DOCUMENT RESUME

ED 350 944 HE 025 922

AUTHOR Lewis, David C.; Faggett, Walter L.TITLE Policy Report of the Physician Consortium on

Substance Abuse Education.INSTITUTION Health Resources and Services Administration

(DHHS /PHS), Rockville, MD. Bureau of HealthProfessions.

REPORT NO HRSA-P-DM-91-3PUB DATE 91

NOTE 38p.

PUB TYPE Reports General (140)

EDRS PRICE 1701/PCO2 Plus Postage.DESCRIPTORS Adolescents; Alcohol Abuse; Children; *Continuing

Education; Drug Abuse; *Educational Needs; EthnicGroups; Graduate Medical Education; Health Programs;*Health Promotion; Higher Education; *MedicalEducation; Minority Groups; National Surveys;Physicians; Professional Education; *Substance Abuse;*Undergraduate Study

IDENTIFIERS Primary Prevention

ABSTRACTThis report contains the recommendations of the

Physician Consortium for significantly improving medical educationand training to enhance the physician's role in early identification,treatment, and prevention of substance abuse. In addition, theconsortium subcommittees report on their examination of substanceabuse treatment needs of ethnic and racial minority groups and on theunique training needs that are especially germane to the care ofadolescents and children. Recommendations address the need forchanges in undergraduate medical education, graduate medicaleducation, and continuing medical education; they also focus specialattention on the concerns of adolescents and children and themulticultural issues in substance abuse education and training ofphysicians. The report concludes with background information on theproblems of substance abuse in general and cn certain specificsubstances--cocaine, marijuana, alcohol and tobacco products--inparticular. Contains 32 references. (GLR)

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The views expressed in this document are solely those of the Physician Consortium onSubstance Abuse Education and do not necessarily represent the views of the

Health Resources and Services Administration nor of the United States Government.

13 o IL:CY REF lr

OF THE PHYSICIAN CONSORTIUMON SUBSTANCE ABUSE EDUCATION

David C. Lewis, M.D., Chairperson

Walter L. Faggett, M.D., Vice Chairperson

Supported by theHEALTH RESOURCES AND SERVICES ADMINISTRATION

Bureau of Health ProfessionsDivision of Medicine

Staffed by theSpecial Projects and Data Analysis Branch

Special Projects Section

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICESPublic Health Service

Publication No. HRSA-P-DM-91-3

iii

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Bureau of Health Professions

Robert G. Harmon, M.D.AdministratorHealth Resources and Services Administration

Dear Dr. Harmon:

Health Resources andServices Administration

Rockville MD 20857

I am pleased to submit to you the Policy Report of the PhysicianConsortium on Substance Abuse Education. This document containsthe recommendations of the Physician Consortium for significantlyimproving medical education and training to enhance the physician'srole in early identification, treatment and prevention of substanceabuse. These recommendations address the need for changes inundergraduate medical education, graduate medical education, andcontinuing medical Education; they also focus special attention onthe concerns of adolescents and children and the multiculturalissues in substance abuse iucation and training of physicians.

The Bureau of Health Professions' Division of Medicine has servedas the Physician Consortium's organizer, facilitator andsecretariat in producing this report. Through this effort thepublic and private sectors have worked together effectively tobring to the attention of medical educators the changes needed inmedical education to improve medical care related to substanceabuse. The Bureau recognizes the importance of healthprofessionals in the struggle to ameliorate Lne suffering and lowerthe costs associated with the health problems stemming fromsubstance abuse. As the recommendations of this report becomeimplemented across medical education and physicians incorporatethis new knowledge and skill in their practice, physicians willbecome ever more important in diagnosing, treating and preventingthe health problems brought about through substance abuse in oursociety.

With the submission of the Policy Report of the PhysicianConsortium on Substance Abuse Education, the Physician Consortiumbrings to a successful conclusion its first major task. I want tothank personally each member of this group for contributing to thisimportant effort. As the Director of the Bureau of HealthProfessions, I look forward to facilitating the continuing work ofthe Physician Consortium as it moves forward with its agenda toimprove medical education in substance abuse.

Fi hug Mullan, M.D.Di ctoAs stant Surgeon General

Enclosure

i v

ACKNOWLEDGEMENT

The preparation of this Policy Report of thePhysician Consortium on Substance AbuseEdu-cation was assisted greatly by staff in the

Health Resources and Services Administration.The Physician Consortium on Substance AbuseEducation was supported by the Division of Medi-cine and staffed by the Special Projects Section ofthe Special Projects and Data Analysis Branch.Marilyn H. Gaston, M.D., Director, Division ofMedicine, Bureau of Health Professions, served asExecutive Secretary to the Consortium, and subse-quently Janet B. Horan, M.P.H., R.N., C., served asthe Acting Executive Secretary. Brenda E. Selserand Robert M. Politzer, M.S., Sc.D., served asProgram Staff Liaisons to the Consortium. RuthH. Carlsen Kahn, D.N.Sc.,Health Manpower Edu-cation Specialist, Special Projects Section, SpecialProjects and Data Analysis Branch, and CarolGleich, Ph.D., Chief, Special Projects and DataAnalysis Branch, performed the final editorial workon the report.

Although the Consortium chairperson, vicechairperson, subcommittee chairpersons, andmembers accept all responsibility for this PolicyReport of the Physician Consortium on Substance Abuse

Education, the following professional staff mem-bers should be cited for their special contributions:Dona L. Harris, Ph.D., Scholar-in-Residence, Divi-sion of Medicine, Bureau of Health Professions;and professional staff of the Alcohol, Drug Abuse,and Mental Health Administration: Jo Brady,Chief, Training and Evaluation Branch, Office ofSubstance Abuse and Prevention; Frances Cotter,M.P.H., Chief, Health Professions Education Pro-gram, National Institute on Alcohol Abuse andAlcoholism; and Dorynne Czechowicz, M.D.,Assistant Director for Medical and ProfessionalAffairs, National Institute on Drug Abuse. RobertPetersen, Ph.D., provided technical and editorialassistance in the earlier draft report.

Particular acknowledgement is given to the fineadministrative support provided by John Heyob,Deputy Director, Division of Medicine, and to theexcellent secretarial assistance provided by PennyKing, Branch Secretary, Special Projects and DataAnalysis Branch, and Sandy Weaver, Section Sec-retary, Special Projects Section.

For further information regarding this PolicyReport of the Physician Consortium on Substance AbuseEducation, please contact:

Ruth H. Carlsen Kahn, D.N.Sc.Special Projects SectionDivision of Medicine, BHPrParklawn Building5600 Fishers Lane, Room 4C-25Rockville, Maryland 20857Telephone (301) 443-6785

V

PREFACE

he momentum for including substanceabuse education within the mainstream ofmc:dical education has increased steadily over

the past five years. Virtually every national medi-cal professional society now has a task force orworking group dealing with the issue. AMERSA,the national medical faculty organization for phy-sicians and other health professional devoted tosubstance abuse education, has doubled its mem-bership and tripled its national conference atten-dance over the last five years. Federal initiativesby Health Resources and Services Administrationand ADAMHA (NIAAA, NIDA, OTI, and OSAP)have added to the momentum by supporting de-velopment of new medical school curricula, fac-ulty development, and training opportunities forprimary care physicians.

This report and the work of the PhysiciansConsortium on Substance Abuse Education arepart of the momentum. It is an historic event inthat it is the first time that representatives of somany national professional societies have con-vened and achieved a published consensus on thissubject.

This work, however, is not without precedent.Both the Macy Foundation Report of 1972 and theAnnenberg Center Conference of 1985 were itsforerunners. The Macy Conference, about thesame size as the Consortium, was made up ofthirty leaders in academic medicine, rather thanrepresentatives of national organizations. Whileits advice received practically no notice a t the time,it is still timely advice and quite consistent withcurrent thinking.

"The absence in most teaching hospitalsof specialized clinical facilities for treatingdrug abusers leaves the same gap in thetraining of today's medical students as in

the past. After a brief didactic introduc-tion to the problems of drug abuse in thebasic pharmacology course, most studentsreceive only accidental and sporadic rein-forcement in their clinical years. The Con-ference postulated that the treatmentandprevention of drug abuse should betaught systematically so that students canlearn to approach the issue of drug abusejust as they learn to approach the prob-lems of cardiovascular disease, cancer andmental illness." From Medical Educationand Drug Abuse: Report of a Macy Confer-ence.

The Annenberg Center Conference did have animpact. Its report, "Consensus Statement from theConference-Alcohol, Drugs, and Primary CarePhysician Education: Issues, Roles, Responsibili-ties," presaged a whole series of private and publicinitiatives to develop and introduce competency-based training into substance abuse medical edu-cation.

There has been general agreement for yearsabout what needs to be done in medical educationabout substance abuse, but the level of accom-plishment has fallen far short of the need. Thisreport of the Physician Consortium on SubstanceAbuse Education is a working document, designedto make things happen. While its recommenda-tions are neither original nor difficult to achieve,the measure of its success will be the action that itstirs. in a year, we plan to seek feedback fromnational professional societies, residency reviewcommittees, medical boards, medical schools,regulatory bodies, and government programs toassess the implementation of the Report's recom-mendations. We hope that the report will beuseful to the organization and individuals who areready to move ahead with us.

David C. Lewis, M.D.Chairperson

vi

PHYSICIAN CONSORTIUMON SUBSTANCE ABUSE EDUCATION

CHAIRPERSON

Elected by the Physician ConsortiumDavid C. Lewis, M.D.

VICE CHAIRPERSON

Elected by the Physician ConsortiumWalter L. Faggett, M.D.

EXECUTIVE SECRETARY

Director, Division of MedicineMarilyn H. Gaston, M.D. - 1989-1990Marc L. Rivo, M.D. 1991 - Present

vii

ORGANIZATIONS REPRESENTED

Accreditation Council for Graduate Medical Education(ACGME)515 North State StreetChicagc Illinois 60610(312) 464-:.7)00

John Gienapp, Ph.D.

Ambulatory Pediatric Association (APA)6728 Old McLean Village DriveMcLean, Virginia 22101(703) 556-9222

William Bithoney, M.D.

American Academy of Child and Adolescent Psychiatry(AACAP)3615 Wisconsin Avenue, N.W.Washington, D.C. 20016(202) 966-7300

Peter Cohen, M.D.

American Academy of Family Physicians (AAFP)8880 Ward ParkwayKansas City, Missouri 64114(816) 333-9700

Neil H. Brooks, M.D. (Current Representative)Roger B. Rodriguez, M.D. (Former Representative)

American Academy of Pediatrics (AAP)P.O. Box 927Elk Grove Village, lllirois 60009(312) 228-5005

S. Kenneth Schonberg, M.D.

American Academy of Psychiatristsin Alcoholism and Addiction (AAPAA)P.O. Box 376Greenbelt, Maryland 20770.301) 220-0951

Sheldon I. Miller, M.D.

American Board of Family Practice (ABFP)2228 Young DriveLe;:ington, Kentucky 40505(606) 269-5626

Raymond Anderson, M.D.

American Board of Medical Specialties (ABMS)One Rotary Center, Suite 805Evanston, Illinois 60201(708) 491-9091

Donald Langsley, M.D.

American Board of Pediatrics (ABP)Ill Silver Cedar CourtChapel Hill, North Carolina 27514(919) 929-0461

Catherine DeAngtlis, M.D.

American College of Emergency Physicians (ACEP)P.O. Box 619911Dallas, Texas 75261(214) 550-0991

H. Arnold Muller, M.D.

American College of Obstetrics and Gynecology (ACOG)409 12th Street, S.W.Washington, D.C. 20024(202) 638-5577

Constance Bohon, M.D.

