Articles  |   September 2007
Improving Physician and Medical Student Education in Substance Use Disorders
Author Notes
  • Dr Wyatt is on the speakers bureau of Reckitt Benckiser Pharmaceuticals. 
  • Address correspondence to Stephen A Wyatt, DO, Medical Director, Dual Diagnosis Program, Middlesex Hospital, 28 Crescent St, Middletown, CT 06457 E-mail: 
Article Information
Addiction Medicine / Medical Education / Psychiatry
Articles   |   September 2007
Improving Physician and Medical Student Education in Substance Use Disorders
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES27-ES38. doi:
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES27-ES38. doi:

Medical and psychosocial problems related to substance use disorders (SUDs) remain a major source of national morbidity and mortality. This situation exists despite greater understanding of genetic, neurobiologic, and social underpinnings of the development of these illnesses that has resulted in many advances in addiction medicine. The value of assessment and brief intervention of this disease is well documented. Patients need to be identified and engaged in order for them to be treated. A variety of evidence-based pharmacologic and psychotherapeutic treatments are now available. Strong evidence exists that treatment of patients for SUDs produces results similar to or better than those obtained from treatment for other chronic illnesses. It is also clear that physicians can play a pivotal role in helping to reduce the burden of disease related to SUDs However, to do this, physicians need to be better educated.

Through such education comes greater confidence in identification and providing treatment. Also, the discomfort and stigma often associated with this disease are reduced. The federal government—through the Office of National Drug Control Policy, the Surgeon General, the Center for Substance Abuse Treatment, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Highway Traffic Safety Administration of the Department of Transportation (DOT)—is expending concerted efforts to improve physician education in addiction medicine. These efforts culminated in the Second Leadership Conference on Medical Education in Substance Abuse in December 2006. The osteopathic medical profession was represented at this conference.

This article reviews not only the recommendations from this meeting, but also the nature of the problem, how members of the osteopathic medical profession are currently addressing it, and a strategy for improvement endorsed by the American Osteopathic Academy of Addiction Medicine.

A2005 report reviewed the state of addiction medicine education in osteopathic medical schools, residencies, and continuing medical education programs.1 I had help in that effort from William Vilensky, DO; James J. Manlandro, Jr, DO; and Michael A. Dekker, OMS II. This review is an update of that article, including recommendations (Figures 1,2,3,4,5,6,7,8,9) from the Second Leadership Conference on Medical Education in Substance Abuse that was held in December 2006. It includes important observations, both good and not so good. 
Dimensions of the Problem
Physicians often agree that substance use disorders (SUDs) contribute significantly to the disease burden in the United States. In 2006, the Institute of Medicine released a seminal report on “Improving the Quality of Health Care of Mental Illness on Substance-Use Conditions.”2 The report recommends improving coordination of mental health and SUD services with general health care services. It notes that combined with mental health illnesses, SUDs are the leading cause of death and disability in women of all ages and for men between the ages of 15 and 44 years. Katon3 points out that mental health and SUDs are associated with a variety of general medical illnesses. Examples include the profound association of cigarette smoking with lung disease; high prevalence of hepatitis C in all substance users (27%), and in particular injection drug users (76%); and the strong association of trauma victims with drug or alcohol intoxication (60%). 
Current information on prevalence of dependent use of drugs and alcohol in the United States shows rates of cigarette smoking dropping from 26% in 2003 to 24.9% in 2005; heavy alcohol use continually hovering at 7% during the same period; and illicit drug use also having had little change with marijuana remaining approximately at 6%, cocaine at 1%, and nonprescribed pharmaceuticals such as opiates and benzodiazepines at 2.6%. There has been more positive news in younger age groups. Those younger than 18 show trends downward in their use of marijuana (8.2% to 6.8%), and a leveling off in the overall rate of nonmedical use of prescription drugs at 2.6%. This decline followed a dramatic rise in pharmaceutical opiate use since 1991 in this population. There was, however, a rise in inappropriate use of such medications in the group of those aged 18 to 25 years. In the aging baby boomer population, those between the ages of 50 to 59 years showed an overall rise in illicit drug use from 2.7% to 4.4%.4 
The fact that mental illness and SUDs carry such a high mortality rate in all women and younger men is a troubling fact, particularly when evidence-based treatments are available. Approximately 3 million people receive treatment each year in the United States, but more than 22 million are estimated to have a SUD.4 At the second Leadership Conference on Medical Education in Substance Abuse in December 2006, Dr. Bertha Madras, deputy director of Demand Reduction with the Office of National Drug Control Policy (ONDCP), pointed out that not all 22 million people with a SUD need specialized physician treatment. Such assistance could come from a wide range of healthcare professionals. However, patients need to be screened in order to be identified and for a level of care to be established. Physicians are in an excellent position to provide such therapy. Policy and reimbursement incentives exist to help promote physician involvement. However, if the physician lacks knowledge in addiction medicine, improvement will be minimal. It is a goal of this article to have the reader understand how physician competence in screening, brief intervention, and coordination of treatment of patients with SUDs can be improved through education, policy change, and reimbursement incentives. 
