Melinda Campopiano von Klimo, JBS International, Inc. 
Laura Nolan, JBS International, Inc. 
Wilson M. Compton, National Institute on Drug Abuse, National Institutes of Health 

By now, addiction specialists understand the depth and impact of the drug overdose death crisis in the United States. We’ve read that, “Drug overdoses are one of the leading causes of injury death in adults and have risen over the past several decades… In 2022, 107,941 drug overdose deaths occurred.” Studies published in the past year alone highlight the toll overdose is taking on communities and families, with health disparities and inequities in care often exacerbating negative health outcomes for those most in need. For example, “Overdose deaths increased in pregnant and postpartum women from early 2018 to late 2021,” “More than 321,000 U.S. children lost a parent to drug overdose from 2011 to 2021,” and “Unintentional drug overdose deaths among teens 15-19 remained elevated well into 2022.” These trends have been fueled by the inclusion of illegally made fentanyl, which is increasingly found in the illegal drug supply, as evidenced by, “Over 115 million pills containing illicit fentanyl seized by law enforcement in 2023.”  

Despite these grim statistics and headlines, widespread efforts to support people with substance use disorders have been implemented, including the development of evidence-based practices to identify and treat opioid use disorder and other substance use disorders in practice. For example, screening, brief intervention, and referral to treatment is an effective approach in general medical settings to reduce drug and alcohol use.^1-4 And safe and effective behavioral therapies and pharmacotherapies for nicotine, alcohol, and opioid use disorders were approved over the last 25 years.^5-7 In addition, medication monitoring and psychosocial interventions can support people in recovery to reduce current use or to avoid a recurrence of use by helping them identify and cope with triggers.⁸ Finally, harm reduction strategies (eg, naloxone co-prescribing, drug checking and testing, syringe service programs) provide substantial benefits for people who use drugs and for those not seeking abstinence-based treatment^9-11; these approaches help prevent overdose deaths and reduce the transmission of infectious diseases. 

The problem is that clinicians’ use of evidence-based practices to address the ongoing morbidity and mortality related to substance use disorders is lacking. Interdisciplinary teams, including advanced practice nurses, physician assistants, counselors, and social workers, are essential to provide a comprehensive response to addiction and to successful treatment outcomes. These professionals’ practice and collaborative care models are often contingent upon physician participation, making physician engagement critical to addressing substance use disorder care deficiencies.¹²

Working toward change: examining why physicians are reluctant to intervene in addiction 

Given all of that, why are physicians reluctant to intervene in addiction? How can we make a change? Change can only be borne from understanding both the barriers to and facilitators of success, so we sought to identify modifiable factors related to reluctance, which could reduce barriers to physician implementation of evidence-based addiction care, if addressed. 

Barriers. Through a systematic review, our team analyzed 283 studies over the last 61 years; we then systematized data analysis of reluctance reasons, using a theoretical domains framework, and grouped reasons into 10 categories.¹³ The analysis revealed that a physician’s “institutional environment” was the reason physicians most frequently reported, as cited in 81% of the studies, as their reason for their reluctance to intervene. The “institutional environment” refers to various factors, such as lack of support from a physician’s institution or employer, insufficient resources (eg, staff, training), challenges in organizational culture, and competing demands. Physicians also noted reimbursement concerns for the cost of delivering addiction interventions.  

Addressing these requires (1) greater commitment from health systems to implement workflow and staffing changes; (2) integration of substance use disorder treatment services with medical and mental health care; and (3) reimbursement that fully covers the cost of addiction care for providers, which is also critical to address competing priorities and the time necessary to adequately treat patients with substance use disorders. 

Other reluctance reasons included insufficient skill (74%), lack of cognitive capacity to manage a certain level of care (eg, too busy, too overwhelming, competing needs) (74%), and inadequate knowledge (72%). Although a multitude of continuing education trainings for providers exists on this topic, few offer instruction in ways that physicians are typically taught (ie, by observation and supervised practice). It stands to reason that more training might also improve cognitive capacity issues. 

Another recent systematic review highlighted that stigma against patients with substance use disorder exists among health care professionals. The authors found stigma to be prevalent and either similar to, or worse than, stigma patients experienced as a result of other chronic conditions. In our study, the team found that approximately 66% of studies cited negative social influences or beliefs about public and community acceptance of addiction care, while 56% of studies cited fear of harming the patient-physician relationship as deterrents for physicians to intervene in addiction. These may represent the manifestation of health care professional stigma associated with substance use disorder and its treatment, as might some of the other reluctance reasons highlighted. 

Facilitators. Although the study did not initially intend to examine factors that facilitate physician intervention in addiction in this review, our team observed them in data and conducted a limited review of studies citing them. The results aligned with the barriers, as we found that physicians could benefit from adequate education and training; institutional support and environments that foster peer-collaboration and resources; and improved intra-and interpersonal factors like self-confidence, positive work experiences, motivation, and an understanding of addiction as within their scope of practice. Regulatory reforms could also improve physician intervention in addiction.  

