OFFICE OF NATIONAL DRUG CONTROL POLICY 

Leadership Conference


on Medical Education in Substance Abuse


“Let us bring to all Americans who struggle with...addiction this message of hope: 

The miracle of recovery is possible, and it could be you.” 

President George W. Bush, State of the Union Address,


January 20, 2003 


Washington, DC


December 1-2, 2004

CONFERENCE AGENDA 

OFFICE OF NATIONAL DRUG CONTROL POLICY 

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE 

Washington, DC, December 1-2, 2004 

WEDNESDAY, DECEMBER 1, 2004 

6:00 - 9:00 PM 

5:00 pm Registration opens (Hotel Mezzanine) 

6:00 pm Dinner Meeting (Consulate Room, 

Mezzanine Level) 

6:00 - 6:10 pm Welcome and Acknowledgments 

Addison D. “Tad” Davis IV 

Acting Deputy Director for Demand 

Reduction Office of National Drug 

Control Policy 

6:10 - 7:00 pm Dinner (generously sponsored by The Robert 

Wood Johnson Foundation) 

7:00 - 7:10 pm Introduction of the Panelists (Mr. Davis) 

7:10 - 8:00 pm Panel Discussion 

Dr. Bertha K. Madras, 

Dr. Sheldon Miller, Dr. Mark L. Kraus 

8:00 - 8:30 pm Questions and Discussion 

8:30 - 9:00 pm Overview of Thursday’s Activities and 

Adjourn for the Evening 

Mr. Davis & 

Bonnie B. Wilford, 

Conference Facilitator 

THURSDAY, DECEMBER 2, 2004 

8:00 AM - 5:00 PM 

8:00 - 8:30 am	 Registration and Continental Breakfast 

8:30 - 9:00 am	 Introduction of Director Walters 

Mr. Davis 

Address and Charge to the Conferees 

John P. Walters 

Director, Office of National Drug 

Control Policy 

9:00 - 9:20 am	 Health Professions Education: The View 

from NIDA 

Nora D. Volkow, M.D. 

Director, National Institute 

on Drug Abuse 

THURSDAY, DECEMBER 2, 2004 continued 

9:20 - 9:40 am	 Health Professions Education: 

The View from NIAAA 

Ting-Kai Li, M.D. 

Director, National Institute on 

Alcohol Abuse and Alcoholism 

9:40 - 10:00 am	 Questions and Discussion 

(Dr. Volkow & Dr. Li) 

10:00 - 10:10 am	 Overview of the Day and Introduction 

of the Small Group Chairs 

Mr. Davis & Mrs. Wilford 

10:15 - 10:30 am	 Break 

10:30 - 12:00 pm Small Groups Meet — Session 1 

Group 1 (Undergraduate Medical Education) 

Group 2 (Graduate Medical Education) 

Group 3 (Continuing Medical Education) 

12:00 - 12:50 pm Working Lunch 

12:50 - 1:10 pm	 Health Professions Education: 

The View from NHTSA 

Jeffrey Runge, M.D. 

Administrator, National Highway 

Traffic Safety Administration 

1:10 - 1:15 pm	 Overview of the Afternoon 

Mr. Davis & Mrs. Wilford 

1:15 - 1:30 pm	 Break 

1:30 - 3:00 pm	 Small Groups Meet — Session 2 

3:00 - 3:15 pm	 Break 

3:15 - 3:35 pm	 Health Professions Education: 

The View from the Surgeon General 

Vice Admiral Richard H. Carmona,


M.D., M.P.H.


Surgeon General of the United States


3:35 - 4:30 pm	 Small Group Discussion Summaries 

4:30 - 5:00 pm	 Planning for the Future 

Mr. Davis & Mrs. Wilford 

5:00 pm	 Conference Adjourns 
LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


PREFACE AND ACKNOWLEDGEMENTS


Conference Chair Addison D. Davis IV, Assistant Deputy Director for Demand Reduction,


Office of National Drug Control Policy, welcomed the conferees:


ADDISON D. “TAD” DAVIS IV, 

CONFERENCE CHAIR 

On behalf of ONDCP’s Director, 

Mr. John Walters, it is my 

distinct privilege and honor to 

welcome each and every one of you. 

We meet as leaders of private sector organizations and Federal 

agencies to discuss ways to enhance the training of physicians 

in the prevention, diagnosis, and management of drug and 

alcohol problems and related medical disorders. Indeed, the conference represents a new level of engagement between government and the medical community on this important issue. 

A key component of expanding the Nation’s treatment 

capacity lies in engaging health professionals — particularly 

physicians — in the identification, counseling, referral, and 

ongoing medical management of persons with substance use 

disorders. From screening for addiction, to emerging modalities of treatment, to the prevention of prescription drug 

diversion and abuse, the need for more comprehensive 

medical education on substance use disorders is clear. 

We look to you — the leaders of organized medicine, medical 

education, and licensure and accreditation — to counsel and 

advise us on the most effective ways to reach out to physicians 

and training institutions. Because the need is so compelling, 

and the work already accomplished so important, I am 

confident that this conference will help us achieve a major 

step forward toward our goal. 

I want to conclude by thanking many of you who helped to 

bring this meeting together. On behalf of all my colleagues, I 

want to thank all of our Federal agency partners: you have 

always helped us whenever we asked. Particular thanks go to 

Mr. Charles Curie, Administrator of the Substance Abuse and 

Mental Health Services Administration, who has been a 

tremendous supporter of this effort. I’d also like to recognize 

Dr. Westley Clark, who directs the Center for Substance Abuse 

Treatment, and Beverly Watts Davis, who is Director of the 

Center for Substance Abuse Prevention. And then finally, my 

predecessor — but more importantly, my mentor and friend, 

Dr. Andrea Barthwell, who has been a driving force in the 

effort that we are about to undertake. I want to thank her for 

being here, but more importantly, for her energy and courage and dedication to the field, which has really set an example 

for all of us. 

Some time ago, Dr. Barthwell was approached by Dr. Mark 

Kraus, Dr. Bud Isaacson, Dr. Jonathan Ritvo, and Dr. Petros 

Levounis with the idea for this conference. I want to express 

my gratitude to them, and to the other members of the Expert 

Panel as well. 

