Résumés
Abstract
Background: The responsibility for addressing the healthcare needs of PWUS is the responsibility of all physicians. Within the healthcare system, research consistently reveals inequitable experiences in healthcare with people who use substances (PWUS) reporting stigmatization, marginalization, and a lack of compassion.
Objectives: The aim of this scoping review was to find and describe competencies being taught, developed, and fostered within medical education and then to provide recommendations to improve care for this population of patients.
Results: Nineteen articles were included. Recommended knowledge competencies tend to promote understanding neurophysiological changes caused by substances, alongside knowing how to evaluate of ‘risky’ behaviours. Commonly recommended skills relate to the screening and management of substance use disorders. Recommended attitude competencies include identifying personal bias and establishing a patient-centered culture among practice teams. The disease model of addiction informed all papers, with no acknowledgement of potential beneficial or non-problematic experiences of substance use. To enhance knowledge-type competencies, medical education programs are advised to include addiction specialists as educators and prevent stigmatization through the hidden curriculum.
Conclusion: To reduce experiences of stigmatization and marginalization among patients who use illicit substances and to improve quality of care, knowledge, skills, and attitudes competencies can be more effectively taught in medical education programs.
Résumé
Contexte : Il incombe à tous les médecins de répondre aux besoins en matière de soins de santé des consommateurs de substances psychoactives. Au sein du système de santé, les recherches révèlent régulièrement des expériences inéquitables en matière de soins de santé, les consommateurs de substances faisant état de stigmatisation, de marginalisation et d'un manque de compassion.
Objectifs : L'objectif de cette étude exploratoire était de trouver et de décrire les compétences enseignées, développées et encouragées dans le cadre de la formation médicale, puis de formuler des recommandations pour améliorer les soins prodigués à ces patients.
Résultats : Au total, 19 articles ont été inclus. Les compétences recommandées en matière de connaissances tendent à promouvoir la compréhension des changements neurophysiologiques causés par les substances, ainsi que la connaissance de l'évaluation des comportements « à risque ». Les compétences couramment recommandées concernent le dépistage et la gestion des troubles liés à l'usage de substances. Les compétences recommandées en matière d'attitude comprennent l'identification des préjugés personnels et l'instauration d'une culture centrée sur le patient au sein des équipes de praticiens. Tous les articles s'appuient sur le modèle pathologique de la toxicomanie et ne reconnaissent pas les expériences potentiellement bénéfiques ou non problématiques de la consommation de substances. Pour améliorer les compétences en matière de connaissances, il est conseillé aux programmes de formation médicale d'inclure des spécialistes de la toxicomanie en tant qu'éducateurs et de prévenir la stigmatisation par le biais d'un programme d’études caché.
Conclusion : Pour réduire les expériences de stigmatisation et de marginalisation parmi les patients qui consomment des substances illicites et pour améliorer la qualité des soins, les connaissances, les aptitudes et les attitudes peuvent être enseignées plus efficacement dans les programmes de formation médicale.
Parties annexes
Bibliography
- Statistics Canada. Alcohol and drug use in Canada, 2019 2021 Available from: https://www150.statcan.gc.ca/n1/daily-quotidien/211220/dq211220c-eng.pdf [Accessed on Jan 25, 2024].
- Government of Canada. Substance use spectrum 2023 Available from: https://www.canada.ca/en/health-canada/services/substance-use/about-substance-use.html. [Accessed on Feb 25, 2024].
- Touesnard N, Patten S, McCrindle J, et al. Hear us, see us, respect us: respecting the expertise of people who use drugs (3.0). Zenodo 2021. https://doi.org/10.5281/zenodo.5514066
- McNeil R, Small W, Wood E, Kerr T. Hospitals as a “risk environment”: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med 2014 Mar; 105:59–66. https://doi.org/10.1016/j.socscimed.2014.01.010
- Velez CM, Nicolaidis C, Korthuis PT, Englander H. “It’s been an experience, a life learning experience”: a qualitative study of hospitalized patients with substance use disorders. J Gen Intern Med. 2017 Mar; 32(3):296–303. https://doi.org/10.1007/s11606-016-3919-4
- Strike C, Robinson S, Guta A, Tan DH, O’Leary B, Cooper C, et al. Illicit drug use while admitted to hospital: Patient and health care provider perspectives. PloS One. 2020;15(3):e0229713. https://doi.org/10.1371/journal.pone.0229713
- Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users. J Gen Intern Med. 2002 May; 17(5):327–33. https://doi.org/10.1046/j.1525-1497.2002.10625.x
- British Columbia Center on Substance Use. A guideline for the clinical management of opioid use disorder. 2017. Available from: http://www.bccsu.ca/care-guidance-publications/. [Accessed on Jan 25, 2024].
