcity of SA resources in community, leading to frustration of residents (and staff)

52. Residency Directors Want & Need: Survey of Participants Innovative curricula that help residents better understand these problems. Assistance in SA training Physicians who care for people with addictions regularly How to incorporate this important material in a curriculum that has little time for more.

53. Residency directors (cont’d): Videos for didactics or outside lectures on a variety of subjects such as detox protocols, teen addiction, treatment. Speakers and support from MERF or CSAM in training residents. Recommendations from CSAM on what is essential info. and skills. Clinical or research fellowships in ADM

54. Summary & Conclusions Acknowledge and understand obstacles that interfere with substance abuse teaching. Obtain support from inside and outside of program. Foundation support provides a unique incentive for faculty and program directors. Goal: Integrate instead of compete for curricular time.

55. Summary & Conclusions (cont’d): Designated faculty member(s) as local “champions” promote ongoing development and expertise for faculty and residents. Promote 3 ingredients for successful education: –Clinical experiences (with positive outcomes) – –Supervision by expert role models –Ongoing access to addiction medicine consultant throughout training

56. Substance Use Disorders Curriculum Guidelines Endorsed by AAFP, STFM, ADFM, AFPRD. http://www.aafp.org/x16533.xml

57. Selected Websites www.projectmainstream.netwww.projectmainstream.net An interdisciplinary national effort to improve health professional education on substance abuse. www.projectmainstream.net www.amersa.orgwww.amersa.org Association for Medical Education and Research in Substance Abuse www.amersa.org Alcohol Screening and Brief Intervention Curriculum http://www.bu.edu/act/mdalcoholtraining/slides/in dex.html An excellent multimedia curriculum from Boston University. http://www.bu.edu/act/mdalcoholtraining/slides/in dex.html http://www.bu.edu/act/mdalcoholtraining/slides/in dex.html

58. Selected References Helping Patients Who Drink Too Much, A Clinician’s Guide, 2005 Edition, US Department of Health and Human Services, NIH Publication No. 05-3769, www.niaaa.nih.gov www.niaaa.nih.gov Chappel, JN, Schnoll, SH. Physician attitudes: effect on the treatment of chemically dependent patients. JAMA 1977;237:2318-2319

59. Selected References Weisner, C, Matzger, Helen (2003). Missed opportunities in addressing drinking behavior in medical and mental health services, Alcohol Clin Exp Res, 27:1132-1141 Missed Opportunity: National Survey of Primary Care Physicians and Patients, 2000, National Center on Addiction and Substance Abuse (CASA) www.casacolumbia.org www.casacolumbia.org

60. Selected References Substance Abuse and Mental Health Administration Center for Substance Abuse Treatment Treatment Improvement Protocol (TIP) Series A Guide to Substance Abuse Services for Primary Care Clinicians #24 Brief Interventions and Brief Therapies for Substance Abuse #34 Enhancing Motivation for Change in Substance Abuse Treatment #35 National Clearinghouse for Alcohol and Drug Information (800) 729 – 6686 or (301) 468 – 2600 (800) 729 – 6686 or (301) 468 – 2600 www.health.org