Research Breakthroughs
Advances have been made in our knowledge of SUDs and treatment of patients with SUDs. The Substance Abuse and Mental Health Service Administration (SAMHSA) sponsored a number of states in their efforts to study the effects of screening, brief intervention, and referral to treatment (SBIRT). Preliminary data from the Washington State site shows that a substantial number (74%) of high-risk individuals lowered their drug or alcohol consumption after one or more brief treatment sessions. There also continued to be reductions at 6-month follow-up. Healthcare cost savings following SBIRT, reported from the Ben Taub Trauma Center in Houston, Tex, were estimated at $4 million.5 
Figure 1.
Highest priority competencies with direct application to care of patients with substance use disorders and with relevance to all medical disciplines and specialties.
Figure 1.
Highest priority competencies with direct application to care of patients with substance use disorders and with relevance to all medical disciplines and specialties.
Brief advice from a physician and office-based counseling interventions can reduce the use of alcohol in problem drinkers.6,7 There is evidence that as the physiologic symptoms associated with heavy drinking increase, there is greater likelihood that a physician intervention will be more effective in motivating a patient to seek treatment.8 Therefore, if a physician were well trained in recognizing early physiologic signs of heavy drinking (eg, liver enzyme elevations or abnormal blood count indices), an earlier effective intervention could be made. As drinking levels go down, medical and societal costs, which clearly outweigh the cost of an intervention, are reduced concurrently.9 
We continue to learn ever more about the causes, consequences, prevention, and treatment of SUDs. Research funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) has identified primary receptors for every major class of abused drug (including alcohol), identified their genetic code, and cloned the receptors.10,11 Researchers have mapped locations of those receptors in the brain and determined the neurotransmitter systems so involved.12 They have demonstrated the activation of these regions during addiction, withdrawal, and craving13; they have identified and separated mechanisms underlying drug-seeking behavior and physical dependence14; and they have developed animal models for drug self-administration.15 Most important, they have demonstrated that the mesolimbic dopamine system is the primary site of dysfunction caused by abuse of drugs.15 This neuroscience research into addiction has contributed substantially to recent advances in neurology and psychiatry. 
Buprenorphine hydrochloride, effective in reducing opiate use, has now been in use in wider practice and shows tremendous potential as a safe and effective treatment of opiate-dependent patients.16 Naltrexone hydrochloride and acamprosate calcium have gained a somewhat greater acceptance by primary care physicians as a result of their efficacy in treating patients with alcohol dependence.17,18 Varenicline, a nicotine partial agonist, is showing great promise in reducing the craving of nicotine following abstinence of tobacco.19 
Efficacy of nonpharmacologic modes of treatment for drug-dependent patients is also well established. These modalities include cognitive behavioral therapy, motivational enhancement treatment, and contingency management.20 There have been positive studies of effectiveness of 12-step mutual-support groups, such as Alcoholics Anonymous, as an adjunct to treatment and aftercare.21-23 
Figure 2.
Recommended action items for upgrading undergraduate medical education on substance use disorders.
Figure 2.
Recommended action items for upgrading undergraduate medical education on substance use disorders.
Figure 3.
Recommended action items for advancing graduate medical education on substance use disorders.
Figure 3.
Recommended action items for advancing graduate medical education on substance use disorders.
The Centers for Medicare and Medicaid Services (CMS) has adopted codes for Medicaid that will allow physicians and other providers to be reimbursed for performing screening and brief intervention. There is currently a group working to develop and submit the Current Procedural Terminology (CPT) code application. Obtaining these codes will have the potential of expanding payment for screening and brief intervention into primary care physicians' offices. 
