Substance use disorder (SUD) remains undertreated and is among the most stigmatized conditions in medicine.1,2 Only 6.5% of adults with SUD in 2020 received any treatment in the preceding year.3 In response, healthcare systems have begun to integrate addiction treatment into general medical settings. For patients with SUD, access to addiction services during medical hospitalization can become a “reachable” or “intervenable” moment.4,5 The creation and expansion of dedicated Addiction Consultation Services (ACS) within hospitals has moved us closer to this goal.6,7 ACS are multidisciplinary teams led by addiction specialists aiming to increase access to evidence-based SUD care for hospitalized patients.7,8 We posit that ACS teaching services have an important role in combatting stigma and rewriting the hidden curriculum around SUD in medical settings.

STIGMA AND THE HIDDEN CURRICULUM

Stigma is a multifactorial construct characterized as “attitudes, beliefs, behaviors, and structures that interact at different levels of society (i.e., individuals, groups, organizations, systems) and manifest in prejudicial attitudes about and discriminatory practices against people with mental and substance use disorders.”1 A recognized concept in the field of medical education is the “hidden curriculum,” the collective attitudes, practices, and implicit influences occurring within healthcare organizations and conveyed via educational structures, which has been posited as a larger predictor of trainee learning than formal medical curricula itself.9,10,11 Defining the hidden curriculum is challenging, as it is “felt and not seen.”.11

It is well-established that healthcare professionals generally hold negative attitudes toward patients with addiction,1,12 with this emerging as early as medical school13,14 and worsening progressively into independent practice.15,16,17 One reason for the pervasiveness of SUD stigma is suspected to be the learning environment itself. Hafferty described medical training as “a process of moral enculturation” in which, regardless of what students are taught in formal didactics, they learn to mimic the attitudes and actions of their superiors greatly influencing future practice.9

Hospital medicine teams have a unique opportunity to change this narrative. Hospitalists care for the bulk of inpatients and interact with health professionals across specialties and disciplines to optimally coordinate a patient’s care. One study of general internists found that 72% of those surveyed found it less satisfying to care for patients with SUD.18 These attitudes are implicitly and explicitly conveyed to learners: skepticism about acute pain treatment for a patient with opioid use disorder, indifference about a valve replacement for a patient who injects drugs, or offhand comments about patients with recurrent admissions being “frequent flyers” can overtly give the perception of dismissiveness on the part of the clinician and covertly support the biased yet unspoken view that such patients are less deserving of care than others.

ADDICTION CONSULT SERVICES

ACS models vary from collaborative approaches for treatment of injection drug use–related infections to opioid- and alcohol-specific treatment teams.6,19 In addition to clinical care, ACS provide a rich environment for educational initiatives around SUD treatment. Multidisciplinary ACS teaching services commonly include an addiction medicine or psychiatry attending, fellow and/or resident physicians, medical and/or health professions students,6 and a social work professional and/or peer support specialist. Stigma permeates all aspects of SUD care, including implementation of ACS, which has not been without challenges; from organizational infrastructure and resource scarcity to staff undereducation and workforce limitations20, many of these barriers relate directly or indirectly to stigma.3

HOW ACS CAN REWRITE THE HIDDEN CURRICULUM

Medical practice has historically reflected paternalism, with the movement toward shared decision-making being a more recent phenomenon.21 In the paternalistic model, the physician “expert” identifies what is best for the patient and implements that treatment without extensive regard for the patient’s own ideas.21 ACS espouse anti-paternalism by employing motivational interviewing (MI), an evidence-based clinical approach for evoking motivation already present instead of imposing what is missing.22 MI empowers the patient as an equal partner in treatment and is the ultimate form of patient-centered care, whereby physicians work collaboratively with patients to support change in a manner congruent with the patient’s own values. ACS cultivate in clinicians an openness to what the patient brings to treatment and emphasize greater prioritization of the patient’s perspective.

Dismantling the hidden curriculum that perpetuates stigma toward patients who use drugs and alcohol has the potential to significantly impact the next generation of physicians to better care for this underserved population. Educational experiences crafted to reduce stigma among early trainees have been shown to decrease stigma and should be incorporated in curricula to reduce the likelihood that students will fall prey to the hidden curriculum and emulate biased instructors.14,23,24 ACS offer an opportunity for students to learn about caring for patients who use substances from experts in addiction medicine and psychiatry who use MI and harm reduction approaches to meet patients where they are at; cultivating compassion and respect for this marginalized population.25

Integrating medical students into ACS sends the message that learning how to care for patients with SUD is important and a priority for the clinical institution. Role modeling by faculty, fellows, and residents and collegiality with social work and peer specialists communicates to medical students the importance of collaboration and teamwork. In addition to acute medical interventions, ACS teams identify social determinants of health that contribute to hospitalization and inform discharge planning. This approach recognizes that comprehensive, compassionate care requires tending to the patient’s psychosocial and socioeconomic needs. Importantly, it further promotes empathy and aligns with educational initiatives around diversity, equity, and inclusion.

INSTITUTIONAL EXAMPLES

Development of an educational experience for medical students and residents that allows for direct patient care in the field of addiction medicine or psychiatry varies with institutional resources. Two examples of ACS in large Midwestern academic medical centers, led by the authors, demonstrate that identifying physician leaders in either addiction medicine or addiction psychiatry can serve as a starting point.