American College of Physicians (ACP)Independence Mall West6th Street at RacePhiladelphia, Pennsylvania 19106-1572(215) 351-2400

Michele Cyr, M.D.

American Medical Association (AMA)515 North State StreetCh:ago, Illinois 60610(312) 464-5000

John J. Ambre, M.D., Ph. D. (Current Representative)Bonnie B. Wilford (Former Representative)

American Medical Student Association (AMSA)1890 Preston White DriveReston, Virginia 22091(703) 620-6600

Joan Hedgecock

American Osteopathic Association (AOA)142 East Ontario StreetChicago, Illinois 60611-2864(312) 280-5800

Eugene Oliveri, D.O.

American Pediatric Society, Incorporated (APS)6728 Old McLean Village DriveMcLean, Virginia 22101(703) 556-9222

Catherine DeAngelis, M.D.

American Psychiatric Association (APA)1400 K Street, N.W.Washington, D.C. 20005(202) 682-6000

Sheldon I. Miller, M.D.

American Society of Addiction Medicine (ASAM)5225 Wisconsin Avenue, N.W., Suite 409Washington, D.C. 20016(202) 244-8948

James Callahan, D.P.A.Emanuel M. Steindler

Association for Medical Educationand Research in Substance Abuse (AMERSA)Brown University Box GProvidence, Rhode Island 02912(401) 863-3173

David C. Lewis, M.D.

Association of American Medical Colleges (AAMC)1 DuPont Circle, N.W., Suite 200Washington, D.C. 20036(202) 828-0579

Lcis Bergeisen (Current Representative)Gretchen C. Chumley (Former Representative)

Association of American Indian Physicians (AAIP)10015 South Pennsylvan'a, Building DOklahoma City, Oklahoma 73159(405) 692-1202

Philip Smith, M.D.

Charles R. Drew University of Medicine and Science1621 East 120th StreetLos Angeles, California 90059(213) 563-4974

Lewis M. King, M.D.

InterAmerican College of Physicians and Surgeons (ICPS)299 Madison AvenueNew York, New York 10017(212) 599-2737

Rene F. Rodriguez, M.D.

Medical College of Virginia HospitalVirginia Commonwealth UniversityBox 109, MCV Station Richmond, Virginia 23298-0001(804) 786-9914

Sidney H. Schnoll, M.D., Ph.D.

Meharry Medical College1005 David B. Todd Boulevard,Box A7 Nashville, Tennessee 37208(615) 327-6774

Lloyd C. Elam, M.D.

Morehouse School of Medicine720 Westview Drive S.W.Atlanta, Georgia 30310(404) 752-1780

Omowale Amuleru-Marshail, Ph.D.

National Association of Medical Minority Educators, Inc.(NAMME)Michigan State UniversityA-236 East Fee HallEast Lansing, Michigan 48824(517) 353-5440

Wanda Lipscomb, Ph.D.

National Board of Medical Examiners (NBME)3930 Chestnut StreetPhiladelphia, Pennsylvania 19104(215) 349-6400

Robert L. Voile, M.D.

National Medical Association (NMA)1012 10th Street, N.W.Washington, D.C. 20001(202) 347-1895

Walter L. Faggett, M.D.

Society of Adolescent Medicine (SAM)10727 White Oak Avenue, Suite 101Granada Hills, California 91344(818) 368-5996

S. Kenneth Schonberg, M.D.

Society of General Internal Medicine (SGIM)700 13th Street, N.W., Suite 250Washington, D.C. 20005(202) 393-1662

JudyAnn Bigby, M.D.

Student National Medical Association (SNMA)1012 10th Street, N.W.Washington, D.C. 20001(202) 371-1616

Daniel LaRoche

The Society of Teachers of Family Medicine (STFM)8880 Ward Parkway P.O. Box 88729Kansas City, Missouri 64114(816) 333-9700

James Finch, M.D.

ix

FEDERAL REPRESENTATIVES

Agency For Health Care Policy And Research5600 Fishers Lane, Room 18-05Rockville, Maryland 20857

J. Jarrett Clinton, M.D.AdministratorJacqueline Besteman, J.D., M.A.Executive Assistant to the Agency Administrator

Alcohol, Drug Abuse and Mental Health AdministrationOffice for Treatment ImprovementRockwall 11 Building, 10th Floor5600 Fishers Lane Rockville, Maryland 20857

Beny Primm, M.D.Associate AdministratorSaul Levin, M.D.Special Assistant to the AdministratorSpecial Expert to the Director, OTI

Health Resources and Services AdministrationBureau of Health Professions (BHPr)5600 Fishers LaneRockville, Maryland 20857

Fitzhugh Mullan, M.D.DirectorMarilyn H. Gaston, M.D. - Former Executive SecretaryDirectorDivision of Medicine - 1989 - 1990

Marc L. Rivo, M.D. - Current Executive SecretaryDirectorDivision of Medicine 1991 - Present

Carol Gleich, Ph.D.ChiefSpecial Projects and Data Analysis BranchDivision of Medicine

Dona L. Harris, Ph.D.Scholar-in-ResidenceOffice of the DirectorDivision of MedicineJanet Horan, M.P.H., R.N., C.ChiefSpecial Projects SectionDivision of MedicineRobert M. Politzer, M.S., Sc.D.Special Assistant to the DirectorNeil H. SampsonSubstance Abuse CoordinatorDirectorAssociated & Dental Health Professions DivisionBrenda E. SelserChiefResidency and Advanced Grants SectionGrants Management BranchOffice of Program Support

Joint Staff 14Pentagon, Room 2C28Washington, D.C. 20318-4000

Evan R. Arrindell, D.S.W.Medical Readiness DirectorateMedical Mobilization Division

National Institute on Alcohol Abuse and Alcoholism(NIAAA)5600 Fishers LaneRockville, Maryland 20857

Frances Cotter, M.P.H.ChiefHealth Professions Education ProgramDivision of Clinical and Prevention Research

National Institute on Drug Abuse (NIDA)5600 Fishers LaneRockville, Maryland 20857

Dorynne Czechowicz, M.D.Associate DirectorMedical and Professional AffairsDivision of Clinical ResearchRebecca S. Ashery, D.S.W.AIDS Education and TrainingCommunity Research Branch

Office for Substance Abuse Prevention (OSAP)5600 Fishers Lane, Rockwall IIRockville, Maryland 20857

Jo BradyChiefTraining and Evaluation BranchDivision of Prevention Implementation

Office of the Assistant Secretary for Health (OASH)HHH Building200 Independence Ave. S.WWashington, D.C. 20201

Maria Segarra, M.D.Program Development OfficerSenior Medical AdvisorOffice of Minority Health

X

CONSORTIUM SUBCOMMITTEES

Undergraduate Medical Education

Eugene Oliveri, D.O., ChairpersonLois Be.: :-ienOmowale Ameruli-Marshall, Ph.D., M.P.H.Joan HedgecockDona Harris, Ph.D., Resource PersonDonald Langsley, M.D.Daniel LaRoche

Graduate Medical Education

Sheldon I. Miller, M.D., ChairpersonMichele Cyr, M.D.Frances Cotter, M.P.H., Resource PersonJohn Gienapp, Ph.D.Lewis M. King, M.D. H.Arnold Muller, M.D.Neil Brooks, M.D.Sidney H. Schnoll, M.D., Ph.D.

Continuing Medical Education

Bonnie B. Wilford, ChairpersonRaymond Anderson, M.D.Jo Brady, Resource PersonLloyd C. Elam, M.D.James Finch, M.D.David C. Lewis, M.D.Emanuel M. Steindler

Multicultural Issues

JudyAnn Bigby, M.D., ChairpersonJames Callahan, D.P.A.Maria Segarra, M.D., Resource PersonWanda Lipscomb, Ph.D.Rene F. Rodriguez, M.D.

Adolescents and Children

S. Kenneth Schonberg, M.D., ChairpersonWilliam Bithoney, M.D.Dorynne Czechowicz, M.D., Resource PersonConstance Bohon, M.D.Catherine DeAngelis, M.D.Walter L. Faggett, M.D.Phillip Smith, M.D.

xi

TABLE OF CONTENTS

ACKNOWLEDGEMENT iv

PREFACE v

PHYSICIAN CONSORTIUM ON SUBSTANCE ABUSE EDUCATION vi

ORGANIZATIONS REPRESENTED

CONSORTIUM SUBCOMMITTEES x

I. EXECUTIVE SUMMARY

II. PHYSICIAN CONSORTIUM ON SUBSTANCE ABUSE EDUCATION 5

PURPOSE, HISTORY AND GOAL 5

THREE-YEAR AGENDA AND APPROACH 6

III. FINDINGS AND RECOMMENDATIONS OF SUBCOMMITTEES 7

UNDERGRADUATE MEDICAL EDUCATION 7

GRADUATE MEDICAL. EDUCATION 10

CONTINUING MEDICAL EDUCATION 12

MULTICULTURAL ISSUES 14

ADOLESCENTS AND CHILDREN 16

IV. BACKGROUND ON THE SUBSTANCE ABUSE PROBLEM 19

REFERENCES 23

BIBLIOGRAPHY 24

1

I. EXECUTIVE SUMMARY

This Executive Summary of the Policy ReportOf The Physician Consortium On SubstanceAbuse Education states the purpose of the

Physician Consortium on Substance Abuse Edu-cation, presents the consensus statements of thefindings, and reports the recommendations of thefive subcommittees. These recommendations un-derscore the need for changes in medical educa-tion and training curricula in order to cope withthe mounting problems of substance abuse. TheExecutive Summary also briefly describes the his-tory, goal, three-year agenda, and the Consortium'sapproach to its work. The full text includes thecomplete reports of the five subcommittees, whichdetail the findings and recommendations forchanges in medical education and training devel-oped by each of the five subcommittees. Thereport concludes with background information onthe problems of substance abuse generally.

Purpose of the Physician ConsortiumThe purpose of the Physician Consortium is to

promote the role of the physician in prevention,early identification, and treatment of substanceabuse by improving medical education and train-ing.

The Physician Consortium on Substance AbuseEducation is expected to make a major contribu-tion to meeting the significant national medicaleducation need of preparing the Nation's physi-cians to respond to the health problems related toalcohol and substance abuse. The Consortium hasbeen asked to assess educational needs of physi-cians, to identify the barriers which prevent phy-sicians from treating the problems associated withsubstance abuse, and to make recommendationsfor needed change in the education and training ofphysicians that would extend to curricula of medi-cal schools and residency programs as well ascontinuing medical education. The Consortium'srecommendations are intended to focus on im-provements needed in medical education in orderto enable physicians to intervene effectively inprevention, early identification, and treatment ofsubstance abuse.

Consortium Consensus On FindingsConsortium members agreed by consensus that

substance abuse education and training for alllevels of medical education is markedly deficient.Medical education programs incorporating sub-stance abuse problems of minority groups andyouth are also seriously lacking. Although somemedical education curricula focusing on substanceabuse have been developed for specific medicalspecialties (general and family practice, pediat-rics, internal medicine, obstetrics and gynecology,emergency medicine, and psychiatry), few of theseare in widespread use. Substance abuse educationand training continue to be poorly integrated intogeneral medical education, and the minimal sub-stance abuse training that does exist fails to takeinto account the special problems and needs ofminorities. A basic difficulty repeatedly noted byeach of the Consortium subcommittees is the needto overcome physician prejudice regarding sub-stance abusers including the belief that abusershave a poor prognosis. A related problem is thatof physician uncertainty about who has ultimateresponsibility for substance abuse interventionwith patients. One reason physicians may bereluctant to accept responsibility for interventionwith patients is that existing medical treatmentstandards permit varying degrees of possible phy-sician involvement. A second major area identi-fied by all the subcommittees is the need to de-velop trained faculty who can provide appropri-ate education and training supervision and serveas role models in this area. Finally, a third concernidentified is that of how to alter definitively thephysicians' actual practice behavior, rather thansimply construct medical education programs thatadd to general knowledge of substance abuse.

