(94) The Evolution of Attitudes Towards Substance Use Disorder Throughout Medical Education

Background & Introduction: Physicians across all specialties treat patients with substance use disorder (SUD) whether as their chief complaint or as a comorbid condition as more than 1 in 10 adults in the United States report having a substance use disorder in their lifetime (1). Physician bias towards those with SUDs influences the quality-of-care they receive as patients. When those struggling with SUD experience bias within the medical system, it reduces the likelihood that they will seek out medical care and follow through with treatment (2). It is important to analyze the prevalence of bias, how it manifests, and how it develops throughout medical education to improve training and, as a result, patient care and outcomes for those with SUDs. Prior studies have shown that physician bias against individuals with SUDs increases throughout specific residency training however, there is limited research looking at how bias evolves through medical school and residency, across all specialties (3, 4). The goal of this study was to examine the way attitudes towards SUDs change from the first year of medical school through the end of residency.

Methods: A survey invite was sent via email to all medical students at the Larner College of Medicine at the University of Vermont and all residents at the University of Vermont Medical Center (N=834). The survey consisted of demographic information and the Medical Condition Regard Scale (MCRS) for individuals with 10 different conditions: alcohol use disorder, tobacco use, marijuana use disorder, prescription drug misuse disorder, opioid use disorder, IV drug use disorder, stimulant use disorder, major depressive disorder, clinically significant schizophrenia, and currently unhoused. The MCRS is a non-condition specific 11 question survey that has been validated to assess biases, expectations and emotions evoked by medical conditions (5). A higher score indicates a more positive attitude towards the condition. Participants received a $25 electronic gift certificate for completing the survey. Mean MCRS score magnitude was estimated for MCRS type and educational year using a general linear mixed effects model. This model allowed us to correct for effects from demographic factors and accounted for intra-person correlations of variability. Post-hoc pairwise comparisons are presented using a Sidak correction for p-values. Analysis was performed using SPSS.

Results: We received 456 responses for a response rate of 54.7%. 42.3% of respondents were male, 53.9% female, and 3.7% other. 21.3% were first year medical students, 17.5% second year, 14.5% third year, and 13.4% fourth year. 7% were first year residents, 8.1% second year, 5.9% third year, 4.8% fourth year, 3.7% fifth year, 3.1% sixth year, and 0.6% seventh year and greater. Of the residents, 55 were in surgical specialties and 165 were in non-surgical specialties. 21.3% of respondents were between the ages of 20-25, 51.1% between 25-30, 24.3% between 30-35 and 3.3% 35 and greater. Overall, for each year increase of medical education, MCRS scores decreased by 0.67 (p < 0.001). MCRS scores varied significantly by condition with scores from highest to lowest: major depressive disorder (45.9), unhoused (44.0), clinically significant schizophrenia (42.0), alcohol use disorder (41.3), tobacco use (41.3), opioid use disorder (40.6), prescription drug misuse (40.1), marijuana use disorder (39.8), IV drug use disorder (39.7), and stimulant use disorder (38.7) (p < 0.001).

Conclusion & Discussion: As years of medical education increased, attitudes of medical students and residents towards individuals with SUDs became less positive. There are many possible causes for this decline including burnout, negative experiences treating individuals with SUDs, frustration due to lack of knowledge and support surrounding SUD treatment, limited understanding of the biologic basis of addiction, and limited opportunities to follow individuals into recovery. The data suggests that substance use disorders are generally viewed less favorably than mental health disorders, a pattern that is seen among psychiatry trainees as well (3). This indicates the need for interventions throughout medical training to prevent this decline in attitudes towards SUDs and to reduce stigma towards SUDs. There are limitations to this study including that it only looks at one medical school and residency program, not all participants completed all sections of the survey, and there was not an equal number of participants in each class year.

References: 1. Jones CM, Noonan RK, Compton WM. Prevalence and correlates of ever having a substance use problem and substance use recovery status among adults in the United States, 2018. Drug Alcohol Depend. 2020 Sep 1;214:108169. doi: 10.1016/j.drugalcdep.2020.108169. Epub 2020 Jul 12. PMID: 32682218.

2. Biancarelli DL, Biello KB, Childs E, Drainoni M, Salhaney P, Edeza A, Mimiaga MJ, Saitz R, Bazzi AR. Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug Alcohol Depend. 2019 May 1;198:80-86. doi: 10.1016/j.drugalcdep.2019.01.037. Epub 2019 Mar 8. PMID: 30884432; PMCID: PMC6521691.

3. Avery J, Han BH, Zerbo E, Wu G, Mauer E, Avery J, Ross S, Penzner JB. Changes in psychiatry residents’ attitudes towards individuals with substance use disorders over the course of residency training. Am J Addict. 2017 Jan;26(1):75-79. Doi: 10.1111/ajad.12406. Epub 2016 Oct 17. PMID: 27749984.  

4. Avery JD, Taylor KE, Kast KA, Kattan J, Gordon-Elliot J, Mauer E, Avery JJ, Penzner JB. Attitudes Toward Individuals With Mental Illness and Substance Use Disorders Among Resident Physicians. Prim Care Companion CNS Disord. 2019 Jan 3;21(1):18m02382. doi: 10.4088/PCC.18m02382. PMID: 30620451.  

5. Christison, George W. MD; Haviland, Mark G. PhD; Riggs, Matt L. PhD The Medical Condition Regard Scale, Academic Medicine: March 2002 - Volume 77 - Issue 3 - p 257-262