Advances in treatment and reimbursement provide the groundwork for physicians to play a greater role in helping patients with this preventable and treatable disease of the brain. This paradigm shift will provide unprecedented opportunities to reduce health and social consequences of substance misuse, abuse, and dependence throughout the United States. 
The Role of Physicians
In his opening remarks to the ONDCP conference attendees, Director John P. Walters described the evidence showing that medical students, residents, and practicing physicians should be better trained in the disease of addiction. He described the impact it can have on many other disorders, including cancer, cardiovascular disease, stroke, infectious diseases, mental illnesses, and even obesity. Director Walters challenged addiction medicine physicians and others to find new ways to improve the education of all physicians to reduce the disease burden of addiction. 
Our national healthcare system offers an ideal opportunity to identify and treat these people and thereby reduce associated adverse health, family, and societal effects. Practitioners from various disciplines, including physicians, nurses, pharmacists, dentists, social workers, psychologists, and allied health professionals, are essential participants in national efforts to deal with these problems.24 
Figure 4.
Proposed processes for continuing medical education on substance use disorders (SUDs).
Figure 4.
Proposed processes for continuing medical education on substance use disorders (SUDs).
Physicians are particularly well positioned to play a role in the recognition and treatment of patients with SUDs.25 However, far too little attention has been paid to educating primary care physicians and other health professionals to respond to the needs of the millions of individuals and families affected by SUDs. As a result, primary care physicians neither identify nor diagnose alcohol and drug problems with the same acuity they bring to other medical disorders. The role of these front-line health professionals in prevention, early identification, and referral thus remains largely untapped. 
Primary care physicians can provide preventive guidance, education, and intervention to children, adolescents, adults, and their families. It has been estimated that up to 20% of visits to primary care physicians are related to substance use problems.26 Both generalist and specialist physicians have frequent contact with patients who have SUDs,27-29 thus pointing to the importance of having addiction medicine education as a part of all clinical rotations in medical school. Clearly, the emphasis should be on the primary care physicians because patients with alcohol and other drug problems are twice as likely as patients unaffected by such problems to consult a primary care physician.25,26 
Screening and brief intervention studies have shown that physicians can play an important role in their patients' health decisions.30,31 Smoking cessation research shows that a physician's statement to quit smoking is enough to convince many patients to undertake such an effort. Interventions by emergency physicians have been shown to reduce subsequent alcohol use and readmission for traumatic injuries,32 as well as drinking and driving, traffic violations, alcohol-related injuries, and alcohol-related problems among 18- and 19-year-olds.33 There is strong evidence the public wants such help from their caregivers. For example, in a public opinion survey conducted by Harvard University and The Robert Wood Johnson Foundation,34 74% of respondents said they believe that addicts can stop using drugs, but to do so, they need help from professionals or organizations outside their families. By “help,” two thirds said they meant intervention by a healthcare professional. 
Unfortunately, although primary care physicians are the professionals most often cited by patients and families as the “most appropriate” source of advice and guidance about issues related to the use of alcohol, tobacco, and other drugs (including prescription drugs), they also are reported to be the “least helpful” in actually addressing these issues. Physicians often miss the diagnosis of drug abuse or addiction, and even when they make such a diagnosis, many do not know how to do a brief intervention or develop an organized plan for patient referral or treatment. 
Osteopathic physicians represent just more than 7% of all practicing physicians in the United States. However, it is estimated that as a profession with a strong focus on the education of primary care physicians, we have the responsibility for approximately 17.4% of the population's primary care.35,36 Thus, osteopathic physicians can assume a substantial role in helping patients at risk or currently suffering from a SUD. However, lack of training in osteopathic medical schools and graduate medical education programs often results in a missed opportunity for an appropriate intervention. 
The Status of Medical Education
Osteopathic medicine, through its designation of addiction medicine as a subspecialty, has established itself as a leader in the field of SUDs by instituting the first co-joint specialty board and Certificate of Added Qualifications in Addiction Medicine (CAQ) for osteopathic primary care physicians. However, the CAQ is currently in jeopardy. A recertification examination will be given in 2007, but the certifying examination is now in dormancy. Osteopathic physicians as a profession have the opportunity to remain in the forefront of board certification in addiction medicine by maintaining the co-joint board and working together in training and certifying new physicians in this field. 