Physician ConsortiumRecommendations

The Physician Consortium On Substance AbuseEducation recommends that:

Undergraduate Medical Education

Undergraduate medical education programsshould be developed to overcome the negativeattitudes of faculty and students toward substance

abuse and to establish effective faculty role modelsfor students, house staff, and attending physi-cians.

Specific faculty should be identified, trained,and assigned responsibilities for substance abuseeducation in undergraduate medical educationprograms to ensure that the topic becomes anintegral part of every medical student's educationand training.

Undergraduate medical education and train-ing should introduce students to substance abuseproblems of patients and communities at risk forsubstance abuse.

Multidisciplinary community-based programsshould be utilized to educate students in the entirerange of substance abuse problems and interven-tions.

On-campus confidential student and house staffimpairment prevention policies and programsshould be established to provide drug and alcoholprevention programs directed to medical studentsand physicians at risk.

The Government's role as a funding source andfacilitator in setting priorities for substance abusemedical education and training should be contin-ued.

Private foundations and public agencies shouldbe encouraged to provide internships and otherstipend-supported training opportunities for re-search, clinical and community-based medicaltraining in chemical dependency.

Graduate Medical Education

A basic graduate medical education facultytraining course should be offered as the first levelof training in substance abuse for five additionalgraduate medical education specialties: generalinternal medicine, general pediatrics, obstetricsand gynecology, emergency medicine and psy-chiatry. The Family Medicine Model represents asuccessful effort which could be adopted.

A three-month interdisciplinary course in sub-stance abuse education should be developed fortraining physician faculty of graduate medicaleducation residency programs.

A two-year fellowship program in substanceabuse education should be developed to provideacademic physician leadership in substance abuseeducation for graduate medical education.

Ten "centers of excellence" in substance abuseeducation should be established nationwide whichincorporate linkages of community-based sub-stance abuse programs focusing on preventionand treatment with mental health centers and areahealth education centers. Two periods of training(a three-month course and a longer two-year fel-lowship program) for physician faculty of gradu-ate medical education programs would be offeredin the centers.

All levels of faculty training in substance abuseshould include content on cross-cultural and spe-cial population issues and information related tothe changing demographics of our society.

Graduate medical education residency pro-grams should develop and implement specificsubstance abuse training requirements, and theserequirements should be reflected in specialty boardexaminations.

Continuing Medical Education

Substance abuse continuing medical educationprograms should be targeted to different physi-cian audiences by tailoring programs to meet theiractual needs, interests, and practice patterns.

Physicians should be sensitized to the existenceof alcohol and substance abuse problems in theirpatient population through continuing medicaleducation programs.

The existing skill repertory of physicians shouldbe used as the foundation for new continuingmedical education programs.

A wide range of instructional methods shouldbe utilized in the development of continuing medi-cal education programs to alter physician atti-tudes toward substance abuse, to improve skillsand to increase physician willingness to deal withsubstance abuse problems.

Substance abuse related knowledge and skillsshould be included whenever practice standards,guidelines, parameters and protocols are beingdeveloped or revised by public agencies or privateorganizations.

i a

3

Multicultural IssuesA group of educators, physicians, and sub-

stance abuse experts should be convened to defineknowledge, skills, and attitude requirements inthe substance abuse area specific to ethnic andracial minorities and to identify appropriate meth-ods and teaching strategies.

All medical education and training programs insubstance abuse should be required to explicitlyinclude specific training modules focusing on theneeds of ethnic and racial minority groups.

The Secretary's Task Force on Black and Minor-ity Health recommendations concerning substanceabuse should be pursued.

Substance abuse training programs linked withservice programs which target racial and ethnicminority populations should include informationfrom current research on minority use patternsand effective intervention.

Substance abuse training specifically address-ing issues relevant to ethnic minorities should beincluded during residency training in primarycare disciplines.

Adolescents and ChildrenOutpatient training settings along with psychi-

atric residential facilities should be utilized inorder that the full spectrum of youthful drug abus-ers be represented.

Faculty with a primary interest in adolescentmedicine should be provided the opportunity todevelop expertise in substance abuse issues and toconvey that expertise to trainees. Training shouldbe multidisciplinary and involve cooperation andcoordination of education among the disciplinesof family medicine, pediatrics, child and adoles-cent psychiatry, gynecology, and internal medi-cine.

The use of screening devices for detecting drugabuse should be taught as an integral componentof education programs that focus on adolescentsubstance abuse.

Data on effective prevention strategies for ado-lescent substance abuse should be used in teach-ing programs and disseminated to those workingwith youthful populations.

Legal and ethical issues of substance abuseshould be incorporated in substance abuse educa-tion at all levels of training.

Consortium HistoryThe Physician Consortium on Substance Abuse

Education was organized in 1989 under the aegisof the Public Health Service, Health Resources andService Administration, Bureau of Health Profes-sions, Division of Medicine to examine substanceabuse education for physicians at all levels oftraining. The establishment of the PhysicianConsortium was an outcome of earlier alcoholabuse initiatives of the Office of the Secretary,Department of Health and Human Services. In1988 two meetings were held with physician rep-resentatives of medical organizations and repre-sentatives of the Federal Government to discussthe alcohol training and education needs of thephysician community and the role of licensureexaminations in assuring a minimum level of phy-sician competence in the area of alcohol diagnosisand intervention. In 1989 the Director of theBureau of Health Professions, working in collabo-ration with the American Medical Association,held an invitational conference to discuss the topic"The Primary Care Physician's Critical Role inPreventing Alcohol Abuse and Alcoholism". Alsoduring this time period, the Public Health Serviceissued the "Year 2000 Draft Objectives for Reduc-ing Alcohol and Other Drugs" and established aTask Force on Illicit Drugs. In response to theclearly identified need for better educated andtrained health professionals, the Bureau of HealthProfessions established health professional con-sortia to focus on the education and training needsof practitioners in the area of substance abuse. ThePhysician Consortium on Substance Abuse Edu-cation was formed by expanding the membershipof the previous work groups to include organiza-tions responsible for physician training and edu-cation. This newly constituted group, which in-cluded representatives nominated by their medi-cal associations, societies, specialty boards, andmedical schools, met for the first time in June, 1989,under the auspices of the Bureau of Hea!th Profes-sions, Division of Medicine.

t6

4

Consortium GoalThe Physician Consortium's goal is consistent

with the Department of Health and Human Ser-vices' recently released Healthy People 2000, Na-tional Health Promotion and Disease Prevention Ob-jectives (DHHS,1991). These objectives aim to re-duce sharply drug abuse and the high medical tollit now exacts. The Consortium expects that thePolicy Report of the Physician Consortium on Sub-stance Abuse Education will contribute to improvedunderstanding of the physicians' role in medicalissues associated with substance abuse. The Con-sortium also expects that physicians will morebroadly and directly influence the medical prob-lems of substance abuse when the changes recom-mended for medical education and training havebeen implemented.

Consortium Agendaand Approach to Work

The Policy Report of the Physician Consortium onSubstance Abuse Education is the product of theConsortium's first year of work on a three-yearprojected agenda. The Policy Report presents infull the Consortium's findings on medical educa-tion in substance abuse and makes recommenda-tions for improving the quality of medical educa-tion related to substance abuse. The Policy Reportis intended for widespread circulation to nationalmedical organizations and to Federal and Stateagencies for their use in overcoming barriers to thetreatment of substance abuse through improvedmedical education. Also during this agenda timethe Consortium through the assistance of the Divi-sion of Medicine developed and distributed to theConsortium members a catalog of educationalmaterials on the prevention, diagnosis, and treat-ment of substance abuse. The second year ofConsortium agenda will be devoted to fostering adialogue among private and public organizationsto encourage the establishment of new policiesand programs consonant with the recommenda-tions contained in the Policy Report. During thethird year the Consortium will focus on changesthat either will or have been implemented and onevaluation of the overall effort in bringing aboutimproved understanding of substance abuse inmedical education curricula.

The Consortium's work was facilitated and di-rected by the systematic approach developed bythe Steering Committee. Five subcommittees wereformed to examine information, determine thefindings, and develop specific recommendationsfor improving medical education related to sub-stance abuse. Subcommittees examined variousoptions to improve undergraduate, graduate, andcontinuing medical education. Subcommitteesalso examined the substance abuse treatment needsof ethnic and racial minority groups and the uniquetraining needs for the care of adolescents andchildren. These subcommittees are titled: Sub-committee on Undergraduate Education; Subcom-mittee on Graduate Education; Subcommittee onContinuing Medical Education; Subcommittee onMulticultural Issues; and Subcommittee on Ado-lescents and Children. The complete reports of thefive subcommittees are included in the full body ofthe report.

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II. THE PHYSICIAN CONSORTIUMON SUBSTANCE ABUSE EDUCATION

Purpose, History and GoalThe Department of Health and Human Ser-

vices' Healthy People 2000, National Health andDisease Prevention Objectives (DHHS, 1991) forReducing Alcohol and Other Drug Problems,stresses the important role health professionalscan play in the early detection, treatment andreferral of persons with substance abuse problems

The purpose of the Consortium is to promotethe role of the physician in the prevention, earlyidentification and treatment of substance abuse byimproving medical education and training.

Many barriers to effective prevention and earlyidentification of alcohol and other drug abusehave been recognized and reported. However,developing effective strategies to eliminate thosebarriers remains a difficult task. The gap betweenthe awareness of substance abuse problems andeffective medical intervention to cope with themcontinues to be significant.

Early in 1987, the Secretary of Health and Hu-man Services set out to build on the work alreadyaccomplished in the alcohol abuse field by solicit-ing the support of health professionals and inter-ested organizations to further raise the nationalawareness of alcohol-related problems. On behalfof the Secretary, two meetings were convened inAugust and October of 1988. One outcome ofthese meetings was a conference in February of1989 on the role of the primary care physician incoping with alcohol abuse and alcoholism. Partici-pants in this meeting unanimously agreed that agroup representing organizations responsible forphysician training should be formed to addressalcohol-related medical education issues. Theyalso concluded that the membership of the groupshould be expanded and that the scope of workshould include the entire spectrum of abused drugs.Also, the challenge to the profession of the alcohol-abusing patient was addressed by the Secretary ofHealth and Human Services and the AmericanMedical Association (Bowens and Sammons, 1988).

The Public Health Service issued the "Year 2000Draft Objectives for Reducing Alcohol and OtherDrugs" and established a Task Force on IllicitDrugs. The Bureau of Health Professions wasassigned the responsibility for establishing healthprofessional consortia to meet the education andtraining needs of practitioners in the area of sub-stance abuse. The Physician Consortium on Sub-

stance Abuse Education was formed by expand-ing the membership of the earlier work groups toinclude organizations responsible for physiciantraining and education. This new 30-memberconsortium established by the Bureau of HealthProfessions included representatives from medi-cal associations and societies, specialty boards,and medical schools selected by the respectiveorganizations. The first meeting of this consor-tium convened in June of 1989 and was chaired bythe Bureau Director. The second meeting in No-vember 1989 was chaired by its current electedleadership. Bureau of Health Professions' staffserve as its secretariat.

The Consortium is a valuable link between theFederal Government and academic and profes-sional organizations. Members workcollaboratively, both within the Consortium andwithin their respective organizations, to build onthe work that has already been done in the alcoholand drug abuse fields. They actively solicit thesupport of health professionals and organizationsin eliminating barriers to effective prevention andearly identification of substance abuse. One ap-proach to the elimination of barriers is through theimprovement of the quality of substance abusemedical education and training.