At the University of Wisconsin Hospital, fourth-year medical students experience a two-week elective with the addiction medicine ACS, a multidisciplinary consult service providing assessments and treatment recommendations to primary medical, psychiatric, and surgical teams caring for hospitalized adult and pediatric patients across the institution’s three hospitals in Madison, Wisconsin. The elective averages 20 students per year. Students work alongside board-certified addiction medicine faculty also trained in family medicine, addiction medicine fellows, family and internal medicine residents, and certified substance use counselors. Observations of faculty, fellows, and counselors give students an appreciation for varying interview styles and engagement strategies. Students learn to conduct patient interviews, deliver MI and education to patients, and document clinical encounters. Addiction medicine faculty and fellows provide feedback following patient encounters helping students develop a de-stigmatized and compassionate approach to the care of patients with SUD. The team’s certified substance use counselors work with medical students to develop MI skills and understand the role of certified substance use counselors on a multidisciplinary team.

Interwoven throughout the experience is completion of a self-guided 15-h online curriculum developed by Yale University faculty, “Addiction Treatment: Clinical Skills for Healthcare Providers.” This course includes six modules emphasizing stigma, the importance of nonjudgmental language, and how to provide evidence-based addiction care with compassion. Topics include screening, diagnosis, referral to treatment, pharmacotherapy, and evidence-based psychotherapies for addiction.26

At the University of Nebraska Medical Center, the addiction psychiatry ACS is an interdisciplinary team providing consultation to hospitalized patients with substance-related and/or other psychiatric needs. Developed as a teaching service, the ACS hosts learners from medical and other health professions, as well as psychiatry residents and addiction medicine fellows. The ACS serves as one of several sites to which medical students are randomly assigned for their third-year psychiatry clerkship (3 weeks) and also offers an elective sub-internship for fourth year students (4 weeks). The service is co-directed by subspecialty board-certified psychiatrists in addiction medicine and consultation-liaison psychiatry, and also includes a licensed clinical social worker.

The ACS emphasizes the supervised clinical experience for learners in addiction care, starting with a comprehensive orientation to the service including teaching on the components of the psychiatric interview and maximizing therapeutic rapport with use of non-stigmatizing, clinically accurate terminology. Students are engaged as members of the ACS team and are responsible for patient interviews/exams, case presentations, communication with interdisciplinary team members, and encounter documentation. The attending psychiatry faculty provide teaching rounds, and actively supervise and provide feedback with encouragement and correction to promote learners’ growth.

A didactic curriculum links the real-life patients seen to peer-reviewed literature on pathophysiology and epidemiology of their respective conditions. Topics include addiction psychiatry’s role in liver transplantation, perioperative management of patients receiving medications for opioid use disorder, evaluation and management of psychosis in methamphetamine use, and addressing co-occurring anxiety and alcohol use disorders. Students learn about pharmacotherapy for opioid, alcohol, and tobacco use disorders, with a perspective on the history of drug regulation in the USA and its impact on current laws that contribute to the structural separation of the SUD treatment sphere from mainstream medicine. Students receive oral instruction from faculty along with handouts and reading materials. The role of healthcare providers in propagating or reducing stigma is highlighted throughout the block, empowering learners with knowledge and skills to counteract this stigma.

ACS: DISMANTLING THE HIDDEN CURRICULUM

While developing a scientific knowledge base and clinical skillset are goals of all clinical learning experiences, the ACS trainee’s experience prioritizes dismantling the hidden curriculum. Specifically, learners should:

  • Observe patient-centered and destigmatizing approaches to care of patients with at-risk substance use and SUD

  • Develop skills to interview patients regarding alcohol and substance use

  • Practice non-stigmatizing SUD-related terminology

  • Identify harm and risk reduction strategies

  • Practice self-reflection on identification and mitigation of biases

  • Describe local resources available to patients who use substances

  • Explore the fields of addiction medicine and psychiatry to guide career decision-making

Developing the learner experience to achieve these goals should involve opportunities for observation of experienced clinicians including non-physician team members as well as active practice with specific, in-person feedback. Team discussions regarding challenging cases, ethical care considerations, and adverse outcomes become opportunities for reflection and development of compassion for patients who use substances.

ACS: VISION

Rewriting the hidden curriculum may take generations of medical learners to fully achieve; however, significant progress can be made through early, purposeful efforts to educate and expose medical and other health professions students to evidence-based SUD care. ACS provide a disruptive innovation to jump-start this revision and align with calls to transform the educational ecosystem for SUD through continuous curriculum improvement and institutional change.27 With recent elimination of the Drug Addiction Treatment Act 2000 waiver for buprenorphine prescribing came a new requirement for anyone renewing or applying for a Drug Enforcement Agency license to complete an 8-h training on SUD management starting in June 2023.28 This training can be waived for those who graduate from a health professional program that provides qualifying addiction training within their curriculum. This change not only acknowledges that all physicians need basic competencies in addiction care, but also incentivizes institutions to implement SUD training as part of the required curriculum. Developing ACS and incorporating learners onto it can offer one effective way of providing key components of this required addiction curriculum.

Importantly, ACS can promote interdisciplinary learning beyond the clinical realm — if an institution has connections to experts in social sciences, humanities, and the legal field — it could help students understand the issues affecting people with SUD from multiple angles with a focus on social determinants. Given the known disparities in overdose death rates and access to SUD treatment for patients from minoritized communities, a community component to ACS curricula could help students reflect on the SUD system of care and their role within it. Although every medical student would benefit from rotating on an ACS, there is unlikely to be capacity to offer this opportunity to everyone; beginning with an elective experience may provide a starting off point for future expansions. While ACS vary in composition, all are united by a commitment to provide and model compassionate care to people with SUD. Future work is needed to evaluate the impact on student attitudes, clinical competency and career choice as a result of exposure to ACS during medical school.