Osteopathic medical schools are recognizing the need for more education in this field. The previous edition of this article1 noted an unpublished 2000 review of osteopathic medical schools by the American Osteopathic Academy of Addiction Medicine (AOAAM) reporting that only 4 (22%) of 17 schools had a required curriculum on addiction medicine. A 2004 report of the American Association of Colleges of Osteopathic Medicine (AACOM)37 shows that 22 of 23 schools required an addiction medicine program. Many schools have an addiction medicine component as part of a clerkship rotation; and a few offer it as an elective. Association of American Medical Colleges (AAMC) data indicate that since 1979, the proportion of allopathic medical schools requiring instruction in SUDs has increased from 70% in 1979 to nearly 100% in 2006.38 Although these numbers are impressive, great disparity exists in curricula being taught and expertise of instructors. 
There has been and continues to be a brighter picture when looking at education devoted to harmful effects of cigarette smoke, in part because of inclusion of core areas of instruction as programs were established. Osteopathic and allopathic medical schools have a similar record in covering 13 core content areas, 7 basic science areas, and 6 clinical science areas. However, more than 20% of schools had a required tobacco curricular component of 3 hours or less in the entire 4 years of undergraduate education. All too often, a minimum requirement is fulfilled with little carry-over into the clinical years where the training of practicing clinical skills takes place. All osteopathic medical schools with 4-year programs reported less than 1 hour of tobacco cessation instruction in the previous year; two schools reported a required course on tobacco-related illnesses.39 There are on average 51 hours of nonclinical hours of neuroscience, 49.2 hours of behavioral medicine and 19.2 hours of preventive medicine/public health required in the first 2 years of osteopathic medical school.40 There is good reason to examine more closely how these hours are being used in an attempt to find ways to expand the education of substance use effects on the body and skills surrounding screening and brief intervention. 
Figure 5.
Figure 5.
Figure 6.
Figure 6.
Every year, AACOM compiles a survey of senior osteopathic medical students near the end of the academic year and publishes the results in the annual report.41 Seniors were asked to rate various topics covered in their 4 years of education. The results showed 78.2% in 2002 and a slight drop to 76.2% in 2004 thought that they had had adequate didactics on drug and alcohol abuse; 18.1% in 2002 and 21.3% in 2004 believed that it was inadequate; and 3.7% in 2002 and 2.5% in 2004 thought that it was excessive. These trends indicate student recognition of the need to better understand this important area of disease. 
Similar data are available from the AAMC: 90% of respondents thought that the amount of time spent was appropriate. Once again, however, there is no delineation of what constitutes an “adequate” curriculum or building of clinical skills.38,40,41 Despite this progress, basic clinical skills in screening, assessment, and diagnosis, developing a treatment plan, and ongoing monitoring—capabilities that physicians routinely apply in managing other chronic disorders—clearly need attention regarding SUDs.42 There is a need to establish some consistency in the content in the drug and alcohol abuse curricular component and in the experience and expertise of those teaching it. 
Many medical students are recognizing this area of medicine as an important part of their education. In 2006, Health Professional Students for Substance Abuse Training (HPSSAT) merged with the American Medical Education and Research in Substance Abuse (AMERSA) organization. AMERSA and HPSSAT have compatible goals, with AMERSA promoting SUD education for health professionals, and HPSSAT promoting SUD education for health professional students. Coauthor Michael A. Dekker, OMS III from Nova Southeastern University College of Osteopathic Medicine (NSU-COM) in Fort Lauderdale, Fla, was present at the 2006 ONDCP meeting and described a variety of efforts under way to increase student awareness of SUDs and how patients with SUDs are treated. 
Various activities are in progress at medical school campuses around the United States; NSU-COM has conducted a variety of optional noon lectures on various subjects. This program was spearheaded by Donna M. Kaminski, OMS II. There was a large voluntary turnout to a series on various problems associated with drugs and alcohol as well as a well-attended visit to a treatment facility. Students have been involved in outreach programs teaching middle school students about the hazards of nicotine use and dependence. The preteens reportedly enjoyed hearing from these young physicians, as they responded with enthusiasm and lots of questions. This outreach program provides great feedback to the osteopathic medical students as they prepare for careers as health advocates. It helps to build a positive association with the promotion of a healthy avoidance of drugs. 