The Consortium interacts with other PublicHealth Service entities such as the Office of theSurgeon General and the Alcohol, Drug Abuse,and Mental Health Administration (ADAMHA).ADAMHA includes the National Institute on DrugAbuse (NIDA), the National Institute on AlcoholAbuse and Alcoholism (NIAAA), the NationalInstitute of Mental Health (NIMH), and the newlyestablished Office for Treatment Improvement(OTI). It also works with the Centers for DiseaseControl (CDC) and the Health Resources and Ser-vices Administration (HRSA) to achieve its objec-tives.

The Physician Consortium's goal is consistentwith the Department of Health and Human Ser-vices' recently released Healthy People 2000, Na-tional Health Promotion and Disease Prevention Ob-jectives (DHHS, 1991). These objectives aim toreduce sharply drug abuse and the high medicaltoll it now exacts. The Consortium anticipates thatthe Policy Report of the Physician Consortium onSubstance Abuse Education will contribute to im-proved understanding of the physician's role inmedical issues associated with substance abuse.

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The Consortium also expects that physicians willmore broadly and directly influence the medicalproblems of substance abuse with implementa-tion of the changes recommended for medicaleducation and training curricula.

Three-Year Agenda and ApproachThe Consortium has initiated a three-year pro-

gram. During its first year this Policy Report of thePhysician Consortium on Substance Abuse Educationhas been completed for circulation to nationalmedical organizations as well as to agencies inFederal and. state governments. The Report in-cludes recommendations to both private and pub-lic sector organizations of ways in which the qual-ity of medical education concerning substanceabuse can he improved. Also during the first yearthe members of the Consortium through the assis-tance of the Division of Medicine prepared a cata-log of educational materials on the prevention,diagnosis, and treatment of substance abuse.During the second year the Consortium will en-courage a dialogue among these organizations toencourage them to establish new policies and pro-grams. The third year of this multifaceted agendawill be devoted to implementing the suggestedpolicies and programs and to evaluating how suc-cessfully the public and private sectors have beenin pursuing and achieving the Consortium's rec-ommendations.

The work of the Consortium is summarizedbelow:

The Consortium requested that a resource docu-ment be compiled of current material on substanceabuse education. The Bureau of Health Profes-sions' Division of Medicine responded by devel-oping a catalog of educational materials on sub-stance abuse prevention, diagnosis and treatment.This catalog provides a brief description of educa-tional materials available both to primary carephysicians and for distribution to their patients.

The Consortium established five subcommit-tees to address specific substance abuse trainingissues in undergraduate, graduate and continuingmedical education as well as the education ofphysicians providing treatment for ethnic and ra-cial minorities and of physicians caring for adoles-

cents and children. Subcommittee membersadopted a list of priority areas for specific consid-eration at their future meetings.

A Steering Committee was established to de-fine the role, organization and work of the Consor-tium. Members of this committee established theConsortium's subcommittee structure, leadership,direction, purposes and resources. They proposedthe focus and content for the Policy Report. Theyprepared the agenda for the full Consortium meet-ing in November 1989. The Steering Committeerecommended that the Consortium elect a chair-person and a vice chairperson from its member-ship.

Subcommittees met separately during the nextmeeting to develop their findings and to frametheir recommendations.

Subcommittee chairpersons summarized thedeliberations of their respective subcommittees,and subcommittee reports were drafted for theConsortium membership. In most instances thefindings and recommendations of the subcommit-tee reports were based upon information from theprofessional literature. In some instances little orno published information was available, and thefindings were derived by consensus of subcom-mittee member experts.

Draft reports were circulated to members forreview and comment.

A draft final report composed of the revisedindividual subcommittee reports was developedin preparation for the first anniversary meeting ofthe full consortium, which was to be held in June1990.

Based on the review and comments of the Con-sortium members at the June meeting, a draft finalreport was prepared for the November meeting.

At the November meeting of the Physician Con-sortium, the full report was reviewed and anychanges made were agreed to by the full Consor-tium membership. This Policy Report of the Physi-cian Consortium on Substance Abuse Education incor-porates the changes made to the draft final reportduring the November meeting.

Section III of this report provides the completereports of the findings and recommendations ofthe five subcommittees. Background informationon the substance abuse problem is covered inSection IV.

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III. FINDINGS AND RECOMMENDATIONSOF THE SUBCOMMITTEES

A. Undergraduate Medical EducationThe subcommittee on undergraduate medical

education agreed that current medical educationfails to teach appropriately and adequately thesubject of substance abuse despite the well-docu-mented harmful effects of substance abuse on asignificant portion of the population. The publichealth responsibilities of the medical professionrequire that this subject be taught at a basic educa-tional level in our medical schools. Medical schoolsmust recognize that chemical dependency is notsimply a mental health concern, but also hasbroader health implications involving all medicalspecialties, particularly those providing primarycare. The subcommittee also concluded that medi-cal students need to be better sensitized to theirown high personal risk of becoming substanceabusers.

Substance abuse training is not universally in-tegrated into medical school curricula and is notan integral part of primary care medicine (Davis etal., 1988; ADAMHA, 1988). Inappropriate, thoughpersistent, negative attitudes toward substanceabuse and abusers and a resistance to expandingeducation in this area are primary hurdles whichneed to be overcome if training is to be betterintegrated into our undergraduate medical cur-ricula.

FINDINGS

Finding A-1. Alcohol and other drug abuseeducation is not an integral part of primarycare medical education.

Medical schools and residency programs varywidely in the extent to which substance abuseunits are integrated into their curricula. There is alack of comprehensive substance abuse training inspecialties that train primary care physicians. Inthe small percentage of schools where programsare integrated the units taught usually deal withthe abuse of alcohol as well as of other drugs.Integrated training programs also frequently in-clude provision of clinical experience with sub-stance abusers. However, this approach repre-sents an exception to the much more commonmedical school pattern of offering only electives insubstance abuse to students especially interestedin those problems (Davis et al., 1988). Tradition-ally, psychiatry was the only specialty area that

routinely included substance abuse topics in itstraining. In the past, departments of psychiatryhave been relied upon to provide a large portion ofthe substance abuse training received by medicalstudents. The current trend toward includingsubstance abuse training in other primary carespecialties should lead to better integrated cover-age of the topic. Training should stress the pri-mary care physician's important role in prevent-ing as well as in identifying, treating, or referringsubstance abusing patients.

Finding A-2. The traditional emphasis on hospi-tal-based, technologically complex diagnosis andtreatment, on organ pathology, and on a cure-oriented approach to acute illness is ill-suited todealing with chronic behavioral pathology thatantedates the development of organ pathologyin alcohol or drug abusers.

Teaching substance abuse content as though itprimarily involves a constellation of drugs withspecific pathological effects on various organ sys-tems is appropriate in relatively discrete and well-defined areas. By contrast, teaching about sub-stance abuse as a primary disease is atypical andcontent is seriously deficient (Kinney et al., 1984).Substance abuse is a disease state that intimatelyinvolves behavioral as well as more traditionalmedical aspects.

Along with an increasing appreciation of theimportance of teaching about substance abuse,there is growing recognition that a combination ofteaching methods and clinical settings is neces-sary. Using only inpatient settings for this train-ing, especially in general medical facilities, is ques-tionable. Relying on such settings should be recon-sidered (Davis, et al, 1988). Training sites wherestudents and residents are more likely to see theentire range of patients with substance abuse prob-lems are preferable. Outpatient and community-based settings also provide significantly betteropportunities to learn about prevention, early di-agnosis, and intervention. These facilities offerstudents opportunities to take histories, performphysical examinations, and complete medical as-sessments of substance abusing patients.

Involvement with community preventionprojects and with substance abusing patients earlyin medical training can effectively introduce medi-cal students to the health risks as well as to the

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resources that can be mobilized for dealing withthe problem. Specifically, students can participatein community activities by working with adoles-cent groups, in mental health units, as well as byattending self-help group meetings (e.g., Alcohol-ics Anonymous, physician impairment groups).

A major challenge in teaching substance abusecontent is to stimulate medical students' activeinterest and involvement. Faculty need to identifythe underlying reasons for students' limited inter-est in this area such as the absence of suitable rolemodels for becoming involved. Greater emphasismust also be placed on "learner driven" teaching,which emphasizes experiential learning throughcase studies, interaction with expert researchersand clinicians, and the open discussion of physi-cian attitudes toward substance abusing patientswhich interfere with their effective treatment(ADAMHA, 1988).

Greater attention should be paid to integratingsubstance abuse education into overall medicalcurricula and to teaching relevant preventive, di-agnostic and treatment skills throughout the en-tire medical education system.

Finding A-3. Preparing a core group of faculty toteach substance abuse and to develop and imple-ment curricula can facilitate recognition that sub-stance abuse training is an integral part of allmedical education.

The Consortium consensus is that faculty canencourage students to actively explore the impli-cations of chemical dependence as a health prob-lem as well as help them to recognize its impor-tance in the total health carp ,..ontinuum. Earlyemphasis on, and exposure ), substance abuseeducation is likely to counter the perception thatsubstance abuse is of only narrow specialist inter-est rather than a widely prevalent problem withprofound health implications.

Finding A-4. Implementing an integrated sub-stance abuse curriculum requires knowledge-able faculty with expertise in academic as well ascommunity clinical settings, who are experiencedin the prevention, diagnosis and treatment ofsubstance abuse-related disorders and who aremotivated to learn and to teach about those top-ics.

Finding A-5. Interdisciplinary training, as op-posed to more narrowly focused emphasis onmore specialized disciplines, can expedite cur-ricular improvements and a more fundamentalawareness of substance abuse problems.

The key to sustained change in medical educa-tion concerning substance abuse lies in providingindividual and institutional role models for suchtraining (Lewis, 1989). The limited availability oftime to pursue curriculum issues is a serious prob-lem which faces all medical educators. The amountof time available for the curriculum is finite, anincreasing amount of information is mandatory,and there is constant pressure to introduce newmaterial. Given the typical lack of faculty exper-tise concerning substance abuse, it is not surpris-ing that this area is often neglected.

Collaboration of faculty in several departmentsas well as in community settings is likely to mobi-lize broad support for increasing the curriculumtime devoted to substance abuse. Interspecialtycurricula also provide multispecialty role modelsand encourage team building. These benefits arelikely to improve treatment of drug abusers withinthe health care delivery system as well as to resultin better teaching about substance abuse (Coggan,1987).

Finding A-6. As members of the medical com-munity, faculty and medical students are notimmune from substance abuse problems, par-ticularly from therapeutic agents and alcohol.

Medical students need to understand that theymay be at increased risk of becoming substanceabusers because of their membership in the medi-cal profession. Some studies reflect medical stu-dents' heightened awareness of the dangers ofabusing drugs. Recent studies indicate medicalstudents' use of cocaine (Conrad et al., 1989) and ofother illicit drugs (Conrad et al., 1988) is generallylower than that of their non-medical school peers,but medical student use of tranquilizers and ofalcohol exceeds that of non-medical peers. More-over, Conrad et al. (1988) found that most medicalstudents view physician drug use as a seriousmatter and favor programs for impaired physi-cians which combine treatment with various pro-fessional sanctions. Studies also reflect the ambi-guity of drug usage perceived by medical stu-dents. Medical students surveyed expressed le-

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niencv regarding occasional illicit or inappropri-ate drug use. Occasional use of drugs by physi-cians, like substance abuse in the larger society,has also increased over the past two decades(McAuliffe et al., 1986).