- British Columbia Center on Substance Use. Provincial guideline for the clinical management of high-risk drinking and alcohol use disorder. 2019 Available from: https://www.bccsu.ca/clinical-care-guidance/. [Accessed on Jan 25, 2024].
- Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care. Can Fam Physician. 2019 May; 65(5):321–30.
- Spithoff S, Kahan M. Primary care management of alcohol use disorder and at-risk drinking: Part 1: screening and assessment. Can Fam Physician Med Fam Can. 2015 Jun; 61(6):509–14.
- Stockley D, Egan R, Van Wylick R, et al. A systems approach for institutional CBME adoption at Queen’s University. Med Teach. 2020 Aug; 42(8):916–21. https://doi.org/10.1080/0142159X.2020.1767768
- Lane DS, Ross V. The importance of defining physicians’ competencies: Lessons from preventive medicine. Acad Med. 1994 Dec; 69(12):972. https://doi.org/10.1097/00001888-199412000-00010
- Dagnone D, Stockley D, Flynn L, et al. Delivering on the promise of competency based medical education – an institutional approach. Can Med Educ J. 2019 Mar 13; 10(1):e28–38. https://doi.org/10.36834/cmej.43303
- Dagnone JD, Chan MK, Meschino D, et al. Living in a world of change: Bridging the gap from competency-based medical education theory to practice in Canada. Acad Med J Assoc Am Med Coll. 2020 Nov; 95(11):1643–6. https://doi.org/10.1097/ACM.0000000000003216
- Morris-Williams Z, Monrouxe L, Grant A, Edwards A. Teaching postgraduates about managing drug and alcohol misuse. BMJ. 2012 Sep 4; 345:e5816. https://doi.org/10.1136/bmj.e5816
- Royal College of Physicians and Surgeons of Canada. About CanMEDS. Available from: https://www.royalcollege.ca/content/rcpsc/ca/en/canmeds/about-canmeds.html [Accessed on Oct 26, 2023].
- Kidd JD, Smith JL, Hu MC, et al. Medical student attitudes toward substance use disorders before and after a skills-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) curriculum. Adv Med Educ Pract. 2020 Jun 30; 11:455–61. https://doi.org/10.2147/AMEP.S251391
- Tricco AC, Lillie E, Zarin Wet al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018 Oct; 169(7):467–73. https://doi.org/10.7326/M18-0850
- Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. Natl Med J India. 2019; 32(1):32–7. https://doi.org/10.4103/0970-258X.272115
- Ayu AP, el-Guebaly N, Schellekens A, et al. Core addiction medicine competencies for doctors: an international consultation on training. Subst Abuse. 2017; 38(4):483–7. https://doi.org/10.1080/08897077.2017.1355868
- Ayu AP, Schellekens AFA, Iskandar S, Pinxten L, De Jong CAJ. Effectiveness and organization of addiction medicine training across the globe. Eur Addict Res. 2015; 21(5):223–39. https://doi.org/10.1159/000381671
- Ashburn MA, Levine RL. Pennsylvania State core competencies for education on opioids and addiction. Pain Med Malden Mass. 2017 Oct 1; 18(10):1890–4. https://doi.org/10.1093/pm/pnw348
- Koh JJ, Paterson QS, Ong M, Martin LJ, Woods RA, Dong K. Addressing the opioid crisis in the era of competency-based medical education: recommendations for emergency department interventions. CJEM. 2019 Jul; 21(4):452–4. https://doi.org/10.1017/cem.2019.20
- Servis M, Fishman SM, Wallace MS, et al. Responding to the opioid epidemic: Educational competencies for pain and substance use disorder from the medical schools of the University of California. Pain Med Malden Mass. 2021 Feb 4; 22(1):60–6. https://doi.org/10.1093/pm/pnaa399
- Wallace PM, Warrier S, Kahn MJ, Welsh C, Fischer M. Developing an opioid curriculum for medical students: A consensus report from a national symposium. Subst Abuse. 2020; 41(4):425–31. https://doi.org/10.1080/08897077.2019.1635971
- Antman KH, Berman HA, Flotte TR, Flier J, Dimitri DM, Bharel M. Developing core competencies for the prevention and management of prescription drug misuse: a medical education collaboration in Massachusetts. Acad Med. 2016 Oct; 91(10):1348. https://doi.org/10.1097/ACM.0000000000001347
- Lande RG, Wyatt SA, Przekop PR. Addiction medicine: a model osteopathic medical school curriculum. J Am Osteopath Assoc. 2010 Mar; 110(3):127–32.
