When you are a twenty-something medical student, fists clenching nervously in the pockets of your white medical coat, learning to get gruff, grizzled Chris McQ to disclose uncomfortable truths is not readily gleaned from a textbook. Mr. McQ is crusty and defensive. As students resorted to the same chirpy rejoinder — “Awesome!”— he tried not to flinch. The man just wanted pain meds.
In each small-group session, a student had 15 minutes to assess Mr. McQ and make a plan. Mr. McQ once had a cocaine problem. His girlfriend was taking hydromorphone, known as Dilaudid, for back pain. Was he at risk for misusing opioids?
“Ask him about his pain first, ” Dr. Wlasiuk told the students. “Language matters. Avoid saying, ‘I found this out.’ Instead, say, ‘This was in your urine screen.’ You want to keep that conversation going, not shut it down.”
The students had learned about “motivational interviewing,” a technique that encourages patients to articulate health goals. As medicine moves away from doctor-knows-best paternalism, students are being schooled in engaging the patient with a joint-decision-making, team approach.
Before Mr. McQ entered the classroom, the students debated: Was he selling Percocet to buy cocaine? Stealing his girlfriend’s Dilaudid?
Dr. Buchheit cautioned: “Substance use disorder is a chronic, relapsing disease. So is diabetes. Diabetics don’t follow a diabetic diet 100 percent of the time. If they were to have a slip-up, we would figure out what went wrong and say ‘Is there anything else we can do?”
Despite the urgent need for addiction medicine education, there are considerable barriers to establishing it. Hours of training have already been meted out to conditions deemed critical. Making time in a jammed schedule can mean another subject has to be shrunk.
Because addiction medicine is young , most medical schools can’t rely for expertise on fellows—post-graduate students who steep themselves in a subspecialty. Fellows would typically consult on addiction-related cases in hospitals and clinics, educate medical students and supervise residents in primary care fields where these patients first appear: family medicine, emergency medicine, obstetrics.
And so the field of addiction medicine struggles to perpetuate itself.
Dr. Daniel Alford, a professor and associate dean at Boston University, is a driving force behind its curriculum. “The biggest challenge now is how do you sustain it?” he said. “Who keeps updating it? When faculty leave, who will replace them?”
There is not much incentive to specialize in addiction medicine. According to a 2017 study, insurance disparities can be striking. Insurance views addiction treatment as an afterthought to mental health therapy, which itself trails reimbursement for physical health care.
The reasons for resisting this career are also cultural. The stigma that attaches to patients also clings to doctors who treat them. The patients are often dismissed as manipulative and incurable; caring for them is seen as a thankless endeavor.
“I really enjoy working with these patients,” Dr. Buchheit told the students. “They have often been kicked to the curb by the formal medical system. They don’t trust us. So for them to walk into a room and have a doctor say, ‘It’s great to see you, thank you for coming in,’ is very powerful. And then you can see them get better with treatment. It can be very rewarding work.”
The students tried out approaches on Mr. McQ. “You called our office and wanted an early refill on your Percocet,” said one. “But it’s important that you come in. I’m glad you’re here and we can maintain our relationship.”
Mr. McQ told one student that his pain had worsened — that he ran through his prescription, tried to get more and took some of his girlfriend’s Dilaudid.
Mr. McQ suggested that the doctor switch him to Dilaudid.
“Time out!” Mr. Yin, the student, said, turning to the class.
“What are you struggling with?” Dr. Wlasiuk asked him.
Mr. Yin replied that he didn’t want to reward the patient’s behavior with a prescription for stronger medication, but also didn’t want to drive the patient away. “I trust the patient’s story about pain,” he said, “but I don’t want to be naïve.”
Another student asked: “By increasing his dose, are you protecting him from getting the drugs off the street?”
Dr. Wlasiuk said that although medical training typically urges students to come up with absolute answers, treating these patients often means getting comfortable with ambiguity.
The students brainstormed with her and Dr. Buchheit. Some offered to raise the Percocet dose if he agreed to frequent office visits; others urged him to try physical therapy and acupuncture.
A few remembered to caution Mr. McQ about opioids. (“Percocet is an opioid?” Mr. McQ responded. “I’m not one of those people! “)
In an evenhanded tone, Chioma Anyikwa, 25, marched through Mr. McQ’s history and pain, which he had previously listed as four of 10.
“A seven-plus, ” he said.
“Wow, that’s pretty high,” she said. “Did you do anything else to treat it?” Hesitantly, he spoke about sharing his girlfriend’s Dilaudid.
“In your urine screen we also saw some cocaine,” she continued. “Do you know anything about that? I appreciate you being honest with me.”
Mr. McQ looked uneasy. “It’s not gonna mess me up if I tell you?”
She shook her head. “No, we just want to help you regroup and fix the problem,” she said.
He admitted that a friend had been in town and they did a few lines for old times’ sake.
Afterward, Ms. Anyikwa braced for the group’s feedback.
“Did I talk too much?” she asked.