I want to express our appreciation to The Robert Wood Johnson 

Foundation, which has been involved in this field for many, many 

years, for their generous grant in support of the conference. 

Finally, I want to thank you, the conferees. I know that all of 

you have enormously crowded schedules, so thank you for 

being here. Thank you for what you have done, and for what 

you will do. I look forward to the results of this meeting and 

to our ongoing relationship. If we do our job, we will help 

extend your efforts to save many more lives. 

Now I’m going to ask Bonnie Wilford, our conference facilitator, to explain what we’ll be doing over the next two days. 

Any organization needs someone to keep everyone on track, 

and that’s her task. I think she’s done an excellent job in getting 

us here this evening and preparing this fine program for us. 

Bonnie served for 10 years with the American Medical Association as Director of the Department of Substance Abuse 

and was the first woman to direct the AMA’s Division of Clinical Science. We’re delighted to have her to guide us through 

the conference activities. 

WASHINGTON, DC • DECEMBER 1-2, 2004 1

PREFACE AND ACKNOWLEDGEMENTS


BONNIE B. WILFORD 

CONFERENCE FACILITATOR 

As I stand here, I’ll admit that I am forced to adopt a 

new paradigm. In the past, I’ve used what I call the 

“file cabinet test” to measure how far the addiction 

field has come. When I joined the AMA in 1981, my first 

assignment was to prepare a little handbook on substance 

abuse for primary care physicians. The sum total of the 

research that we gathered for that book filled barely two drawers of a file cabinet. 

More recently, I have been privileged to collaborate on a textbook of addiction medicine that’s published by the American 

Society of Addiction Medicine. The textbook itself is 1,600 

pages, and it could have been longer. The editors of the next 

edition, two of whom are with us at this conference, will 

struggle to keep the fourth edition to less than 2,000 pages. 

The volume of knowledge in the addiction field is exploding, 

which is why it’s so exciting. The documents that chronicle 

our understanding of the causes and manifestations and 

management of substance use disorders now fill entire libraries. So the results of the file cabinet test are among the most 

encouraging indicators I’ve seen. 

But now I have a new paradigm, which I’ll call the “generational test.” The person who brings this home to me is Michael 

Dekker, a medical student who is with us as a representative 

of the American Medical Student Association. I am very 

happy to have him with us, particularly because I know his 

father. When Dr. Anthony Dekker and I first worked together, 

he was a resident who, in his spare time, was working with a 

street clinic for homeless kids in Chicago. I was at the AMA 

at the time, and we used AMA funds to help purchase 

medications that Tony’s clinic couldn’t otherwise afford. 

Tony went on to become a leader in both osteopathic 

medicine and addiction medicine. I’m confident Michael will 

do the same. But I don’t want to wait for another generation 

to come along — for Michael’s son to be at a similar meeting 

25 years from now — before we meet the challenge of educating physicians about substance use disorders. 

The new paradigm says that this is our chance. Dr. Barthwell 

and Dr. Lewis are right: a rare constellation of forces is in place 

at this moment in time. We have a President who uses his State 

of the Union address to speak of the devastation of addiction 

and the promise of recovery. We have a Surgeon General of 

the United States who speaks openly and movingly about his 

experiences growing up in a family affected by alcohol and 

drug problems. And we have Director Walters, who is a 

member of the President’s Cabinet, and the leaders of our 

major health agencies who are willing to provide real support to this initiative. That’s an astonishing and unparalleled 

convergence of leadership. So I’m optimistic about our 

chances to effect real change. 

Now to the specifics. First, you may be wondering exactly 

why you’ve been invited to be here. There were two categories 

of invitations: Some of you are here because you are change 

agents in the organizations you represent. You’re the folks 

designated by your organizations to help us understand what 

the world looks like from the perspective of internal medicine, 

or the licensing boards, or the accreditation agencies. Others 

of you are experts on medical education or substance abuse. 

You are here because you have deep experience in creating 

the kinds of educational ventures we want to encourage. 

We’ve tried to organize your time at the conference so as to 

maximize the opportunities for you to talk to each other and 

to our Federal partners, who are here not because they have 

to be, but because they share our enthusiasm and commitment to change. Your discussions in the working groups 

tomorrow are at the heart of your mission here. There are 

groups for undergraduate, graduate, and continuing education, as well as a group for the representatives of the Federal 

agencies. In the morning, you will talk and listen to each other, 

and you will explore how the world looks from your multiple 

vantage points. In the afternoon, you will be asked to devise 

specific strategies to move us forward from this meeting. 

You will be supported in every way we can think of. We have 

provided professional facilitators to assist your working 

groups, as well as note takers who will record your thoughts 

and conclusions. We are very fortunate to have with us a 

research librarian who specializes in substance abuse issues, 

who has set up a reference library for you. So anything you 

can think of that we can do for you, we’ll be delighted to do. 

At the end of the day tomorrow, each of your groups will be 

asked to report your conclusions and recommendations to the 

entire conference. We’re also asking you to give us advice as 

to how we can keep the momentum going. There are so many 

good people who helped to bring about this meeting, we don’t 

want the energy to dissipate. So please give us solid ideas about 

practical steps we can take to keep the initiative vibrant. 

Following the conference, a report will be circulated to you, 

first for your input, then as the official proceedings of the conference. We also will ask you to think about opportunities within 

your own organizations to undertake relevant activities. And 

the core group of conference planners will continue to meet. 

The last thing I want to say, because I’ve heard my name mentioned an uncomfortable number of times tonight, is that a very 

active planning committee is responsible for this event. In addition to Martha Gagne and Tad Davis, Peggy Murray of NIAAA, 

Cindy Miner of NIDA, and Anton Bizzell of CSAT have been 

the real leaders of the effort. We thank all of them very much. 

