Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making

The authors of “Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making” highlighted several explanations for why primary care physicians may insufficiently prescribe medications for the treatment of alcohol use disorder (AUD).1 One important reason that deserves further attention and scrutiny is the lack of formalized substance use disorder training cited amongst participants.1 Given the prevalence and comorbidity of alcohol use disorder in the US, we must urgently increase physician competency in AUD diagnosis and management, which should start strategically at the residency education level.
Primary care physicians have repeatedly identified the lack of training on medications for AUD as a barrier for prescribing effective treatment.2,3 Family physicians, who are at the forefront of chronic disease treatment, must know how to appropriately treat alcohol and other substance use disorders because the delays to specialty care are substantial. Yet, in a recent study of Family Medicine residency programs, only 28.6% of the responding programs mandated curricular experiences in addiction medicine, and less than half of the program directors expected residents to prescribe medications in clinical practice for substance use disorders.4 Inadequate residency education about AUD (and addiction in general) as a treatable disease perpetuates uncertainty on AUD treatment efficacy and ultimately correlates with underutilization of treatment.
Even with the updated ACGME guidelines now listing behavioral health training as a program requirement,5 the interpretation of how often and how much substance use training should exist in program curricula is unclear. More specific, standardized milestones in addiction medicine as part of the ACGME competency requirements for patient care would provide the impetus for Family Medicine programs to develop curricula tailored to their individual program’s needs. One solution could be to require residents to complete a certain number of clinical hours in substance use identification and treatment across clinical domains. This structured training would 1) help to de-stigmatize AUD, 2) encourage collaboration of faculty across programs, 3) provide a solution to the shortage of addiction trained faculty, and 4) ultimately address the problem of inadequate physician training on AUD. Family Medicine residency education needs purposeful re-structuring to adequately prepare practitioners to care for patients with AUD.

References:
1. Bhardwaj A, Sousa JL, Huskamp HA, et al. Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making. The Annals of Family Medicine. 2023;21(4): 332-337. doi: 10.1370/afm.2997
2. Ponce Martinez C, Vakkalanka P, Ait-Daoud N. Pharmacotherapy for Alcohol Use Disorders: Physicians' Perceptions and Practices. Front Psychiatry. 2016;7:182. Published 2016 Nov 14. doi:10.3389/fpsyt.2016.00182
3. Hagedorn HJ, Wisdom JP, Gerould H, et al. Implementing alcohol use disorder pharmacotherapy in primary care settings: a qualitative analysis of provider-identified barriers and impact on implementation outcomes. Addict Sci Clin Pract. 2019;14(1):24. Published 2019 Jul 10. doi:10.1186/s13722-019-0151-7
4. Tong S, Sabo R, Aycock R, et al. Assessment of Addiction Medicine Training in Family Medicine Residency Programs: A CERA Study. Fam Med. 2017;49(7):537-543. Accessed August 26 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996005/
5. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Family Medicine. July 1, 2023. Accessed August 26, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/120_fami...