Osteopathic medical student Dekker and Brian Hurley, MS IV, from Keck School of Medicine at the University of Southern California in Los Angeles, presented a workshop, “Physician-in-Training Opportunities to Improve Substance Abuse Curricula in Medical Education” at the 2007 American Society of Addiction Medicine Annual Medical-Scientific Conference, which was held April 26 to 29 in Miami, Fla. There, they had the opportunity to speak with the many other physician student attendees. Reportedly, there was general agreement that the schools are teaching the basic science of addiction. However, an informal survey showed that most did not feel comfortable enough to provide screening and brief intervention. Nor did these students understand how and where to refer patients with a SUD. 
Figure 7.
Figure 7.
Although several professional organizations have issued calls for greater integration of substance abuse education into allopathic and osteopathic residency training programs, the impact of these recommendations has been variable. Information reported in 1988 indicated that there are Resident Review Committee program requirements regarding substance abuse education in only 5 of the 99 specialty training programs (anesthesiology, family practice, internal medicine, obstetrics/gynecology, and psychiatry).43 
A 1999 report following a 74% response rate to the authors' survey revealed that the proportion of departments that offered a curriculum unit in substance abuse was 93 (40%) of 232 for internal medicine, 195 (68%) of 288 for family medicine, 38 (27%) of 139 for pediatrics, and 153 (91%) of 169 for psychiatry.44 There is evidence to indicate that these proportions have improved some following the report of a 2000 study showing 56% of 1831 residency programs required an addiction medicine curriculum.45 The proportion ranged from 95% in psychiatry to only 32% in pediatrics. The combined average was 65%. The programs had a medium range of 3 to 12 curricular hours. Grand rounds were the most commonly identified format for teaching. Psychiatry (75%) and family medicine (55%) programs had the highest proportion reporting clinical rotations in addiction medicine.43 In surveying programs, the most commonly cited factors limiting further integration of substance abuse training into residency programs included a perceived lack of time, faculty expertise, identified training sites, and institutional support.43,45 Consequently, what remains are poor requirements, poor consistency between programs surrounding the curriculum, and a lack of expertise within faculty. 
In continuing medical education of practicing physicians, a change has occurred during the past decade in the general dissemination of information. A 2005 report46 indicates that most physicians gain the greatest amount of information from coworkers (89%) and seminars or conferences (86%). Most respondents (59%) endorsed e-mail summaries of journal articles as a “very helpful” source of information. This is important information in attempting to formulate a plan for future efforts to transfer information on addiction medicine topics to practicing physicians. However, hurdles other than education need to be surmounted, including the lack of reimbursement and time that contributes to physicians' poor showing in identifying and working with these patients. 
The other important roadblock to physicians' appropriately treating these patients is the stigma associated with the disease of addiction. Similar stigmas are associated with obesity as it relates to various medical problems, but rarely are obese patients turned away to the degree that the patient with a SUD is. A turnabout may come when physicians begin to recognize the role of genetics and neurochemistry in the development of behavior. Attendant to such recognition may be improvement in physician attitude and the potential for positive engagement with the patient that result in better outcomes. 
A National Spotlight on the Issue
The second National Leadership Conference on Medical Education in Substance Abuse, an invitational 2-day conference of leaders from various public and private organizations, was held in Washington, DC, in December 2006. The sponsoring organization was the ONDCP, under the guidance of Conference Chair Bertha K. Madras, PhD, deputy director for demand reduction. Many educational institutions and organizations along with policy makers and others with a strong interest in SUDs were represented, including NIDA, NIAAA, SAMHSA, DOT, licensing and certification bodies, insurance experts, and academicians. This conference had greater attendance of individuals not currently involved in addiction care or research compared with the first such convocation in December 2004. 
The purpose of this meeting was to provide a framework for developing specific recommendations to improve the current level of education and practice of addiction medicine. The goal was to improve interfacing between organizations involved in accreditation and licensing of educational programs, hospitals, and physicians. Also included were funders—both private and public—allowing for discussion of how financial incentives or disincentives could play a role. 
Figure 8.
Figure 8.
Dr Madras in her welcoming remarks stated: 

We enlist your expertise in developing strategies to promote medical education curricula on drug and alcohol related disorders, the improvement of medical education after graduation, implementation of screening and brief intervention in mainstream medical care, obtaining appropriate physician reimbursement for these services, and preventing the non-medical use of prescription medications.

During the conference, many policy makers made it clear that the federal government, with its oversight of standards of public health and as a significant funder, is interested in improving physicians' understanding of addiction medicine and increasing the medical role in identification and care of these patients. Dr Madras solicited the conferees to make specific recommendation and a work plan to implement the recommendations by the conclusion of the conference. 