2 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


CONTENTS


PREFACE, ACKNOWLEDGEMENTS, AND CONFERENCE ORGANIZATION .............. 1


EXECUTIVE SUMMARY............................................................................................................... 5


OVERVIEW OF MEDICAL EDUCATION IN SUBSTANCE ABUSE ................................. 9


The Challenge of Substance Abuse ........................................................................................... 9


Core Values and Paradigms of Physicians ..................................................................................... 11


Physician Training .............................................................................................................................. 11


Defining the Core Competencies ..................................................................................................... 13


PERSPECTIVES OF THE PRIVATE SECTOR LEADERS........................................................ 17


Opening Panel Discussion: Bertha K. Madras, Ph.D.,


Sheldon I. Miller, M.D., and Mark L. Kraus, M.D., FASAM........................................................... 17


General Discussion: David C. Lewis, M.D., Beverly Watts Davis,


Lawrence S. Brown, Jr., M.D., M.P.H., FASAM, Winston Price, M.D.,


Richard Suchinsky, M.D., William O. Vilensky, D.O., R.Ph., FASAM,


and Andrea G. Barthwell, M.D. ......................................................................................................... 20


PERSPECTIVES OF THE FEDERAL LEADERS ......................................................................... 23


Remarks of John P. Walters, Director


Office of National Drug Control Policy........................................................................................... 23


Remarks of Nora D. Volkow, M.D., Director


National Institute on Drug Abuse .................................................................................................... 26


Remarks of Ting-Kai Li, M.D., Director


National Institute on Alcohol Abuse and Alcoholism ................................................................... 30


Remarks of Jeffrey Runge, M.D., Administrator


National Highway Traffic Safety Administration ........................................................................... 32


Remarks of Vice Admiral Richard H. Carmona, M.D., M.P.H.


Surgeon General of the United States ............................................................................................. 35


WASHINGTON, DC • DECEMBER 1-2, 2004 3

CONTENTS


REPORTS FROM THE WORKING GROUPS ............................................................................. 37


Undergraduate Medical Education .................................................................................................. 37


Graduate Medical Education ............................................................................................................ 38


Continuing Medical Education ......................................................................................................... 40


Role of the Federal Agencies ............................................................................................................ 41


Action Plans ........................................................................................................................................ 43


REFERENCES ............................................................................................................................................ 44


RESOURCE DOCUMENTS .................................................................................................................. 47


American Medical Association (1979): Guidelines for Physician Involvement


Macy Conference (1994): Recommendations for Training About


Models of Undergraduate, Graduate and Continuing Medical


in the Care of Substance-Abusing Patients. ................................................................................... 47


Alcohol and Substance Abuse for All Primary Care Physicians .................................................. 49


Recommended Physician Competencies ........................................................................................ 51


Education Programs ........................................................................................................................... 56


Program Model ................................................................................................................................... 56


APPENDICES ............................................................................................................................................. 57


A. Conference Agenda ..................................................................................................................... 57


B. Acknowledgements ...................................................................................................................... 58


C. Conference Participants and Small Group Assignments ........................................................ 59


D. Follow-up Survey of the Conferees ........................................................................................... 67


E. Glossary ......................................................................................................................................... 69


F. Acronyms ...................................................................................................................................... 70


G. Supporting Literature .................................................................................................................. 71


4 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


EXECUTIVE SUMMARY


I

n December 2004, the Office of National Drug Control 

Policy (ONDCP) in the Executive Office of the President 

hosted an important Leadership Conference on Medical 

Education in Substance Abuse. The conference brought together 

leaders of private sector organizations, Federal agencies, 

organized medicine, and licensure and certification bodies to 

discuss ways to enhance the training of physicians in the prevention, diagnosis, and management of alcohol and drug use 

disorders, including prescription drug abuse. Participants were 

charged with identifying strategies and action steps to improve 

physician knowledge and skills through enhanced undergraduate, graduate, and continuing medical education. 

The conference was co-sponsored by the Center for Substance 

Abuse Treatment of the Substance Abuse and Mental Health 

Services Administration, as well as the National Institute on 

Alcohol Abuse and Alcoholism and the National Institute on 

Drug Abuse of the National Institutes of Health, with the 

assistance of the Robert Wood Johnson Foundation. 

CONFERENCE GOALS. Conference participants were charged with identifying competencies, objectives, and action steps to help all physicians 

master core competencies in preventing, identifying, and 

managing substance use disorders (SUDs). As the Surgeon 

General of the United States, Richard H. Carmona, M.D., 

M.P.H., observed in his address to the conferees, the medical 

community — particularly primary care physicians — has a 

pivotal role to play in helping to identify patients who may 

have substance use disorders and guiding them to appropriate treatment. For this to occur, he said, medical students, 

residents, and practicing physicians need more and better 

training about the disease of addiction and the impact it can 

have on many other medical and psychiatric disorders. 

ONDCP Director John P. Walters pledged that his office and 

other Federal agencies will continue to support scientific 

research and clinical education that help to reduce the illness 

and deaths associated with substance use disorders. He also 

promised support for research that helps bring the medical 

community better tools to identify, prevent, and treat those 

who are at risk for or experiencing such disorders, including 

problems with prescription drugs. 

Director Walters added that the current conference represented a unique opportunity to achieve those objectives because it had created an unprecedented gathering of leaders 

at the highest levels of multiple government agencies and 

private sector organizations. 

CONFERENCE ORGANIZATION. In planning the Leadership Conference, ONDCP drew on 

several past efforts to identify essential physician competencies related to substance use disorders. These competencies 

have been defined with growing specificity over the past 25 

years. For example, the “AMA Guidelines for Physician 

Involvement in the Care of Substance-Abusing Patients,” 

adopted as the policy of the American Medical Association 

(AMA) in 1979, articulates the principle that every physician 

must assume clinical responsibility for the diagnosis and 

referral of patients with SUDs, and broadly defines the competencies required to meet that responsibility. 

The Macy Conference on Training About Alcohol and Substance Abuse for All Primary Care Physicians, held in 1994, 

moved the conversation forward by elaborating on the 

competencies articulated in the AMA policy statement. The 

report of the conference also contained a number of thoughtful essays on the subject by conference chair David Lewis, 

M.D., and other leaders in medical education (Lewis, 1994). 