The personal stress under which physiciansfunction is reflected in their higher divorce andsuicide rates compared to their non-medical peers.Physicians who are members of a minority groupare under still greater pressure in having to copewith institutional racism and the often rigid socialstandards and expectations of the minority com-munity in addition to the usual stresses of medicalpractice (Carter, 1989). The substance abuse riskendemic to being a physician should be acknowl-edged early in the educational process. Height-ened awareness helps to eliminate moralistic atti-tudes and encourages a more tolerant and objec-tive approach. It also pays dividends for prospec-tive physicians in overcoming their psychologicalbarriers to treating substance abusers and helpsphysicians to acknowledge their own vulnerabil-ity more easily.

Medical schools should also examine practicesof condoning or sponsoring school functions inwhich alcoholic beverage indulgence rather thanmoderation is encouraged. Careful considerationshould be given to the ways in which students areplaced at still greater risk of abusing drugs wheninappropriate behavior of their role models ormaking light of heavy social drinking is accepted.

RECOMMENDATIONS

Recommendation A-1. Undergraduate medicaleducation programs should be developed to over-come the negative attitudes of faculty and stu-dents toward drug abuse and to establish effec-tive faculty role models for students, house staff,and attending physicians.

Physicians' interest, motivation, and skills mustbe enhanced in order to build confidence and toconvince physicians that they should attend tosubstance abuse problems. Physicians must bepersuaded to do something meaningful about theproblems.

Recommendation A-2. Specific faculty shouldbe identified, trained, and assigned responsi-bilities for substance abuse education to ensurethat the topic becomes an integral part of everymedical student's education and training.

Medical schools should draw from existing cur-ricula and enhance faculty development programscurrently underway. They should also utilize suchresources as those of the American Academy ofPsychiatrists in Addictions, the Association forMedical Education and Research in SubstanceAbuse, the American Society of Addiction Medi-cine, and the American Osteopathic Academy ofAddictionology. Each medical school should iden-tify appropriate full-time or community facultywhose responsibility will be to integrate the ap-propriate resources.

Recommendation A-3. Undergraduate medicaleducation and training should introduce stu-dents to substance abuse problems of patientsand communities at risk for substance abuse.Multidisciplinary community-based programsshould be utilized to educate students in theentire range of substance abuse problems andinterventions.

Providing substance abuse education in com-munity, clinical, and didactic settings early in un-dergraduate medical education introduces all stu-dents from the beginning of their medical trainingto substance abuse problems and exposes stu-dents to patients and communities at risk for sub-stance abuse. This is best done in amultidisciplinary setting. The Liaison Committeefor Medical Education (LCME) and the AmericanOsteopathic Association's Bureau of ProfessionalEducation should make certain this training expe-rience occurs by making it one of their accredita-tion requirements.

Recommendation A-4. On-campus confidentialstudent and house staff impairment preventionpolicies and programs should be established toprovide drug and alcohol prevention programsdirected to medical students and physicians atrisk.

Early in their education physicians should bemade aware that they are at risk of alcohol anddrug abuse. By establishing student and house

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staff impairment prevention policies and educa-tional programs, medical schools will demonstratetheir commitment to enhance this awareness.*

Recommendation A-5. The Government's roleas a funding source and facilitator in settingpriorities for medical education should be con-tinued.

The Government should also examine how toimprove third party payment coverage and howto eliminate reimbursement "disincentives" fortreating substance abuse.

Recommendation A-6. Private foundations andpublic agencies should be encouraged to provideinternships and other stipend-supported train-ing opportunities for research, clinical and com-munity-based medical training in chemical de-pendency.

B. Graduate Medical EducationMany of the findings and recommendations

pertaining to undergraduate and continuing medi-cal education are equally applicable to those set-tings in which graduate medical education is pro-vided. Moreover, the consensus of the Consor-tium is that a continuum of substance abuse edu-cation from medical school through internship,residency and beyond is essential if physicians'practice behavior with respect to this area is tochange fundamentally. This section will, how-ever, emphasize those findings and recommenda-tions that are unique to graduate medical educa-tion.

The majority of these recommendations focuson faculty development. While the Consortiumrecognizes the need to improve residency trainingas well, the consensus is that residency programsare unlikely to incorporate substance abuse train-ing without better prepared faculty. Once trainedfaculty are in place, recommendations specific toprograms can be implemented.

* P.L. 101-226 (Drug-Free Schools and Communities ActAmendments of 1989), which requires all postsecondary edu-cation institutions receiving Federal funds to develop drug andalcohol prevention programs, applies directly to this recom-mendation. Also significant programming is already in place insome medical schools that may be useful as developmentmodels.

FINDINGS

Finding B-1. Education regarding substanceabuse is now primarily limited to the formalstructural curricula of schools of medicine andpublic health. Substance abuse is not beingadequately taught at the postgraduate and con-tinuing education levels. It is essential that medi-cal education at these levels include substanceabuse education.

Finding B-2. The residency period is rarely usedto reinforce previous alcohol and drug abusetraining or to provide an expanded focus fordeveloping clinical competency with a greaterdiversity of populations and modes of treatment.

The Consortium members agreed that the spe-cialties of family medicine, internal medicine, pe-diatrics, psychiatry, emergency medicine, andobstetrics and gynecology have substance abusetraining goals and curricula adequate for theirintended purposes. However, this training hasnot been widely incorporated into residency pro-grams. There are approximately 1600-1700 suchprograms. Each of these requires faculty to teachabout prevention, substance abuse problem rec-ognition, appropriate treatment, and referralchoices.

Currently, the Society of Teachers of FamilyMedi;:ine, in contract with the Federal govern-ment, i; training faculty from the 180 Federally-funded family medicine residency programs acrossthe country. This model is an acceptable one forintroducing teaching skills on substance abuse toother departments and residency programs aswell. Residency review committees need to de-velop requirements for each of their programs.The individual specialty curricula guidelines canbe useful in providing a framework for develop-ing such requirements.

Finding B-3. Faculty seldom make substanceabuse teaching an integral part of their broaderclinical and research responsibilities.

An effective way to gain both added curricu-lum time and to increase respect for substanceabuse training is to emphasize its strong researchbase. Through the incorporation of recent re-search findings into clinical curriculum studentsare likely to gain an increased understanding thatsubstance abuse is integral to other areas of medi-cal science and clinical practice. Comorbidity is

another important area of research knowledgewhich needs to be highlighted in clinical training(ADAMHA, 1988).

RECOMMENDATIONS

Recommendation B-1. A basic faculty develop-ment course should be offered as the first level oftraining in substance abuse for five additionalspecialties: general internal medicine, generalpediatrics, obstetrics and gynecology, emergencymedicine and psychiatry. The Family MedicineModel represents a successful effort which couldbe adopted.

Participants should have some prior interest insubstance abuse. This faculty development effortwill establish working groups within each spe-cialty in order to build an infrastructure and net-work for coordinating, supporting, and continu-ing faculty and resident education and training.

The proposed course could be supported by theFederal Government and/or receive private sup-port.

Recommendation B-2. A three-month interdisci-plinary course in substance abuse educationshould be developed for training physician fac-ulty of graduate medical education residencyprograms.

This training should be conducted at the "tencenters of excellence" and would represent a sec-ond tier of faculty development. Funding for sucha three-month training course would likely comefrom Federal sources. Other funding sources mightinclude the use of confiscated drug dealer funds,money raised from selling dealers' confiscatedproperty, Medicare funds that were withdrawnfrom graduate medical education, private philan-thropists, or the substance abuse treatment indus-try.

Recommendation B-3. A two-year fellowshipprogram in substance abuse education should bedeveloped to provide academic physician lead-ership in substance abuse education for graduatemedical educatien.

This fellowship program should be developedas a third level of training at one of the ten centersof excellence to provide the Nation with academicleadership in substance abuse training and re-search. It should be coordinated with existingfellowships. In order to attract candidates, Federaland /or private support should be obtained tounderwrite financial incentives such as scholar-ships, bonuses, and loan repayment arrangements.Incentives underwritten by the Federal Govern-ment would require service in the public sector.

Recommendation B-4. Ten "centers of excel-lence" in substance abuse education should beestablished nationwide which incorporate link-ages of community-based substance abuse pro-grams focusing on prevention and treatment withmental health centers and area health educationcenters.

The two longer periods of training (a three-month course and a two-year fellowship program)for physician faculty of graduate medical educa-tion programs would be offered in the centers.These centers should incorporate strong linkageswith community health centers, community men-tal health centers, and area health education cen-ters.

Recommendation B-5. All levels of faculty train-ing in substance abuse should include contenton cross-cultural and special population issuesand information related to the changing demo-graphics of our society.

This recommendation should be implementedby residency review committees, which wouldassure that such content would be included ingraduate medicine education curricula.

Recommendation B-6. Graduate medical educa-tion residency programs should develop specificsubstance abuse training requirements.

These essential requirements will have to bedeveloped by the respective residency review com-mittees on accreditation. They will have to bephased in contingent upon availability of suffi-cient faculty resources to meet the new trainingrequirements.

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Recommendation B-7. Substance abuse contentissues should be reflected in specialty boardexamination questions.

In the development of manuals for certificationin the various specialties attention will have to begiven to skills needed to diagnose and managealcohol and drug problems.

C. Continuing Medical EducationTraining deficiencies concerning alcohol and

other drug dependencies have been amply docu-mented at all levels of formal medical education(Lewis et al. 1987), and corrective measures havebeen proposed (Cotter and Callahan, 1987).

Less attention has been given to the ongoinginformation needs of the 500,000 U.S. physiciansalready in practice. For these physicians, whetherrecent medical school graduates or 40 years pastformal training, providing effective patient coun-seling and intervention for substance abuse prob-lems frequently competes unsuccessfully with theallocation of relatively scarce educational timeand resources required by other areas of clinicalconcern.

Responsibility for meeting the continuing edu-cation needs of these physicians has fallen largelyto medical associations and specialty societies atthe national, state, and local levels. Whatever thesite or sponsorship, designers of continuing edu-cation programs on alcohol and drug abuse topicshave had to confront two major issues.

The first is attitudinal and is often expressed asuncertainty on the part of physicians about theirresponsibility for the clinical care of patients withalcohol or drug-related problems. Is it, for ex-ample, the duty of the primary caregiver to diag-nose and then refer an alcohol-abusing patient fortreatment? Should the physician remain involvedas case manager and as the treater of medicalcomplaints? Should the physician provide defini-tive treatment for all the patient's problems, in-cluding those associated with his or her alcohol orother drug abuse? This role confusion has prob-ably been as great an impediment to physicianinvolvement with patients' alcohol and drug-re-lated problems as the more widely perceived bar-riers of negative stereotyping and hopelessness.Physicians tend to see their role as one of manag-ing clearly defined illnesses, rather than dealing

with more general problems related to lifestylechoices (Bowen and Sammons, 1988). Thus theyare likely to treat only the medical complicationsof alcohol and drug abuse rather than to identifyits underlying causative factors. Physicians' owndrinking and drug use may also influence theirattitudes, leading them to ignore or to minimizetheir patients' substance abuse problems.

The second major issue is strategic; that is, howto construct programs that will change physicians'actual practice behavior. Teaching programs thatfocus on alcohol and drug topics, like other sub-jects of continuing education, are challenged todemonstrate outcomes that go beyond merelycon-veying new information. Experience confirms thatclinical knowledge often does not result in practicechange, and when it does, the role of continuingmedical education is often obscure (Wergin et al,1988). According to one researcher, clinical train-ing is a more important determinant of practicebehavior than attitudes or knowledge (Warburg etal., 1987). The lack of supervised clinical experi-ences is also correlated with professional discom-fort in caring for alcoholic patients (Delbanco andBarnes, 1987).

FINDINGS

Finding C-1. The Minimum Knowledge, Atti-tude, and Skills (KAS) Requirements are not infact "minimum"; rather, they embrace all pos-5;ble levels of involvement for physicians.

