{"id":17603,"date":"2024-07-21T18:02:22","date_gmt":"2024-07-21T17:02:22","guid":{"rendered":"https:\/\/drugprevent.org.uk\/ppp\/?p=17603"},"modified":"2024-10-05T15:04:37","modified_gmt":"2024-10-05T14:04:37","slug":"physician-reluctance-to-intervene-in-addiction-a-systematic-review","status":"publish","type":"post","link":"https:\/\/drugprevent.org.uk\/ppp\/2024\/07\/physician-reluctance-to-intervene-in-addiction-a-systematic-review\/","title":{"rendered":"Physician Reluctance to Intervene in Addiction – A Systematic Review"},"content":{"rendered":"
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Original Investigation –\u00a0<\/span><\/strong>Substance Use and Addiction<\/span><\/strong><\/div>\n<\/div>\n
July\u00a0<\/span>17,\u00a0<\/span>2024<\/span><\/span><\/strong><\/div>\n
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Melinda Campopiano von Klimo, MD1<\/sup><\/a><\/span>;\u00a0<\/span>Laura\u00a0Nolan,\u00a0BA1<\/sup><\/a><\/span>;\u00a0<\/span>Michelle\u00a0Corbin,\u00a0MBA2<\/sup><\/a><\/span>;\u00a0et al<\/a><\/span>Lisa\u00a0Farinelli,\u00a0PhD, MBA, RN, CCRP, OHCC2<\/sup><\/a><\/span>;\u00a0<\/span>Jarratt D.\u00a0Pytell,\u00a0MD3<\/sup><\/a><\/span>;\u00a0<\/span>Caty\u00a0Simon4,5,6<\/sup><\/a><\/span>;\u00a0<\/span>Stephanie T.\u00a0Weiss,\u00a0MD, PhD2<\/sup><\/a><\/span>;\u00a0<\/span>Wilson M.\u00a0Compton,\u00a0MD, MPE2<\/sup><\/a><\/span><\/span><\/h1>\n<\/div>\n
Article Information<\/a><\/div>\n
JAMA Netw Open.\u00a0<\/span>2024;7(7):e2420837. doi:10.1001\/jamanetworkopen.2024.20837<\/span><\/div>\n<\/div>\n
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Key Points<\/span><\/strong><\/div>\n
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Question<\/strong>\u00a0\u00a0What reasons do physicians give for not addressing substance use and addiction in their clinical practice?<\/p>\n

Findings<\/strong>\u00a0\u00a0In this systematic review of 283 articles, the institutional environment (81.2% of articles) was the most common reason given for physicians not intervening in addiction, followed by lack of skill (73.9%), cognitive capacity (73.5%), and knowledge (71.9%).<\/p>\n

Meaning<\/strong>\u00a0\u00a0These findings suggest effort should be directed at creating institutional environments that facilitate delivery of evidence-based addiction care while improving access to both education and training opportunities for physicians to practice necessary skills.<\/p>\n

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Abstract<\/span><\/strong><\/div>\n<\/div>\n

Importance<\/strong>\u00a0\u00a0The overdose epidemic continues in the US, with 107\u202f941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.<\/p>\n

Objective<\/strong>\u00a0\u00a0To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.<\/p>\n

Data Sources<\/strong>\u00a0\u00a0A literature search of PubMed, Embase, Scopus,\u00a0medRxiv<\/i>, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.<\/p>\n

Study Selection<\/strong>\u00a0\u00a0Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.<\/p>\n

Data Extraction and Synthesis<\/strong>\u00a0\u00a0Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.<\/p>\n

Main Outcomes and Measures<\/strong>\u00a0\u00a0The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.<\/p>\n

Results<\/strong>\u00a0\u00a0A total of 183 of 9308 returned studies reporting data collected from 66\u202f732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.<\/p>\n

Conclusions and Relevance<\/strong>\u00a0\u00a0In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.<\/p>\n