Project Mainstream, conducted by the Association for Medical Education and Research in Substance Abuse (AMERSA), 

with assistance from the Health Resources and Services 

Administration and the Center for Substance Abuse Treatment, represents a multi-year effort to describe in detail the 

areas of knowledge and skills required by practitioners of 

many health professions (AMERSA, 2002). The competencies and recommendations offered in the Project Mainstream 

report have been endorsed by many health professions 

organizations, including AMA, the American Osteopathic 

Academy of Addiction Medicine, and the Society of Teachers 

of Family Medicine. 

Taken together, these efforts and the broad areas of consensus they achieved provided a solid foundation for the work 

of the Leadership Conference. 

WASHINGTON, DC • DECEMBER 1-2, 2004 5

EXECUTIVE SUMMARY


PERSPECTIVES ON THE PROBLEM 

AND POSSIBLE SOLUTIONS. Distinguished speakers at the Leadership Conference suggested a number of approaches to address the challenge. 

ONDCP Director John P. Walters described a public health 

approach built on the concept of SUDs as a contagious disease. Director Walters pointed out that, while SUDs are not 

spread by bacteria or other biological agents of infection, they 

are spread by behavior. As an example, he pointed out that 

when young people begin to use alcohol, tobacco, or other 

drugs, they expose their peers to that behavior and thus 

encourage them to begin using. Because peer relationships 

are an important part of adolescent development, this kind 

of “infectious behavior” forces young people to choose 

between emulating drug-using behavior or losing their friends. 

As in dealing with other infectious disorders, Director Walters 

said that preparing physicians to intervene effectively requires 

a comprehensive approach. 

NIDA Director Nora D. Volkow, M.D., adopted a similar paradigm when she suggested that physicians may more readily 

accept their role in preventing, identifying, and managing 

patients with SUDs if training programs and curricula 

emphasize analogies to conditions that are widely understood in the medical community, such as cardiovascular 

disease and diabetes. For example, Dr. Volkow pointed out 

that, although the victim of a heart attack or stroke could 

be said to have brought the disease on himself or herself 

through diet and other lifestyle choices, physicians nevertheless feel an obligation to screen for, diagnose, and treat 

cardiac disorders. In this more productive concept, she 

noted, it makes little difference whether a disease is brought 

on by excessive exposure to fat or to abused drugs; one 

changes the functioning of the arteries and the heart, the 

other changes the functioning of the brain. Both require 

medical intervention. 

NIAAA Director Ting-Kai Li, M.D., told the conferees that 

current efforts to overcome the barriers to physician learning 

and participation are “necessary but not sufficient.” Specifically, Dr. Li recommended that current research and education initiatives be augmented by a collaborative program for 

the development of core faculty in schools of health professions education. Such programs would have both a career 

teacher and a scholar — investigator component, he said, 

describing such an initiative as a way to develop faculty who 

are knowledgeable about SUDs and who are able to invest in 

both teaching and research. Dr. Li said that such career clinical 

scholars and investigators would be key members of the faculty, 

responsible “for education, for conducting research on education and health services research, and for mentoring the 

next generation of clinical scholars and investigators.” 

Dr. Li announced that NIAAA is willing to use its KO7 grant 

mechanism to support both the career development of young 

clinical investigators and the mentoring component of such 

a program. NIAAA is willing to invest in this over the next nine 

years in a collaborative manner, he said, but the success of 

such an initiative will depend on the degree of buy-in from the 

schools of medicine and other health professions. Accordingly, 

he noted that “this proposal to further invest in the goal of 

high-quality alcohol prevention treatment and care can be done 

best in collaboration with the professional schools and with 

other Federal agencies and private sector organizations.” 

The National Highway Traffic Safety Administration (NHTSA) 

Administrator, Jeffrey Runge, M.D., who trained as a trauma 

surgeon, pointed out that one of the keys to case-finding is 

development of a screening approach that will not require 

extra time in the emergency department and other highvolume locations. For example, because emergency physicians often see 15 patients in an hour, they do not have time 

to go through lengthy screening questionnaires with every 

patient. In addition, to help physicians feel comfortable in 

screening patients, Dr. Runge noted that we also have to help 

them believe that they can successfully refer patients for 

formal assessment and treatment. 

The insurance laws build in a disincentive for physicians to 

screen patients in emergency settings, he said, because state 

laws allow insurers to deny payment for care related to alcohol 

or drug use. To remedy the situation, he urged the conferees 

to look to the model legislation prepared by the National 

Association of Insurance Legislators, which bans such discriminatory practices. 

Dr. Runge also suggested that accreditation can be used as a 

motivator. As an example, he noted that that the Committee 

on Trauma of the American College of Surgeons is considering including screening intervention protocols in the requirements for trauma center designation. He added that the Joint 

Commission on Accreditation of Healthcare Organizations 

might want to consider incorporating a similar requirement 

in its accreditation standards. 

Vice Admiral Richard H. Carmona, M.D., M.P.H., told the 

conferees that patients and the public also have a role, saying: 

“To prevent substance abuse and save millions of lives, we 

must focus on closing the gap between what health professionals know about substance abuse and what the rest of 

America understands. I think most of you will agree that in 

our country, we have a largely ‘health illiterate’ society. Health 

literacy is the ability of an individual to access, understand, 

and use health-related information and services to make 

appropriate health decisions. So how does the average person 

deal with all of the great scientific information that we are 

trying to give them to change their behavior to keep them 

healthy, to make their lives better? They simply don’t understand. The literature’s pretty strongly supportive of the fact 

that half of patients don’t understand the appointment slip 

6 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


and when they’re supposed to come back, and a quarter of 

the people don’t understand their prescriptions and what’s 

on them. This health literacy block is very, very significant in 

everything we do.” 

Dr. Carmona concluded that, “there is a gap between those 

of us who have the knowledge and those who need the knowledge,” adding that “Improving health literacy involves giving 

people information about the safe use of prescription drugs, 

about staying away from illegal drugs, and about drinking 

only in moderation, if at all. We also must train ourselves and 

the next generation of medical professionals to watch for signs 

of abuse or addiction in our patients.” 