Evidence suggests that organized medicineclearly recognizes physicans' responsibility fordealing with alcohol and drug problems (Kenward& Wilford, 1988). There is no lack of policy state-ments, clinical guidelines, and other materials tes-tifying to this commitment. Most notable are thestatements of Minimum Knowledge and SkillsObjectives for Alcohol and Other Drug AbuseTeaching recently published by the AmbulatoryPediatric Association, the American College ofEmergency Physicians, the American College ofObstetricians and Gynecologists, the AmericanPsychiatric Association, the Society of GeneralInternal Medicine, and the Society of Teachers ofFamily Medicine.

However, the KAS requirements embrace allthe possible levels of involvement. Practicingphysicians may respond to these statements by

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making individual judgments as to which activi-ties fit into their particular practices, which activi-ties they feel comfortable handling themselves,and which patients they will refer to more special-ized sources of care. (Even practitioners in thesame primary care specialty may make very dif-ferent decisions in these areas.)

In 1979 the AMA determined that the primarymessage to be delivered by an effective program ofcontinuing medical education on alcohol and otherdrug abuse must define the physician's role andresponsibilities. Guidelines developed by theAMA's Council on Scientific Affairs were designedto deliver that message (AMA, 1979).

The 1979 guidelines, which for the AMA havethe force of policy, affirm that physicians have aresponsibility to meet the needs of alcohol andother drug abuse patients by providing care at oneof three levels: (1) diagnosis and referral (desig-nated as the minimum acceptable level of care), (2)acceptance of limited responsibility for treatment(e.g., restoration of the patient to the point of beingable to participate in long-term treatment), and (3)complete care. The guidelines further specify theactions and knowledge required at each of theselevels of involvement. Physicians who choose theminimum level of involvement are expected tohave knowledge and skills in the following areas:

Common terminology and diagnostic criteria.Epidemiology and natural history.Familial, sociocultural, genetic, and biologic risk

factors.Basic pharmacology and pathophysiology.Patient evaluation techniques (including the

personal, family and substance abuse history);selection and evaluation of laboratory tests; inter-pretation of physical findings; and strategies forovercoming denial.

Referral techniques and appropriate referralresources.

Long-term care needs.Legal and regulatory requirements about pre-

scribing for and /or treating alcohol and drug abus-ing patients, release of information, and consentto care.

These skill statements are broadly comparableto those developed in ensuing years for specificspecialty groups.

Finding. C-2. Continuing medical education inalcohol and drugs currently targets only a smallnumber of practicing physicians.

A large number of physicians are employed byagencies such at- a clinic, a health maintenanceorganization (HMO), or a community health cen-ter (CHC). Accordingly, contacting such agenciesmay provide a useful means for gaining access tophysicians.

Access to physicians can be gained by identify-ing them as:

Members of specialty groups (e.g., pediatrics,obstetrics and gynecology, internal medicine, fam-ily medicine, emergency medicine, psychiatry).

Practitioners in various settings (e.g., privateoffice, HMO, hospital-affiliated, hospital-baor public clinic).

Practitioners in particular geographically-basedsettings (e.g., rural areas).

Care providers for certain target populations(e.g., African Americans, Native Americans, His-panics, adolescents, the elderly).

RECOMMENDATIONS

Recommendation C-1. Substance abuse con-tinuing medical education programs should betargeted to different physician audiences by tai-loring programs to meet their actual needs, inter-ests, and practice patterns. Physicians should besensitized to the existence of substance abuseproblems in their patient population throughcontinuing medical education programs. Theexisting skill repertory of physicians should beused as the foundation for new continuing medi-cal education programs.

Physician involvement and decisions about thefollowing considerations would influence the ac-ceptability of educational programs:

Determine what level of involvement is mostsuitable to physician interest and professional re-sponsibilities.

Determine what knowledge and skills areneeded to support this level of involvement.

Employ a wide range of approaches.Focus initially on the most interested, most

reachable, and most enthusiastic physicians.

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First, target individuals who have identified them-selves as interested. Working with motivated indi-viduals is likely to produce the greatest impactand benefit for effort expended, as well as to createpositive and enthusiastic role models.

Create other strategies to establish a minimumacceptable level of skills among all physicians.

Devise specifically tailored programs for physi-cians who care for populations at greatest risk.

Solicit the support of medical administrators oforganizations that educate, represent and employphysicians. Established programs offered byAAPA, AMERSA, ASAM, and AOAM should beused as models whenever appropriate.

Recommendation C-2. A wide range of instruc-tional methods in Continuing Medical Educa-tion should be utilized in the development ofsubstance abuse education programs to alter phy-sician attitudes toward substance abuse, to im-prove skills and to increase physician willing-ness to deal with the substance abuse problem.These programs should meet the physician's needforspecific knowledge, attitudes, and skills (eventhe minimum level of skills) and enhance learn-ing.

Examples of instructional methods follow.The opening segment of any educational pro-

gram should relate the material to be presented tothe physician's practice needs.

Training in interviewing and other fundamen-tal techniques should build on skills already avail-able to the clinician.

Role-playing is one example of a useful meansto enlarge such skills.

Specific information can be conveyed through"stand-alone media" (e.g., capsule sheets, com-puter-assisted learning, brochures, audiotapesandvideotapes,books). Skillsthat involve physi-cian-patient interviewing are best taught in face-to-face interactions or at least through some visualmedium.

When practice is required to gain mastery of askill, small-group sessions may be needed, withtime allowed for non-threatening feedback on theindividual's performance.

Reference materials should be used to reinforceand supplement the educational program.

An information exchange or clearinghouseshould be created to collect and disseminate infor-mation about educational opportunites and tech-niques.

Recommendation C-3. Substance abuse relatedknowledge and skills should be included when-ever practice standards, guidelines, parametersand protocols are being developed or revised bypublic agencies or private organizations.

D. Multicultural IssuesPeople of similar ethnic or cultural origins share

a common sense of identity and behavioral stan-dards. Ethnic differences are therefore of practicalconcern in preventing and treating many medicalproblems. Awareness of these differences is espe-cially important when patients and care providerscome from different ethnic or cultural backgrounds.The difficulties that care providers confront whendealing with patients with alcohol and drug useproblems are still further compounded when theproviders have had different cultural origins andexperiences from those of their patients. Thissection addresses multicultural issues that are fre-quently overlooked.

FINDINGS

Finding D-1. Minimum knowledge and skillobjectives for alcohol and drug abuse teachinghave been identified, but issues that are particu-larly relevant to ethnic and racial minorities havenot been included.

Finding D-2. A comprehensive assessment ofthe current tools available for teaching substanceabuse has been accomplished, but educationalmaterials on substance abuse relevant to ethnicand racial minorities have been rarely identified.

Finding D-3. Appropriate, sensitive, and effec-tive teaching strategies for use in minority sub-stance abuse education have not been devel-oped.

The National Institute on Alcohol Abuse andAlcoholism and the National Institute on DrugAbuse contracted with six professional organiza-tions to identify minimum knowledge and skills

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objectives for alcohol and other drug abuse teach-ing. The specialties of pediatrics, emergency medi-cine, obstetrics and gynecology, psychiatry, gen-eral internal medicine, and family medicine alldeveloped objectives appropriate to their respec-tive disciplines. However, none of these disci-plines considered issues specifically relevant totreating ethnic and racial minorities. The educa-tional process must specify strategies of preven-tion, diagnosis, and treatment of substance abusespecific to minority populations. Differences incultural norms, modes of communication and inacceptable patterns of care provider interventionare all critical aspects of working with minoritypopulations. Educational efforts should take placeat the undergraduate, graduate, and continuingmedical educational levels. It is imperative thatcurricular materials and educational strategiessensitive to dealing with substance abuse in ethnicand racial minorities be developed.

The medical specialty organizations compre-hensively assessed curriculum products and tech-niques available for teaching about substance abuse(Davis et al., 1988). Few references to specificissues involving ethnic and racial minorities werenoted. Resource materials that addressed the edu-cation of health providers on this topic were notidentified.

Substance abuse has been identified as one ofthe major syndromes contributing to the poorhealth status of ethnic and racial minorities (DHHS,1985). Improving physician education about car-ing for ethnic and racial minorities is an importantaspect of improving the health status of ethnic andracial minorities (PHS, 1989).

Finding D-4. Basic and essential informationnecessary to understanding the rate and extent ofsubstance abuse among ethnic and racial minori-ties is generally lacking.

Finding D-5. The inability of physicians to gainaccess for their patients to substance abuse treat-ment will influence the physicians' attitudeswhen physicians are asked to improve theirknowledge and skills related to substance abuse.

Part of the difficulty in determining what toteach about minority substance abuse stems fromthe lack of information on ways to prevent, assess,and treat substance abuse in ethnic and racialminority groups. Basic and essential information

that is necessary to understand the rate and extentof drug abuse among ethnic and racial minoritygroups is generally lacking. In addition, little isknown about specific etiologic factors which playa role in the initiation and maintenance of drugabuse in these groups (DHHS, 1987).

There has also been a lack of long term follow-up research assessing the impact of culturallyspecific treatment programs to determine whetherthey are more effective than more conventionalapproaches. Further epidemiologic and treatmentresearch is needed to define subpopulations withinracial and ethnic minority groups that are at great-est risk for substance abuse. This information isessential if better targeted prevention, early inter-vention, and treatment programs are to be devel-oped which have a greater likelihood of success.To be responsive to the needs of ethnic and racialminorities, programs should have staff of similarethnic and racial backgrounds familiar with thelanguages of the groups, have access to care facili-ties within their local communities, be able toassess sociocultural factors impacting upon apatient's risk for and successful treatment of sub-stance abuse, and overcome socioeconomic barri-ers to seeking and acceptance of treatment.

RECOMMENDATIONS

Recommendation D-1. A group of educators,physicians from the primary care disciplines,and substance abuse experts should be con-vened to define knowledge, skills, and attituderequirements in the substance abuse areaspecific to ethnic and racial minorities and toidentify appropriate methods and teachingstrategies.

Available resources should be identified, suit-able teaching methods determined, and strategiesrecommended for for improving the ability ofphysicans to work with ethnic and racial minoritygroups.

Invitees should include, but not be limited to,representatives of the six specialty organizationswho developed the minimum knowledge and skillsin substance abuse teaching (emergency medi-cine, pediatrics, obstetrics and gynecology, psy-chiatry, family medicine and internal medicine).Representatives from the National Medical Asso-ciation, the Association of American Indian Physi-cians, the National Association of Alcohol and

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Drug Abuse Counselors, the Indian Health Ser-vice, NIDA, NIAAA, and medical school facultyresponsible for undergraduate education shouldalso be included. Minority consumer grc,...psshould be invited to participate and to help shapeculturally sensitive training goals.

Recommendation D-2. All medical educationand training programs in substance abuse shouldbe required to explicitly include specific trainingmodules focusing on the needs of ethnic andracial minority groups.

The Health Resources and Services Adminis-tration, the National Institute of Drug Abuse, theNational Institute of Alcohol and Alcohol Abuseand other appropriate agencies of the Departmentof Health and Human Services should require thatany proposal funded for training health profes-sionals include topics specific to ethnic and racialminority groups. Requests for proposals for healthprofessional training should be monitored to de-termine if substance abuse training concerningracial and ethnic minority groups is included asone of the requirements.

Recommendation D-3. The Secretary's Task Forceon Black and Minority Health recommendationsconcerning substance abuse should be pursued.

Those recommendations included:Reviewing the Department's health professions

training programs to ensure inclusion of educa-tion about substance abuse in curricula.