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Introduction<\/strong><\/span><\/div>\n
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NDPA WEBSITE:\u00a0 Note – In the interests of relative brevity, the References have been omitted from this published version.<\/em><\/strong><\/span><\/div>\n
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Overdose is a leading cause of injury-related death in the US,1<\/a><\/sup>\u00a0with 107\u202f941 such deaths occurring in 20222<\/a><\/sup>\u00a0and annual deaths due to alcohol exceeding 140\u202f000 from 2015 to 2019.3<\/a><\/sup>\u00a0The more than 46.3 million people in the US with a past-year substance use disorder4<\/a><\/sup>\u00a0and a nationwide economic impact of alcohol misuse and illicit drug use that tops $442 billion5<\/a><\/sup>\u00a0further evidences the magnitude of this crisis.<\/p>\n

A variety of safe and effective evidence-based practices (EBPs) to identify, reduce the morbidity and mortality of, and treat substance use disorders exist. Examples include screening, brief intervention, and referral to treatment,6<\/a><\/sup>–10<\/a><\/sup>\u00a0as well as behavioral therapies and pharmacotherapies for nicotine, alcohol, and opioid use disorders.11<\/a><\/sup>–13<\/a><\/sup>\u00a0Furthermore, harm reduction approaches (eg, naloxone training and coprescribing, drug checking and testing, and syringe service programs) offer significant individual and public health benefits for people who use drugs and for those who do not have abstinence-based treatment goals.14<\/a><\/sup>–16<\/a><\/sup><\/p>\n

Clinician adoption of EBPs is necessary; however, screening for substance use disorders remains low,7<\/a><\/sup>\u00a0creating missed opportunities to intervene in harmful substance use or recognize and discuss potential progression to a severe disorder. Treatment capacity is inadequate to meet demand,17<\/a><\/sup>\u00a0with only 6.3% of people with a past-year substance use disorder receiving treatment in the US in 2021.4<\/a><\/sup>\u00a0Our goal is to summarize published data on physician-described barriers to adoption of EBPs for addiction in clinical practice and recommend actions to address them.<\/p>\n

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Methods<\/strong><\/span><\/div>\n
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Data Sources and Searches<\/div>\n<\/div>\n

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA<\/a>) reporting guidelines. The search strategy was developed iteratively with a National Library of Medicine informationist specializing in systematic reviews. We applied this strategy on October 4, 2021, to PubMed, Embase, and Scopus and on October 5, 2021, to\u00a0medRxiv<\/i>\u00a0and SSRN Medical Research Network. In addition, a gray literature search of relevant government and nongovernment websites was conducted on October 5, 2021. We found no previous similar systematic reviews. The systematic review protocol was registered in PROSPERO (CRD42022286208<\/a>) and accepted on January 14, 2022.<\/p>\n

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Study Selection<\/span><\/strong><\/span><\/div>\n<\/div>\n

A 12-person team used Covidence to apply exclusion criteria first to the title and abstract of each study then to the full text of studies not already excluded. Two people (L.N., M.C., L.F., J.P., C.S., and S.W.) reviewed each study in both rounds. Discordant opinions were resolved by a third reviewer (M.C. and W.C.). To be included, the study had to present data on: (1) physicians at any practice level; (2) any substance use intervention(s) (Box<\/a>); and (3) physician reasons for reluctance to intervene in addiction. Studies not in English, letters, editorials, narrative reviews, and commentaries were excluded. Data collection on reasons for reluctance were systemized using the theoretical domains framework (TDF),18<\/a><\/sup>,19<\/a><\/sup>\u00a0a comprehensive approach for identifying behavioral determinants and for assessing implementation problems (eg, clinicians\u2019 behavior) to inform intervention development. The team created a data extraction template with 10 reluctance reason categories (Box<\/a>). We did not formally assess risk of bias in included studies because few used experimental or controlled study designs. Due to patterns observed during data extraction, the team approved the ad hoc collection of data on factors (eg, using a theoretical framework, obtaining target audience input in survey design, and piloting surveys) that could affect the internal validity of individual studies or precision of results. We conducted a limited exploration of facilitators because we observed that many included studies provided at least some data on possible facilitators of intervention in addiction.<\/p>\n

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Definitions of Intervention Type and Reluctance Reasons<\/span><\/h4>\n
Intervention type and definition<\/h5>\n