All the speakers acknowledged past efforts to teach physicians the competencies they need to care for patients with 

SUDs. While many of these efforts have been effective in 

demonstrating the medical basis of SUDs and creating a clinical paradigm similar to that for other chronic diseases, the 

speakers also agreed that the depth of the initiatives varies 

by clinical discipline and academic institution. They called 

for public-private sector collaborations to support efforts to 

more fully integrate effective curricula on SUDs into the 

mainstream of medical education at all levels — undergraduate, graduate, and CME — and across all disciplines. 

CONFERENCE OUTCOMES. 

ONDCP Director John P. Walters pointed out that all the data 

reviewed in the conference underscored the fact that medical 

students, residents, and practicing physicians need more and 

better training about the disease of addiction and the impact 

it can have on many other disorders, including cancer, cardiovascular disease, stroke, infectious diseases, mental illnesses, 

and even obesity. Accordingly, he asked the participants to 

develop action plans to improve physician knowledge and 

skills through enhanced training in undergraduate, graduate, 

and continuing medical education. 

In response to Director Walters’ call to action, the conferees 

agreed that the critical core competencies for physicians 

encompass a thorough understanding of the basic biomedical sciences (e.g., molecular biology, genetics, anatomy, physiology, pharmacology, and pathology), as well as knowledge 

and skills in the following areas: 

1.	 Screening, Prevention, and Brief Intervention. All physicians 

should know how and when to screen patients for SUDs. 

Such screening may involve (1) direct questioning by a 

physician or other health care professional; (2) selfadministered questionnaires; or (3) laboratory tests. 

Physicians also should be able to provide preventive counseling to patients at risk for SUDs, as well as brief interventions to those who screen positive for such disorders. 

(Brief interventions are time-limited, patient-centered 

counseling strategies that focus on changing behavior and 

increasing medication compliance.) 

Training programs should devote specific attention to 

building physicians’ knowledge and skills in these areas. 

For example, a required curriculum in screening, preventive counseling, and brief treatment interventions should 

be integrated into the standard curricula of all medical 

schools and residency training programs. Such a curriculum should outline the components of screening and brief 

intervention. Training programs should emphasize the 

effectiveness of office-based screening and interventions 

in primary care settings. 

2.	 Co-Occurring Medical and Psychiatric Disorders. Physicians 

should understand the medical and psychiatric comorbidities 

and complications of substance use disorders. They also 

should be able to evaluate patients with such co-occurring 

disorders and complications and refer patients to specialized treatment services that match the patients’ individual 

treatment needs. 

Co-occurring disorders can be difficult to detect because 

substances of abuse can cause symptoms that are timelimited but indistinguishable from those seen in many other 

medical and psychiatric disorders; for example, substance 

withdrawal or acute intoxication can mimic almost any 

psychiatric disorder. On the other hand, treating such 

co-occurring disorders can markedly improve the outcome 

of treatment for SUDs. 

To assure that physicians achieve competence in this area, 

a curriculum addressing the medical and psychiatric 

comorbidities of SUDs should be integrated into the 

standard curricula of all medical schools and residency 

training programs. Similarly, curricula on the diagnosis and 

management of conditions that frequently coexist with 

SUDs — such as liver disorders, HIV/AIDS, and eating 

disorders — should incorporate information on the ways 

in which the symptoms, progression, and management of 

those disorders may be affected by an undiagnosed SUD. 

Increased training on co-occurring disorders also should 

be available through continuing medical education 

programs. Such training should focus on the recognition, 

treatment or referral of comorbid medical and psychiatric 

conditions in patients with SUDs. 

3. Prescribing Drugs with Abuse Potential. Physicians should have 

a thorough understanding of the clinical, legal, and ethical 

considerations involved in prescribing medications with 

abuse potential. Such knowledge encompasses drug 

selection, communicating the treatment program to the 

appropriate individuals (patient, family, and other health 

professionals), correctly executing the prescription order, 

WASHINGTON, DC • DECEMBER 1-2, 2004 7

EXECUTIVE SUMMARY


and monitoring the treatment program to determine 

whether changes are needed to achieve optimum 

effectiveness and safety of drug therapy. It also involves 

avoiding undermedication (underprescribing), overmedication (overprescribing), and drug misuse or abuse 

(AMA, 1981). 

This knowledge should be reinforced through undergraduate, 

graduate, and continuing medical education programs in all 

specialties. Physicians who complete such training should be 

able to demonstrate that they are able to prescribe medications in a therapeutic manner to all patients, including those 

at risk for, presenting with, or with a history of SUDs, so as to 

minimize the risk of inducing or perpetuating prescription 

drug misuse or abuse. 

Each of the foregoing competencies is relevant to all disciplines and specialties. In addition, physician education can 

and should be tailored to specific practice situations and 

patient populations. For example, pediatricians have a special 

need for knowledge about SUDs as developmental disorders 

and the skills to perform screening, intervention, and referral. 

Pediatricians also need to consider the issues raised by 

children and adolescents whose parents or other caregivers 

have SUDs and to acquire the skills needed to address such 

situations. Similarly, specialists in obstetrics/gynecology need 

the knowledge and skills to address substance-related 

problems in pregnant and parenting women. Finally, because 

primary care physicians serve diverse populations of patients 

in terms of gender, socioeconomic status, and culture, they 

also must be culturally competent in communicating with 

patients and their families. 

ACTION STEPS. Next, the conferees agreed on a series of specific recommendations and action steps. They pointed to nutrition and 

geriatrics as good examples of how cross-cutting ideas have 

been incorporated into medical education and practice, and 

suggested that they be used as models. Their recommendations included strategies specific to undergraduate, graduate, 

and continuing medical education, as well as the following 

general recommendations: 

1. Ask the Surgeon General to convene a working group of 

medical organizations to draft a strong ethics policy stating 

that physicians may not ignore the signs or symptoms of 

alcohol and drug problems, on the grounds that substance 

use disorders are medical illnesses and may not be ignored 

or left untreated. 

2.	 Work with medical student organizations to help students and 

residents advocate for better education in the identification 

and management of substance use disorders, which afflict 

one in 10 patients in primary medical practice. 