Other potential facilitators that can also be a critical next step to improving adoption of EBPs for addiction care include community outreach efforts, educational materials for patients and families, public health campaigns that promote non-stigmatizing language, and education efforts to understand implicit bias and to reduce stigma toward patients with substance use disorders. 

Addressing barriers is critical to widespread adoption of EBPs 

Physician reluctance to intervene remains a major impediment to full implementation of effective substance-use-related interventions. Addressing barriers will require changes to financing, education, and institutions. Additional systematic reviews focused on reasons for reluctance to intervene in addiction for other clinicians, as well as a deeper exploration of facilitators for intervening in addiction, may be useful complements to the information summarized here. Finally, it is essential to recognize many of the reasons physicians gave for their reluctance as valid and to focus efforts on improving physician abilities in these areas, rather than on stigmatizing physicians who may have inadequate knowledge or skills.  

For more information and to read the topic of this editorial, see the article by Melinda Campopiano von Klimo and colleagues in JAMA Network Open, published July 17, 2024 (doi:10.1001/jamanetworkopen.2024.20837). 

References

¹ Babor TF, Del Boca F, Bray JW. Screening, brief intervention and referral to treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice. Addiction. 2017;112(suppl 2):110–117. doi:10.1111/add.13675 

² Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4):307–317. doi:10.1080/02791072.2012.720169 

³ Krist AH, Davidson KW, Mangione CM, et al; US Preventive Services Task Force. Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(22):2301–2309. doi:10.1001/jama.2020.8020 

⁴ Karno MP, Rawson R, Rogers B, et al. Effect of screening, brief intervention and referral to treatment for unhealthy alcohol and other drug use in mental health treatment settings: a randomized controlled trial. Addiction. 2021;116(1):159–169. doi:10.1111/add.15114 

⁵ Maricich YA, Nunes EV, Campbell ANC, et al. Safety and efficacy of a digital therapeutic for substance use disorder: secondary analysis of data from a NIDA clinical trials network study. Subst Abus. 2022;43(1):937–942. doi:10.1080/08897077.2022.2060425 

⁶ Hilty DM, Ferrer DC, Parish MB, et al. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013;19(6):444–454. doi:10.1089/tmj.2013.0075 

⁷ Hailu R, Mehrotra A, Huskamp HA, Busch AB, Barnett ML. Telemedicine use and quality of opioid use disorder treatment in the US during the COVID-19 pandemic. JAMA Netw Open. 2023;6(1):e2252381. doi:10.1001/jamanetworkopen.2022.52381 

⁸ Babor TF, Del Boca F, Bray JW. Screening, brief intervention and referral to treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice. Addiction. 2017;112(suppl 2):110–117.  

⁹ Puzhko S, Eisenberg MJ, Filion KB, et al. Effectiveness of interventions for prevention of common infections among opioid users: a systematic review of systematic reviews. Front Public Health. 2022;10:749033. doi:10.3389/fpubh.2022.749033 

¹⁰ Campbell EM, Jia H, Shankar A, et al. Detailed transmission network analysis of a large opiate-driven outbreak of HIV infection in the United States. J Infect Dis. 2017;216(9):1053–1062. doi:10.1093/infdis/jix307 

¹¹ Ruiz MS, OʼRourke A, Allen ST, et al. Using interrupted time series analysis to measure the impact of legalized syringe exchange on HIV diagnoses in Baltimore and Philadelphia. J Acquir Immune Defic Syndr. 2019;82(2):S148-S154. doi:10.1097/QAI.0000000000002176 

¹² Brackett CD, Duncan M, Wagner JF, Fineberg L, Kraft S. Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model. Subst Abus. 2022;43(1):240–244. doi:10.1080/08897077.2021.1932698 

¹³ Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician reluctance to intervene in addiction. JAMA Netw Open 2024;7(7):e2420837. Doi:10.1001/jamanetworkopen.2024.20837 

Conflict of Interest Disclosures: Unrelated to the submitted work, Compton reports ownership of stock in General Electric Co., 3M Co., and Pfizer Inc.  

Acknowledgements: The authors of this editorial acknowledge the expert co-authors of the manuscript that is the subject of this editorial-- Michelle Corbin, Lisa Farinelli, and Stephanie T. Weiss of the National Institute on Drug Abuse, Jarratt D. Pytell of the University of Colorado School of Medicine, and Caty Simon of the National Survivors Union. 

Disclaimer: The findings and conclusions of this editorial are those of the authors and do not necessarily reflect the views of the National Institute on Drug Abuse of the National Institutes of Health. 

Funding/Support: This work was funded by the National Institute on Drug Abuse Contract No. 75N95020C00006/NIDA Ref. No. N01DA-20-1159.