Conferees were asked to consider alcohol as: 
  • the third leading cause of death in the United States, behind tobacco, poor diet and physical inactivity (obesity)
  • the second leading cause of disability and disease burden in the United States
  • associated with 41% of traffic deaths and 29% of suicides, which constitute the leading causes of death among persons aged 15 to 35 years.
Then, important questions to ask are: 
  • Why do only 43% of persons who have an alcohol use disorder receive “treatment?”
  • Why does only $1 of every $5 for “treatment” of patients with alcohol disorder get spent on their actual treatment for alcohol abuse or dependence, and the other $4 is spent on their medical treatment for problems complicated by alcohol abuse or dependence?
  • Why is there a similar picture with drugs of abuse, where about 60% of treatment expenditures go to the actual treatment of the patient for drug addiction, and the remaining is spent on treating the patient for associated illnesses and injuries?
  • Why is there not more money going to substance abuse treatment when the most conservative estimate is that there is a savings of $2.80 in healthcare cost for every dollar spent on screening and treatment?
  • Why is there so often a desire to show there is cost savings before we take appropriate care of patients and their families suffering from the disease of addiction?
NIDA has begun a program to help better educate physicians on how they might improve prevention and treatment of drug abuse. This organization announced the development of a Centers of Excellence for Physician Information program at four academic medical institutions to provide training for physicians to better screen, briefly intervene, and refer patients for treatment. In addition to sponsoring research that explores these issues, NIDA is helping prepare primary care physicians to be partners in preventing and treating drug abuse and addiction through a physician work group and a physicians' page on the NIDA Web site. 
There was a call from federal policy makers for integration of the addiction medicine curriculum into the mainstream of medical education at all levels—undergraduate, graduate, and continuing medical education—and across all disciplines. John P. Walters, director of ONDCP, pledged that his organization and other federal agencies will continue to support basic research that enhances physicians' understanding of the causes and consequences of alcohol, tobacco, and drug misuse and abuse, including prescription drug abuse. He also promised support for clinical research that leads to development of better tools to prevent SUDs and identify and treat patients with SUDs in primary healthcare settings. 
All the speakers acknowledged past efforts to teach physicians the competencies they need to care for patients with SUDs.47 
The osteopathic medical profession was represented by William Vilensky, RPh, DO, of the American Osteopathic Association; student representative Michael A. Dekker, OMS III, of HPSSAT (the student organization advocating for schools to better education of graduate healthcare professionals in screening, diagnosis, and provision of appropriate intervention for patients with substance abuse disorders ([]); Douglas M. Leonard, DO, of the AACOM; Anthony H. Dekker, DO, of the AOAAM, also serving as the co-chair of the undergraduate working group; and this article's lead author (S.A.W.), who served as a member of the planning committee and an expert panelist for the undergraduate working group. 
Identifying the Needed Competencies
Following productive discussion, participants in the Second Leadership Conference agreed that the highest priority should be given to three areas of competence (Figure 1). 
All the competencies have direct application to the care of patients with SUDs and are relevant to all disciplines and specialties. Upon completion of each level of training, all medical students, residents, and physicians should be able to demonstrate that they have mastered this core body of knowledge and skill. 
Figure 9.
Figure 9.
Physician education can, and should be, tailored to specific practice situations and patient populations. For example, pediatricians have a special need for knowledge of how SUDs can often be seen as developmental disorders and skills to perform screening, intervention, and referral in the adolescent population. Such physicians also need to consider issues raised by children and adolescents whose parents or other caregivers have SUDs and to acquire skills in screening and intervention in these situations. 
Similarly, specialists in obstetrics and gynecology need the knowledge and skills to address substance-related problems in pregnant and parenting women. Because primary care physicians serve diverse populations of patients in terms of gender, socioeconomic status, and culture, they also must be culturally competent in communicating with patients and their families. 
Recommendations for Action
During the Second Leadership Conference on Medical Education in Substance Abuse, participants were divided into seven working groups with each assigned to look at one of the following: 
  • undergraduate medical education
  • graduate education
  • continuing education
  • licensure/accreditation/certification and standards
  • purchasers and payers of healthcare services
  • prescriber education and prevention of prescription drug abuse
  • public input on medical education in substance abuse
Previous to this meeting, it had been determined that lack of education, financial incentives, and regulatory guidance are important obstacles in the way of physician involvement in the prevention, identification, and management of SUDs. Each of the seven working groups were asked to develop strategies to overcome these obstacles. Figures 2,3,4,5,6,7,8,9 list many recommendations resulting from the working groups' discussions. Nearly all groups identified the need for examiners and licensing regulators to be encouraged to and assisted in establishing test questions and regulations reinforcing the need for SUD education development in the current practice of medicine. 