3. Develop collaborative projects to design useful clinical 

models and tools. Involve multiple government agencies 

and private-sector organizations. 

4. Work with the Federal health agencies to develop and 

fund a program (similar to the Career Teacher program 

of the 1980s) that would support the recruitment and 

training of medical school faculty to become experts on 

SUDs. Experience shows that such faculty members go 

on to become “champions” for adding addiction-related 

content to the curriculum in undergraduate and graduate medical education. 

5. Establish an expert panel to assist the National Board of 

Medical Examiners and the National Board of Osteopathic Medical Examiners in developing test questions 

on substance use disorders for licensure and certification exams. 

6. Teach about prescribing and prescription drug abuse in 

the same way other areas of clinical knowledge and skills 

are taught. Employ multiple focused interventions, which 

research shows are more effective at changing behaviors 

than single exposures. 

7. Amend medical licensure and certification/recertification 

standards to require competency in prescribing controlled 

drugs. For example, DEA could require that, at the time of 

re-registration, physicians present evidence of CME credits 

and/or focused self-assessment to achieve competence 

in this vital area. 

8.	 Address patients’ health literacy needs by working through 

public-private partnerships to evaluate and/or develop 

educational materials that physicians can give to patients 

for whom they prescribe drugs with abuse potential. 

The conferees also recommended that ONDCP schedule a 

follow-up meeting in a year to revisit the objectives, strategies, 

and action steps and to measure progress in implementing 

them. In the interim, they pledged to continue the dialogue. 

This report of the Leadership Conference outlines the 

rationale for greater physician involvement in recognizing 

and treating patients with SUDs, describes current barriers 

to education in this field, and evaluates the impact of prior 

initiatives to improve physician education about SUDs. In 

addition, it proposes core clinical competencies for all 

physicians, based on important work that has been done by 

a number of organizations over the past 30 years (AMA, 

1979; Lewis, 1994; AMERSA, 2002a, 2002b). Finally, it summarizes the recommendations of the leaders in organized 

medicine, medical education, licensure and accreditation, 

and Federal health agencies who gathered for the Leadership Conference. 

8 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


OVERVIEW OF MEDICAL EDUCATION


IN SUBSTANCE ABUSE


Research consistently demonstrates that substance use 

disorders (SUDs) constitute a major public health 

problem. For example, drug abuse is responsible for 

more than 25,000 deaths annually and $100 billion in total 

annual economic costs in the United States (Association for 

Medical Education and Research in Substance Abuse 

[AMERSA], 2002a). Alcohol use in the United States is estimated to be responsible for 100,000 deaths annually and a 

health care cost of $185 billion (Fiellin et al., 2002). Patients 

with alcohol problems consume more than 15 percent of the 

national health care budget, with 39 percent of these costs 

representing morbidity costs from secondary health and social 

effects. Recent surveys indicate that roughly 40 million 

Americans drink in excess of recommended amounts, and 

approximately 70 percent of adults visit a physician once 

every two years (National Institute on Alcohol Abuse and 

Alcoholism [NIAAA], 2001). 

The general health care system in the United States offers an 

ideal opportunity to identify and treat these people and 

thereby reduce associated adverse health, family, and societal effects. Practitioners from various disciplines, including 

physicians, nurses, pharmacists, dentists, social workers, 

psychologists, and allied health professionals, are essential 

participants in national efforts to deal with these problems 

(Fleming, 2002). Physicians are particularly well-positioned 

to play a role in the recognition and treatment of patients 

with SUDs (National Institute on Drug Abuse [NIDA], 1998). 

Yet there is evidence that physicians are not adequately 

trained in the recognition and treatment of SUDs (Fiellin et 

al., 2002). In a survey of 1,082 physicians on their screening 

practices regarding illicit drug use, 68 percent reported that 

they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55 percent reported that they routinely 

offer formal treatment referral, but 15 percent reported that 

they do not intervene (Kessler et al., 1994). In a similar survey 

about alcohol problems, 88 percent of 853 respondent physicians 

indicated that they usually or always ask new outpatients 

about alcohol use. When evaluating patients who drink, 82 

percent routinely offered intervention to problem drinkers 

(Bush et al., 1997), but only 13 percent used formal alcohol 

screening tools. A recent survey of emergency medicine 

residency directors revealed that only 25 percent provide education on specific screening questionnaires, and only 36 

percent teach the NIAAA quantity and frequency guidelines 

for at-risk drinking (Lewis et al., 1987). 

This report outlines the rationale for greater physician 

involvement in recognizing and treating patients with SUDs, 

describes current barriers to education in this field, and 

identifies the successes of prior efforts to improve physician 

education about SUDs. The following section describes core 

clinical competencies for all physicians, based on important 

work that has been done by a number of organizations over 

the past 30 years (American Medical Association [AMA], 

1979; Lewis, 1994; AMERSA, 2002a, 2002b). A concluding 

section summarizes the long-term recommendations and immediate action steps outlined by the leaders in organized 

medicine, medical education, licensure and accreditation, and 

Federal health agencies who gathered for the Leadership 

Conference. 

THE CHALLENGE OF SUBSTANCE ABUSE 

Federally supported research has led to unprecedented 

advances in our understanding of substance use disorders. 

Research funded by NIAAA and NIDA has identified the 

primary receptors for every major class of abused drug 

(including alcohol), identified their genetic code, and cloned 

the receptors (NIDA, 1994, 1996). The researchers have 

mapped the locations of those receptors in the brain and 

determined the neurotransmitter systems involved (Institute 

of Medicine, 1996). They have demonstrated the activation 

of these areas during addiction, withdrawal, and craving 

(Volkow et al., 1996); identified and separated the mechanisms 

underlying drug-seeking behavior and physical dependence 

(Maldonado et al., 1997); and developed animal models for 

drug self-administration (Koob, 2000). Most importantly, they 

have demonstrated that the mesolimbic dopamine system is 

the primary site of the dysfunction caused by abused drugs 

(Wise, 1996). 