Providing assistance to appropriate organiza-tions of health care professionals to ensure thatsubstance abuse is included in their curricula andthat the training includes the diagnosis and pre-vention of substance abuse in a variety of patientpopulations including ethnic minorities.

Referring patients to appropriate settings andproviding direct services and treatment that isrelevant to specific minority patients.

Encouraging private sector organizations totrain minority research scientists and health careproviders in substance abuse research, diagnosisand treatment.

Assistance shoiod be obtained from the Of-fice of Minority Health to determine which of therecommendations have been implemented. Orga-

nizations represented in the Consortium shouldalso identify ways they can help implement theserecommendations.

Recommendation D-4. Substance abuse trainingprograms linked with service programs that tar-get racial and ethnic minority populations shouldinclude information from current research onminority use patterns and effective interven-tions.

Recommendation D-5. Substance abuse trainingspecifically addressing issues relevant to ethnicminorities should be included during residencytraining in primary care disciplines.

The Council on Graduate Medical Education(COGME) and the Committee on PostdoctoralTraining (COPT) (e.g. osteopathic) should reviewthe requirements for substance abuse training spe-cifically addressing issues relevant to ethnic mi-norities during residency training in primary caredisciplines. Reports from COGME and COPT aboutthe feasibility of requiring substance abuse train-ing in graduate medical education programsshould be requested.

E. Adolescents and ChildrenThe strategies necessary to overcome short-

comings in education about substance abuseamong children and adolescents are not specific tothis age group nor to the cohort of physiciansproviding care for these young people. Initiativesto improve substance abuse education for physi-cians in undergraduate, graduate and continuingmedical education settings should also simulta-neously examine skills, attitudes and knowledgeneeded to care for youth. Therefore, this sectionwill not duplicate the previous sections of thisPolicy Report, but instead focus on physician train-ing issues particularly germane to working withchildren and adolescents.

FINDINGS

Finding E-1. Inpatient pediatric units representinadequate training sites for substance abuseeducation, particularly for those physicians treat-ing adolescents and children. Inpatient and out-patient psychiatric and community-based chemi-cal dependency programs represent adequatetraining sites.

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The Consortium members agreed that drugabuse by children and adolescents now rarelyleads to their being treated in an inpatient pediat-ric or family medicine facility. This situation is insome contrast to an earlier era when the physi-ologic consequences of substance abuse in adoles-cents, especially those associated with opiate andbarbiturate abuse, more often led to hospitaliza-tion. In contrast to adult inpatient services, wheresignificant numbers of individuals are hospital-ized for effects of their long term alcohol and otherdrug abuse, children and adolescents are rarelyhospitalized primarily for those reasons. Pediatricinpatient units are, as a result, particularly inad-equate training sites for physician substance abuseeducation. Psychiatric and community-based pro-grams are appropriate sites where there are sig-nificant numbers of children and adolescents be-ing treated for alcohol and other drug abuse.

Finding E-2. Pediatric departments are less likelyto be able to include faculty members whose solesubspecialty interest is in substance abuse. Psy-chiatric departments are more likely to includefaculty members with this subspecialty.

Most departments of pediatrics have at most asingle member of the department with specifictraining in adolescent medicine. It is extremelyunlikely that such departments will be able to fundan attending physician whose sole interest is insubstance abuse. The bio-psycho-social nature ofsubstance abuse contributes to the presence offaculty members in psychiatric departments withthis orientation.

Finding E-3. Education regarding adolescentdrug abuse needs to be provided for all primarycare disciplines.

Only a minority of adolescents in the UnitedStates receive their primary care from pediatri-cians. Most are seen by other primary care special-ists such as internists, family practitioners, emer-gency room physicians, or obstetricians and gyne-cologists. All physicians who treat adolescentsneed training and education concerning substanceabuse in this age group.

Finding E-4. Screening instruments useful indiagnosing substance abuse among adults arenot generally applicable to young people.

Most screening instruments for detecting drugabuse have been developed for use with adults.These instruments are often of little value in iden-tifying the factors or behaviors which should alertthe practitioner to high risk in young persons.However, there are ongoing efforts to create screen-ing instruments for young persons. The develop-ment and evaluation of screening instruments spe-cific to young people will provide not only an aidin diagnosis but also a training tool.

Finding E-5. Concepts of arug abuse primaryprevention are almost exclusively applied to childand adolescent age groups.

Most drug abuse, including that of tobacco andalcohol, has its onset during late childhood andadolescence. Primary prevention must thereforebegin in the pre-teen years and continue duringthe transition period from childhood to adult-hood. Rather specific primary prevention tech-niques have been developed for use with childrenand youth.

Finding E-6. Addressing drug abuse among youthrequires an understanding of adolescentpsychosocial and physiologic development.

The onset of drug abusing behavior needs to beunderstood within the context of other develop-mental issues that are part of the child's evolutionto an adult. Such issues include: separating fromfamily influences, the emergence of the peer groupas an important behavior determinant, and nor-mal adolescent risk taking. In addition, drugabuse has specific implications for the somatic andcognitive development of the adolescent.

Finding E-7. Providing care to young people whoare abusing drugs requires an age-specific knowl-edge of legal and ethical issues with respect toconfidentiality and consent.

Handling issues of confidentiality and consentparticular to the adolescent must be taught inorder to facilitate the involvement of health pro-fessionals in the care of young people. Whilesimilar considerations have little applicability toadult populations, they are critical to the medicalcare of adolescents.

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Finding E-8. Evaluation and management ofyoung people who abuse drugs will requireknowledge not only of the personal and familialfactors which place youth at particular risk butalso an understanding of the skills necessary todeal with the drug abusing child or adolescent aspart of a family unit.

Far more than adults, children and adolescentsneed to be treated as part of their family units.Particular skills and knowledge will be needed notonly to identify familial risk factors for drug abuse,but also to assist patients' families in confrontingsubstance abuse issues.

Finding E-9. Determining the impact of drugabuse upon the fetus and the mother herself, andupon the newborn requires a specific knowledgebase.

Drug abuse during pregnancy raises complexlegal, ethical, and patient management issues whichrequire very specific educational preparation. Thediagnosis of the congenital sequelae of maternaldrug use during pregnancy and the diagnosis andmanagement of neonatal addiction and abstinencesyndromes also require specialized training.

RECOMMENDATIONS

Recommendation E-1. Outpatient training set-tings along with psychiatric residential facilitiesshould be utilized in order that the full spectrumof youthful drug abusers be represented duringthe training of physicians.

There may be a need to encourage the use ofnontraditional health care settings which have ahigh incidence of substance abuse as training sites.These include juvenile detention centers andschool-based clinics. The responsibility for train-ing initiatives will lie with directors of ambulatoryprograms, training directors, and departmentchairpersons. Monitoring responsibility will liewith the residency review committee.

Recommendation E-2. Faculty with a primaryinterest in adolescent medicine should be pro-vided the opportunity to develop expertise insubstance abuse issues and to convey that exper-tise to trainees. Training should bemultidisciplinary and involve cooperation andcoordination of education among the disciplinesof family medicine, pediatrics, child and adoles-cent psychiatry, gynecology, and internal medi-cine.

Recommendation E-3. The use of screening de-vices for detecting drug abuse should be taughtas an integral component of education programsthat focus on adolescent substance abuse.

Recommendation E-4. Data on effective preven-tion strategies for adolescent substance abuseshould be used in teaching programs and dis-seminated to those working with youthful popu-lations.

Recommendation E-5. Legal and ethical issuesof substance abuse should be incorporated insubstance abuse education at all levels of train-ing.

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IV. BACKGROUND ON THE SUBSTANCE ABUSE PROBLEM

Substance abuse continues to be one of the mostserious threats to the health and well-being ofAmericans. Abuse of tobacco, alcohol and otherdrugs is common. Tobacco use is responsible formore than one of every six deaths in the UnitedStates and is the most important single prevent-able cause of death and disease in our society. Yet,nearly one-third of all adults in the United Statescontinue to smoke (OSH, 1989). The most recent(1990) National Household Survey found 31.5 per-cent of young adults continue to smoke despitewidely publicized health hazards of tobacco use(NIDA, 1991). While cigarette smoking has re-mained nearly constant among high school se-niors (12.1 percent) (Johnson et al, 1991), there hasbeen a decrease (0.4 percent) in smoking amongadults ages 18-25 (NIDA, 1991).

Although use of marijuana, cocaine and PCPamong high school seniors has been steadily de-clining since it peaked in 1978, use of those illicitdrugs is still common. The percentage of Ameri-cans 12 years of age or older who have used, atsome time in their lives, illicit drugs is: marijuana14.8 percent, hallucinogens 3.3 percent, cocaine 2.6percent, heroin 0.7 percent, or a tranquilizer drugfor nonmedical purposes 2.7 percent (NIDA, 1991).

Alcohol use among high school students is per-vasive. More than 89.5 percent of high schoolseniors in the Class of 1990 reported having triedalcohol. Some 57.1 percent of seniors had drunkalcohol in the past month; 3.7 percent had done soon a daily basis. More than 40 percent reportedhaving smoked marijuana in their lifetime; 2.2percent did so on a daily basis (Johnston et al,1991). It is particularly disquieting that earlierhigh school survey data found that most children'sinitial experiences with cigarettes, alcohol andmarijuana occur before entry to high school(Johnstone t al. 1987).

The "rational Drug Control Strategy, the 1990repot t of the Bush Administration, outlines thelatest in a series of Federal initiatives to combat thepersistent problem of illicit drugs (White House,1990). A new cabinet-level office, the Office ofNational Drug Control Policy has been formed tooversee these efforts. The national goal is clear:reduce the number of people reporting currentillicit drug use and the number of drug-relatedemergency room incidents by 15 percent in twoyears, by 55 percent in ten years. The Healthy

People 2000, National Health Promotion and DiseasePrevention Objectives (DHHS, 1991) are equallyexplicit. These objectives include:

Reduce cigarette smoking to a prevalence of nomore than 15 percent among people aged 20 andolder, and among pregnant women to less than 10percent.

Reduce by 50 percent or more the use of alcohol,marijuana, and cocaine among young people 12 to25 years of age.

Increase the proportion of high school seniorswho perceive social disapproval associated withthe heavy use of alcohol to 70 percent, social disap-proval associated with occasional use of marjivanato 85 percent, and social disapproval associatedwith trying cocaine once or twice to 95 percent(DHHS. 1991).

These initiatives are intended to diminish to-bacco, alcohol and drug use and to better copewith social and health problems related to theiruse.

Analysis of the data reported in the 1990 Na-tional Household Survey on Drug Abuse (NIDA,1991) has revealed the following trends:

Current prevalence rates for use of any illicitdrug among persons 12 years of age and oldercontinued to decrease from 23 million drug users(12.1%) in 1985, to 14.5 million users (7.3%) in 1988to 13 million users (6.4%) in 1990.

The number of current cocaine users decreasedsignificantly from 2.9 million (1.5%) in 1988 to 1.6million (0.8%) in 1990, continuing a previous de-cline. This represents a 72% decrease in the num-ber of current cocaine users since 1985, whenthere were an estimated 5.8 million (2.9%) currentcocaine users.

Current cigarette use dropped from 32% in 1985to 29% in 1988, and presently stands at 27%, repre-senting a significant decrease from 1988. Thisrepresents a 3.5 million decrease in ti e number ofcigarette smokers in the last two years. The previ-ous three year period, 1985-88, experienced a 3.2million decrease, for a total decrease of 6.7 millionpersons since 1985.

There were 102.9 million current drinkers ofalcoholic beverages in 1990 compared with 105.8million in 1988, and 113.1 million in 1985. The

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alcohol use rates in 1985, 1988, and 1990, for thoseaged 12 and over, are 59%, 53 %, and 51% , respec-tively.