- De Jong C, Luycks L, Delicat JW. The master in addiction medicine program in the Netherlands. Subst Abuse. 2011 Apr; 32(2):108–14. https://doi.org/10.1080/08897077.2011.555713
- Jackson AH, Alford DP, Dubé CE, Saitz R. Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design. BMC Med Educ. 2010 Mar 15; 10(1):22. https://doi.org/10.1186/1472-6920-10-22
- O’Connor PG, Nyquist JG, McLellan AT. Integrating addiction medicine into graduate medical education in primary care: the time has come. Ann Intern Med. 2011 Jan 4; 154(1):56–9. https://doi.org/10.7326/0003-4819-154-1-201101040-00008
- Pinxten WJL, De Jong C, Hidayat T, et al. Developing a competence-based addiction medicine curriculum in Indonesia: the training needs assessment. Subst Abuse. 2011 Apr; 32(2):101–7. https://doi.org/10.1080/08897077.2011.555710
- Schwartz AC, Frank A, Welsh JW, Blankenship K, DeJong SM. Addictions training in general psychiatry training programs: current gaps and barriers. Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2018 Oct; 42(5):642–7. https://doi.org/10.1007/s40596-018-0950-2
- Seale JP, Shellenberger S, Clark DC. Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum. BMC Med Educ. 2010 May 11; 10(1):33. https://doi.org/10.1186/1472-6920-10-33
- Truncali A, Silva K, Stickney I, Johnson M, Holt CT. An asynchronous curriculum to address substance use disorder training needs for medical and surgical residents. J Public Health Manag Pract JPHMP. 2021 Jun 1; 27(Suppl 3):S168–73. https://doi.org/10.1097/PHH.0000000000001305
- Rasyidi E, Wilkins JN, Danovitch I. Training the next generation of providers in addiction medicine. Psychiatr Clin North Am. 2012 Jun; 35(2):461–80. https://doi.org/10.1016/j.psc.2012.04.001
- Rutkowski BA. Specific disciplines addressing substance use: AMERSA in the 21st century. Subst Abuse. 2019; 40(4):392–5. https://doi.org/10.1080/08897077.2019.1686726
- Scalese RJ, Obeso VT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med. 2008 Jan; 23 Suppl 1(Suppl 1):46–9. https://doi.org/10.1007/s11606-007-0283-4
- Pauly BB, McCall J, Browne AJ, Parker J, Mollison A. Toward cultural safety: nurse and patient perceptions of illicit substance use in a hospitalized setting. ANS Adv Nurs Sci. 2015; 38(2):121–35. https://doi.org/10.1097/ANS.0000000000000070
- Ti L, Ti L. Leaving the hospital against medical advice among people who use illicit drugs: a systematic review. Am J Public Health. 2015 Dec; 105(12):e53-59. https://doi.org/10.2105/AJPH.2015.302885
- Hamovitch EK, Choy-Brown M, Stanhope V. Person-Ccentered care and the therapeutic alliance. Community Ment Health J. 2018 Oct; 54(7):951–8. https://doi.org/10.1007/s10597-018-0295-z
- Shippee ND, Domecq Garces JP, Prutsky Lopez GJ, et al. Patient and service user engagement in research: a systematic review and synthesized framework. Health Expect Int J Public Particip Health Care Health Policy. 2015 Oct; 18(5):1151–66. https://doi.org/10.1111/hex.12090
- Canadian Medical Association, Canadian Nurses Association. Principles to guide health care transformation in Canada. 2011 Available from: https://policybase.cma.ca/link/policy10218. [Accessed on Jan 25, 2024].
- Bacchi C. Drug problematizations and politics: Deploying a poststructural analytic strategy. Contemp Drug Probl. 2018 Mar 1; 45(1):3–14. https://doi.org/10.1177/0091450917748760
- Kiepek N, Van de Ven K, Dunn M, Forlini C. Seeking legitimacy for broad understandings of substance use. Int J Drug Policy. 2019 Nov; 73:58–63. https://doi.org/10.1016/j.drugpo.2019.07.014
- Councillor Swanson. Council member’s motion: 4 Decriminalizing poverty and supporting community-led safety initiatives. 2020. Available from https://council.vancouver.ca/20200707/documents/b4.pdf. [Accessed on Feb 16, 2024].