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OVERVIEW OF MEDICAL EDUCATION IN SUBSTANCE ABUSE


Outcomes studies supported by the Center for Substance 

Abuse Prevention (CSAP) and the Center for Substance Abuse 

Treatment (CSAT) have developed a documented body of 

knowledge regarding “what works” in drug abuse prevention, as well as clear evidence that treatment of SUDs is at 

least as effective as the treatment of other chronic medical 

problems. Moreover, these studies have provided direction 

as to how to organize prevention and treatment for specific 

populations to increase the likelihood of success. 

Such advances have provided a clear understanding that substance abuse is a preventable behavior and that addiction is 

a treatable disease of the brain. This paradigm shift provides 

unprecedented opportunities to achieve the overarching goal 

of the Office of National Drug Control Policy (ONDCP): to 

reduce the health and social consequences of substance 

misuse, abuse, and addiction throughout the United States. 

However, there is a gap between research and clinical practice. It is ONDCP’s goal to close this gap in the prevention, 

identification, and treatment of SUDs. In organizing the Leadership Conference, ONDCP sought the advice of experts in 

medical education, licensure, and accreditation, as well as 

addiction medicine and the other medical specialties, as to 

specific steps that can be taken to increase primary care 

physicians’ awareness of SUDs and their motivation and 

knowledge to incorporate the findings of recent research into 

their clinical practices. It thus represents a further step in 

ONDCP’s long-term efforts to foster the adoption of evidencebased prevention and treatment interventions. The benefits 

of adopting such “best practices” are clear. For example, 

pediatricians who are knowledgeable about the risk and 

protective factors for adolescent drug use may be able to work 

with their young patients and their families to strengthen 

protective factors while diminishing risk factors. 

Why Is It Important to Reach 

Primary Care Physicians? 

SUDs are associated with many of the Nation’s most serious 

and tragic problems, including violence, injury, disease, and 

death. Indeed, it has been estimated that, of the more than 2 

million deaths in the United States each year, approximately 

one in four is attributable to alcohol, tobacco, or other drug use 

(AMERSA, 2002b). Some groups, such as members of ethnic 

and cultural minority populations, are disproportionately 

affected by the consequences of drug abuse and addiction. 

Moreover, it is estimated that one out of four children in the 

United States under 18 years of age is exposed to alcohol 

abuse or alcohol dependence in the family — a figure magnified by the countless numbers of other children adversely 

affected by parents and other caregivers who are impaired 

by use of other psychoactive drugs (AMERSA, 2002a). 

As part of the President’s National Drug Control Strategy, 

ONDCP has committed to intensifying its efforts in all areas 

of public and practitioner education. The strategy also commits ONDCP to a special effort to address the problem of 

misuse and abuse of prescription medications. 

As noted earlier, Federally funded research and outcomes 

studies hold the potential for important progress in preventing and treating SUDs. Unfortunately, we have not made 

similar progress in another key area that holds tremendous 

potential: the education and training of the health care 

workforce. Far too little attention has been paid to educating 

primary care physicians and other health professionals — 

nurses, dentists, physician assistants, psychologists, pharmacists, social workers, and others — to respond to the needs 

of the millions of individuals and families affected by SUDs. 

As a result, primary care physicians do not identify and diagnose alcohol and drug problems with the same acuity they 

bring to other medical disorders. The role of these front-line 

health professionals in prevention, early identification, and 

referral thus remains largely untapped. Yet primary care 

physicians are in an ideal position to provide preventive guidance, education, and intervention to children, adolescents, 

adults, and their families. In fact, it has been estimated that 

up to 20 percent of visits to primary care physicians are 

related to such problems (Bradley, 1994). Moreover, patients 

with alcohol and other drug problems are twice as likely to 

consult a primary care physician as individuals without such 

problems (Rush, 1989). 

Recent research shows that the public wants such help from 

their caregivers. For example, in a public opinion survey 

conducted by the Harvard School of Public Health and The 

Robert Wood Johnson Foundation (2000), 74 percent of 

respondents said they believe that addicts can stop using 

drugs, but that to do so they need help from professionals or 

organizations outside their families. By “help,” two-thirds said 

they meant intervention by a health care professional. 

Research also shows that physicians play an important role 

in their patients’ health decisions. For example, a recent review 

of brief interventions for alcohol and drug problems concluded 

that primary care physicians can be effective in changing the 

course of patients’ harmful drinking (Bien et al., 1993; Fleming 

et al., 1997). Smoking cessation research shows that a 

physician’s statement to quit smoking is enough to convince 

many patients to undertake such an effort. And interventions 

by emergency physicians have been shown to reduce subsequent alcohol use and readmission for traumatic injuries 

(Gentilello et al., 1999), as well as drinking and driving, traffic 

violations, alcohol-related injuries, and alcohol-related problems among 18- and 19-year-olds (Monti et al., 1999). 

Moreover, a small number of physicians inappropriately 

prescribe therapeutic medications that have abuse potential, 

thus inducing or sustaining SUDs in their patients and others 

to whom such drugs may be given or resold. This poses an 

10 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


additional educational challenge: how to provide training in 

the clinical, legal, and ethical issues involved in prescribing 

drugs with abuse potential as part of undergraduate, graduate, and continuing medical education in all specialties. At 

the completion of each level of training, physicians should 

be able to demonstrate that they have the knowledge and 

skills required to prescribe in a therapeutic manner to their 

patients, including patients at risk for, presenting with, or with 

a history of SUDs, so as to minimize the risk of inducing or 

perpetuating prescription drug misuse or abuse. 

Unfortunately, although primary care physicians are the 

professionals most often cited by patients and families as the 

“most appropriate” source of advice and guidance about 

issues related to the use of alcohol, tobacco, and other drugs 

(including prescription drugs), they also are reported to be 

the “least helpful” in actually addressing these issues. The 

diagnosis of drug abuse or addiction often is missed by 

physicians and, even when such a diagnosis is made, many 

physicians do not know how to do a brief intervention or 

develop an organized plan for patient referral or treatment. 

Clearly the basic clinical skills of screening, assessment, 

presenting the diagnosis, negotiating a treatment plan, and 

ongoing monitoring — all skills that physicians routinely 

employ in the management of other chronic disorders — need 

attention when it comes to drug abuse and addiction 

(Conigliaro et al., 2003). 