Recommendations Specific to Osteopathic Medicine
Given our current understanding of the role SUDs play in the overall health problems of the United States, it is important that the osteopathic medical profession improve the assessment and education of students, residents, and practicing physicians concerning SUDs. The AOAAM remains the specialty group within the profession that is committed to the treatment of these patients. The AOAAM recommends that the initiatives in Figure 9, specific to osteopathic medical education, be encouraged as a supplement to the national objectives outlined in Figures 2,3,4,5,6,7,8. Many of these initiatives in part were established in 2005 and reported in the original article1; they are now presented either as having been moved forward in part or remaining unchanged. 
Follow-up Activities
The following initiatives have continued to gain momentum since the meeting: 
  • presentation by William Harp, MD, to the Federation of State Medical Boards advocating these recommendations be adopted
  • ongoing discussions with ONDCP, CSAT, NIDA, NIAAA, NIH, and DOT among others to find new funding opportunities
    • —NIDA's granting of funding to four schools or consortiums to establish innovative ways of improving student narcotic prescribing practices
    • —collaboration of AACOM and AAMC with specialty societies to establish communication with addiction medicine faculty with the goal of collaboration in setting forth a more consistent addiction medicine curriculum in the schools
    • —continued strong support by the National Board of Osteopathic Medical Examiners (NBOME) and the National Board of Medical Examiners (NBME) for establishing basic science and clinical competencies in the area of SUDs
    • —an effort by the AOAAM to get a resolution recommending a consistent core curriculum in addiction medicine for all osteopathic medical schools passed by the AOA House of Delegates at its July 2007 meeting. This effort was unsuccessful; however, there was significant support for it, and the resolution will be presented again in 2008.
    • —current efforts by CME providers for federally employed physicians to enhance exposure to these problems in their presentations
There is strong government support for this agenda to move forward; follow-up meetings as an outgrowth of the 2006 Leadership Conference are continuing. Various other recommendations established at the conference have been either completed or are under way. This initiative—apart from representing good practice of medicine—has strong political and academic support to move into the mainstream of medical education. 
Osteopathic physicians as a profession dedicated to maintaining the health of patients and their families must take a serious look at the disease of addiction along with other substance use problems and the significant role it occupies in the morbidity and mortality in our patients. Students and residents in all specialties should be properly trained at a minimum in screening, brief intervention, and treatment planning. 
Better education is needed in the prescribing of opioids, a clear threat to US youth and the entire nation. Most health professionals reading this article have witnessed the tremendous transformation that takes place as patients are treated for this illness and begin to regain their health. Physicians can play an important and extremely satisfying role in engagement and treatment. All patients should have the right to treatment, and osteopathic physicians are in a strong position to assist in seeing that they do. Education is a key element. 
For more information on the Leadership Conference and its follow-up activities, contact the author at  
 Mr Dekker is a third-year student in the DO-MPH program at Nova Southeastern University College of Osteopathic Medicine (NSUCOM) in Fort Lauderdale, Fla.
 This continuing medical education publication is supported by an educational grant from Purdue Pharma LP.
The authors would like to acknowledge the support of Bonnie Wilford, MS, conference facilitator, Johnson, Bassin & Shaw, Inc, andthe Office of National Drug Control Policy in completing this article. 
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Figure 1.
Highest priority competencies with direct application to care of patients with substance use disorders and with relevance to all medical disciplines and specialties.
Figure 1.
Highest priority competencies with direct application to care of patients with substance use disorders and with relevance to all medical disciplines and specialties.
Figure 2.
Recommended action items for upgrading undergraduate medical education on substance use disorders.
Figure 2.
Recommended action items for upgrading undergraduate medical education on substance use disorders.
Figure 3.
Recommended action items for advancing graduate medical education on substance use disorders.
Figure 3.
Recommended action items for advancing graduate medical education on substance use disorders.
Figure 4.
Proposed processes for continuing medical education on substance use disorders (SUDs).
Figure 4.
Proposed processes for continuing medical education on substance use disorders (SUDs).
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Figure 9.