- Culberson JW. Alcohol use in the elderly: Beyond the CAGE. Part 1 of 2: prevalence and patterns of problem drinking. Geriatrics. 2006 Oct; 61(10):23–7.
- d’Angelo LC, Savulich G, Sahakian BJ. Lifestyle use of drugs by healthy people for enhancing cognition, creativity, motivation and pleasure. Br J Pharmacol. 2017 Oct; 174(19):3257–67. https://doi.org/10.1111/bph.13813
- Reiff-Hekking S, Ockene JK, Hurley TG, Reed GW. Brief physician and nurse practitioner–delivered counseling for high-risk drinking. J Gen Intern Med. 2005 Jan; 20(1):7–13. https://doi.org/10.1111/j.1525-1497.2005.21240.x
- Kiepek N, Beagan B, Ausman C, Patten S. “A reward for surviving the day”: Women professionals’ substance use to enhance performance. Perform Enhanc Health. 2022; 10(2):100220. https://doi.org/10.1016/j.peh.2022.100220
- Kiepek N, Ausman C. “You are you, but you are also your profession”: nebulous boundaries of personal substance use. Contemp Drug Problems. 2023; 50(1):63-84. https://doi.org/10.1177/00914509221132301
- Cape G, Hannah A, Sellman D. A longitudinal evaluation of medical student knowledge, skills and attitudes to alcohol and drugs. Addict Abingdon Engl. 2006 Jun; 101(6):841–9. https://doi.org/10.1111/j.1360-0443.2006.01476.x
- Kleinman A. The divided self, hidden values, and moral sensibility in medicine. Lancet. 2011 Mar 5; 377(9768):804–5. https://doi.org/10.1016/S0140-6736(11)60295-X
- Ram A, Chisolm MS. The time is now: Improving substance abuse training in medical schools. Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2016 Jun; 40(3):454–60. https://doi.org/10.1007/s40596-015-0314-0
- Lee CS, Abrantes AM, Colby SM, López SR, Jordan TJ. Medical student judgments of adolescents with alcohol use disorders (AUD). Subst Use Misuse. 2008; 43(5):709–21. https://doi.org/10.1080/10826080701202791
- O’Gara C, Keaney F, Best D, et al. Substance misuse training among psychiatric doctors, psychiatric nurses, medical students and nursing students in a South London psychiatric teaching hospital. Drugs Educ Prev Policy. 2005 Aug 1; 12(4):327–36. https://doi.org/10.1080/09687630500083691
- Aziz S. Global News. There are growing calls for drug decriminalization. Could it solve Canada’s opioid crisis? 2021 Available from: https://globalnews.ca/news/8359890/drug-decriminalization-opioid-crisis/. [Accessed on Oct 26, 2023].
- Zimonjic P. CBC News. Police chiefs call on Ottawa to decriminalize possession of illicit drugs for personal use. 2020 Available from: https://www.cbc.ca/news/politics/chiefs-police-decriminalize-posession-personal-use-1.5643687 [Accessed on Oct 26, 2023].
- Toronto Public Health. Exemption request: Request for exemption to the Controlled Drugs and Substances Act to allow for the possession of drugs for personal use in Toronto. 2022 Available from: https://www.toronto.ca/wp-content/uploads/2022/01/943b-TPH-Exemption-Request-Jan-4-2022-FNLAODA.pdf. [Accessed on Oct 26, 2023].
- Canadian Association of Chiefs of Police. Decriminalization for simple possession of illicit drugs: exploring impacts on public safety and policing. 2020. Available from: https://www.cacp.ca/index.html?asst_id=2189 [Accessed on Oct 26, 2023].
- Government of Alberta. Alberta COVID-19 Opioid response surveillance report Q2 2020. 2020.Available from: https://open.alberta.ca/dataset/f4b74c38-88cb-41ed-aa6f-32db93c7c391/resource/e8c44bab-900a-4af4-905a-8b3ef84ebe5f/download/health-alberta-covid-19-opioid-response-surveillance-report-2020-q2.pdf [Accessed on Oct 26, 2023].
- MacDougall L, Smolina K, Otterstatter M, et al. Development and characteristics of the provincial overdose cohort in British Columbia, Canada. PLoS ONE. 2019 Jan 10; 14(1):e0210129. https://doi.org/10.1371/journal.pone.0210129
- Kiepek N, Jones-Bonofiglio K, Freemantle S, Byerley-Vita M, Quaid K. Exploring care of hospital inpatients with substance involvement. Soc Sci Med. 2021; 281:114071. https://doi.org/10.1016/j.socscimed.2021.114071