The overall current 1990 (past month) preva-lence rate for any illicit drug use (12 years old andover) was 6.4%. Rates for males and females are7.9% and 5.1%, respectively. In addition to males,other demographic subgroups with rates in excessof the overall rate are those for blacks (8.6%), largemetro areas (7.3%), those living in the West region(7.3%, and the unemployed population (14.0%).

The Household Survey (NIDA, 1991) data spe-cific to 1990 revealed:

Overall in 1990, 74.4 million Americans age 12or older (37 percent of the population) had triedmarijuana, cocaine or other illicit drugs at leastonce in their lifetime.

Almost twenty-seven million Americans (13.3%)used marijuana, cocaine or other illicit drugs atleast once in the past year.

Among youth (12 to 17 years old), 15.9% usedan illicit drug in the past year and 8.1% used anillicit drug at least once in the past month. Compa-rable rates for young adults (18-25 years old) are28.7% and 14.9%, respectively; and for adults 26Years old and over the rates are 10.0% and 4.6%respectively.

Over 4.8 million or 8 percent of the 60.1 millionwomen 15-44 years of age (the height ofchildbearing years) used an illicit drug in the pastmonth. Slightly over one-half million or 0.9% usedcocaine and 3.9 million (65%) used marijuana inthe past month.

Among 18-34 year old full-time employedAmericans, 24.4% used an illicit drug in the pastyear, and 10.5% used an illicit drug in the pasmonth. Of these full-time workers, 9.2% usedmarijuana, and 2.1% used cocaine in the past month.

CocaineAmong the 6.2 million people who used cocaine

in the past year (1990), 662,000 (10.6%) used thedrug once a week or more and 336,000 (5.4 %) usedthe drug daily or almost daily throughout the year.While the number of past year and past monthcocaine users has decreased significantly since thepeak year 1985, frequent or more intense use hasnot decreased. Of the 12.2 million past year co-

caine users in 1985, an estimated 647,000 used thedrug weekly and 246,000 used it daily or almostdaily.

Rates for use of cocaine in the past year declinedfor youth (12-17 years old) from 4.0% in 1985, to2.9% in 1988 to 2.2% in 1990. For young adults(aged 18-25), the rates for 1985, 1988, and 1990, are16.3%, 12.1% and 7.5%, respectively. These de-creases between 1985 and 1990 were statisticallysignificant for both age groups.

The 1990 rate of current (past month) cocaineuse was 0.8% overall, a significant decrease fromthe 1988 rate of 1.5. The rate of current cocaine usefor males (1.1%) was over twice as high as that forfemales (0.5%). Other demographic subgroups forwhich the rates of current cocaine use are highwere the unemployed (2.7%), blacks (1.7%) andHispanics (1.9%).

Approximately 1.4% of the population 12 yearsold and over have used crack at some time in theirlives, and one-half of one percent used crack dur-ing the past year. These rates changed very littlefrom those in 1988. This translates to about onemillion past year crack users for each year, 1988and 1990. Past year use in 1990 is highest amongmales (0.8%0), blacks (1.7%), and the unemployed(1.3%). By age group, the highest rate is for youngadults 18-25 years old (1.4%).

MarijuanaMarijuana remains the most commonly used

illicit drug in the United States. Approximately66.5 million American (33.1%) have tried mari-juana at least once in their lives. Nearly threemillion youth, over 15 million young adults, andin excess of 48 million adults aged 26 and olderhave tried marijuana.

In 1990, the lifetime rate of marijuana use foryouth was 14.8% while the rate for young adultswas 52.2%. These rates have been steadily de-creasing since 1979, when they were 31% and 68%,respectively.

Rates of past month use of marijuana did notchange significantly between 1988 and 1990, de-creasing slightly from 5.9% to 5.1%. Rates werehighest for males (6.4%), blacks (6.7%), and theunemployed (12.3%).

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Of the 20.5 million people who used marijuana(at least once) in the past year in 1990, over one-quarter or 5.5 million, used the drug once a weekor more

Alcohol and Tobacco ProductsThe decline in the rates of lifetime alcohol use

seen between 1985 and 1988 (from 56% to 50%) foryouth continued in 1990 to 48%. Past year use was41% in 1990, and has experienced a steady declinesince 1979. In 1990 less than 25% of youth have hadat least one drink during the past month. This issimilar to 1988 survey results.

For young adults, the prevalence of alcoholicbeverage use is substantially higher than for youth:88% have tried alcohol, 80% have used alcohol inthe past year, and 63% have used alcohol duringthe preceding month. Although this representslittle change from 1988, drinking alcohol hassteadily declined since 1985. The 1990 rates fordrinking among young adults in the past year andpast month are significantly lower than those re-ported in 1985 (87% and 71%, respectively).

Of the 133 million people age 12 and older (66%of the population) who drank (alcohol) in the pastyear, nearly one-third, or 42 million, drank at leastonce a week.

Nearly three-quarters of the American popula-tion (73.2%) have tried cigarettes, and slightly overa quarter (26.7%) are past month (current) smok-ers, a decrease from 28.8 percent in 1988. Currentuse among youth of cigarettes is almost 12%; 32%among young adults; and 28% among adults 26and over.

Other DrugsHallucinogens include such drugs as LSD, PCP,

mescaline, and peyote. Past year prevalence ratesfor hallucinogens decreased significantly between1988 and 1990 (1.6% versus 1.1%). Males (1.7%)exhibit the highest prevalence rates. Although1990 past year prevalence is highest among twoage groups, 12-17 (2.4%) and 18-25 (3.9%), lifetimeprevalence is highest among the 26-34 old popula-tion (15.7%).

In 1990 past month nonmedical use ofpsychotherapeutic drugs, i.e., sedatives, tranquil-izers, stimulants, and analgesics, has stabilized at

the 1988 rate of under 2% from the higher (3.2%)rate in 1985. A significant decrease was noted forpast year use for the age groups 18-25 and 26-34. In1988 the rates were 11% and 10%, respectively. For1990 they decreased to 7% and less than 6%. Thisdramatic reduction translates to nearly 3 millionfewer past year users in these two age groups.

Other studies confirm the seriousness of ournational problems.

Hospital emergency rooms reporting to theNation's DAWN system treated four times as manycocaine-related emergencies in 1988 compared to1985 (42,145 versus 10,248) (Adams et al., 1990).

More than half the AIDS-related deaths in NewYork City have been related to intravenous drugabuse (Joseph, 1988); four out of five children withAIDS in New York City have a parent who abusesIV drugs (DesJarlais and Friedman, 1988).

Although the exact extent of illicit drug useduring pregnancy is not known, there is now goodevidence that illicit drug use is associated with lowbirth weight and other more serious neonatal healthcomplications (Hutchings, 1989).

Tobacco use is not only hazardous in itself, butis also highly correlated with use of marijuana andcocaine. For example, young adults who are dailysmokers are over ten times more likely to haveused marijuana and cocaine than those who havenever smoked cigarettes (NIDA, 1990).

Alcohol abuse and alcoholism continue to beserious health problems in the United States, viz.:

Large numbers of underage youth drink heavilyand consistently. More than a third of high schoolseniors drink heavily at least occasionally, and athird also see no great risk in consuming as manyas four or five drinks daily. Nearly one in tenseniors first used alcohol by the sixth grade(Johnston et al., 1987).

Alcohol abuse and alcoholism are estimated tocost society over $128 billion annually, more thanany other public health problem (NIAAA, 1990).

Nearly half of all accidental deaths, suicidesand homicides are alcohol related (NIAAA, 1990).

Alcohol use creates problems for an estimated18 million persons 18 years old and older, rangingfrom dependence to various negative personalconsequences (Hilton, 1987).

The public health burden of substance abuse inour society falls most heavily on minority groupmembers. Although most illegal drug users arewhite, the most serious health consequences affectminority group members to a greater extent thanthe general population. For example, black malesare at much higher risk for alcohol-related ill-nesses than are white males (Herd, 1989). Blackand Hispanic intravenous drug abusers represent51 and 30 percent respectively of the AIDS casesassociated with IV drug use (Curran et al., 1988).

Drinking patterns vary greatly among ethnicand racial groups. For example, abstinence amongblacks is more common than in white groups.Black men who drink are less likely than whitemen to drink heavily. However, the incidence ofalcohol-related medical problems, especially livercirrhosis and cancer of the esophagus, is very highamong blacks, with a mortality rate twice as highas that in the white population. Hispanic Ameri-can men have a higher rate of alcohol use andabuse than the general population and have ahigher rate of mortality from cirrhosis (DHHS,1990). Both individual and collective strategies areneeded if Americans' use and abuse of illicit sub-stances are to be reduced. Healthy People 2000,National Health Promotion and Disease Preven-tion Objectives (DHHS, 1991) to reduce alcoholand other drug problems, stresses the importantrole primary care physicians can play in the pre-vention, identification and referral or treatment ofsubstance abuse problems.

Because more than half of all persons withsubstance abuse disorders obtain all of their carefrom the general medical sector, a great potentialexists in primary care for prevention, detection,treatment, and referral of these patients (Kamerowet al., 1986). A recent study of physicians revealedthat they recognize the magnitude of the sub-stance abuse problem (AMA, 1988); and nine outof ten practicing physicians consider alcohol abusea major national problem. However, primary carephysicians are also ambivalent about substanceabuse problems and feel inadequate to deal withsuch problems. Physicians acknowledge that theirfailure to recognize substance abuse-related healthproblems is the result of knowledge and skilllimitations. Physicians have identified severalfactors which play a role in their professionalinadequacies in this area. They are: inadequate

training, negative attitudes and prejudices con-cerning alcohol and drug abusers, skepticism re-garding treatment effectiveness, and limitationsof their medical education. Physicians have alsohighlighted major deficiencies of the treatmentreimbursement system which discourage themfrom engaging in health promotion activities. Timespent talking with patients about possible sub-stance abuse problems is simply not adequatelyreimbursed (Kamerow et al., 1986).

There is good evidence that education can effec-tively modify negative physician attitudes as wellas providing them with much needed skills todiagnose and treat substance abuse (Warburg etal., 1987). Nevertheless, many physicians fail toappreciate the potential impact they can have ontheir patients' health and well-being by dealingmore effectively with substance abuse problems.Although some progress has been made, espe-cially in the past decade, much remains to be doneif medical education is to enable physicians tobetter cope with substance abuse problems.

Primary care training programs vary widely inthe extent to which substance abuse units havebeen integrated into their curricula; 42% of pro-grams surveyed reported specific training insubtance abuse (Davis et al., 1988). Comprehen-sive substance abuse training is also often absentin specialty training. A 1988 report noted thatpsychiatry was the only medical specialty in whichtraining in substance abuse was nearly universal.Thus, to that time, departments of psychiatry pro-vided most of the medical education in substanceabuse (Davis et al., 1988). Rapid developmentssince 1988 have placed substance abuse trainingwithin family medicine programs.

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Alcohol, Drug Abuse, and Mental Health Administration(ADAMHA). Report on a Symposium Co-sponsored bythe National Institute on Alcohol Abuse and Alcoholismand the National Institute on Drug Abuse. An ADAMHANews Supplement, Vol. 14, No. 5, May 1988.

American Medical Association (AMA). Council on ScientificAffairs. Guidelines for Alcoholism Diagnosis, Treatmentand Referral. Chicago, IL: American Medical Association, 1979.

Bowen, 0. and Sammons, J. The Alcohol-Abusing Patient:A Challenge to the Profession. Commentary. journal ofthe American Medical Association, Vol. 260, No. 15,October 21, 1988.

Carter, J. Impaired Black Physicians: A Methodology forDetection and Rehabilitation. Journal of the NationalMedical Association, Vol. 81, No. 65, pp. 663-667, 1989.

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