CORE VALUES AND 

PARADIGMS OF PHYSICIANS 

Feillin and colleagues (2002) note that physicians’ core values 

include the restoration of health, patient comfort, and quality of life whenever possible. These values are congruent with 

the diagnosis and treatment of patients with SUDs. Although 

many physicians are well equipped to treat the medical and 

psychiatric complications of substance abuse, most are not 

prepared to treat substance abuse as a primary disorder. 

Despite the high prevalence of SUDs in the general population (Kessler et al., 1994), and their increased prevalence in 

medical settings (Bush et al., 1987), most physicians receive 

limited training in the science of addiction. This lack of training frequently results in missed opportunities for care. 

The biomedical model — a central paradigm for physicians 

— is based on the concept that disease is the result of perturbations in anatomy or physiology and stems from a combination of genetic, behavioral, and biologic phenomena. The 

recognition that SUDs fit the criteria for the disease model 

(Lewis et al., 1987; Page, 1988), given validity by the AMA in 

1966 (AMA, 1966), came during a time of discoveries regarding the genetic, physiologic, and behavioral factors involved in 

the etiology, natural history, and treatment of these disorders 

(Nestler & Aghajanian, 1997). 

This biomedical “legitimacy,” running counter to the popular 

misconception that these disorders stem from weakness of 

the will (Dole, 1988; Musto, 1992), provides support for the 

expansion of physicians’ efforts on behalf of patients with 

SUDs. The disease model, particularly the recognition that, 

for many patients, SUDs are chronic diseases with periods of 

remission and relapse (McLellan et al., 2000), has provided a 

basis for physicians to modify the natural history of these 

disorders and to intervene at stages ranging from at-risk use 

to abuse and dependence using standard medical approaches, 

such as prevention, pharmacotherapy, and counseling. Recent 

efforts have focused on incorporating evidence-based medicine into the treatment of patients with SUDs (Fiellin et al., 

1988, 2000; McCrady & Langenbucher, 1996; Mayo-Smith, 

1997; Wilk et al., 1997), which should help assure patients 

the full benefits of basic, clinical and services research. 

PHYSICIAN TRAINING. Practicing physicians in the United States must have obtained 

either an M.D. (doctor of medicine or allopathic physician) 

or a D.O. (doctor of osteopathy) degree (Fiellin et al., 2002). 

Physicians with an M.D. degree represent approximately 93.5 

percent of the current physician workforce, with osteopathic 

physicians representing just over 6.5 percent of the Nation’s 

physicians. 

Physicians can be broadly classified as generalists or specialists. Generalist physicians provide primary and longitudinal 

care to patients in the fields of pediatrics, internal medicine, 

obstetrics/gynecology, and family medicine; in the case of 

emergency medicine, primary care is provided in the emergency setting. By contrast, specialist physicians typically 

provide care focused either by organ system (e.g., gastroenterology, cardiology) or by technical expertise (e.g., 

interventional radiology, plastic surgery). 

Generalist and specialty medical care is delivered in a variety 

of clinical settings. The majority of patient care is rendered 

in outpatient settings, such as private offices, clinics, community health centers, urgent care centers, surgical centers, 

and emergency departments. A much smaller percentage of 

patient care is delivered in hospital settings; however, because 

of the intensity of services provided in the hospital, care 

provided in that setting consumes a disproportionate share 

of health care dollars. Individuals with SUDs are disproportionately high consumers of hospital-based services, which 

makes hospitals a particularly important setting for offering 

substance abuse screening, intervention, and referral services. 

Development of Physician Training About SUDs. 

Early physician involvement in the care of patients with SUDs 

focused primarily on the adverse medical complications of 

alcohol and other substances and tended to have limited 

effectiveness because it was not based on a recognition of 

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OVERVIEW OF MEDICAL EDUCATION IN SUBSTANCE ABUSE


the disease process. More recent involvement by physicians 

in the treatment of patients with these disorders has 

paralleled societal tolerances to the problems of addiction 

(Musto, 1992). Physicians in the late 19th and early 20th 

centuries used medicinal compounds that often included 

high concentrations of alcohol, opium, codeine, heroin, and 

cocaine. Heroin was used for the treatment of cough, and 

cocaine was used for allergy symptoms (Musto, 1992). At 

the turn of the 20th century, physicians providing maintenance treatment for patients with opioid dependence were 

halted by the Harrison Narcotic Act of 1914 and a Federal 

legislative policy against maintenance that accompanied 

Prohibition in 1919 (Musto, 1992). 

Later 20th-century physician efforts in the treatment of SUDs 

include, among others, research on the natural history and 

mechanism of the alcohol withdrawal syndrome (Victor, 1966; 

Bill, 1994), the demonstration of the effectiveness of methadone maintenance for opioid dependence (Dole, 1965), and 

the recognition of the adverse effects of alcohol on fetal 

development (American Academy of Pediatrics, 2000). 

Physicians have also been involved in developing and implementing effective psychosocial treatments for SUDs, including motivational techniques, cognitive behavioral therapy, 

contingency management, and self-help group facilitation 

(Carroll & Schottenfeld, 1997). 

Key elements of these psychosocial interventions have been 

identified and used successfully by physicians during brief 

interventions with patients who have SUDs (Bien et al., 1993; 

Wilk et al., 1997). Recent advances in understanding the neurochemical basis of SUDs have allowed physicians to use 

pharmacological interventions such as the approval of 

buprenorphine and naltrexone for the treatment of drug 

addiction, and of acamprosate for the prevention of alcohol 

relapse (American College of Physicians, 1989; O’Malley et 

al., 1992; Volpicelli et al., 1992; Nestler & Aghajanian, 1997; 

O’Brien, 1997; O’Connor et al., 1997; Fiellin et al., 2000). 

Pharmacotherapies that have been successfully used by physicians for detoxification and relapse prevention of opioid 

dependence include methadone, buprenorphine, naltrexone, 

clonidine, and lofexidine (Dole, 1965; Newman, 1987; 

O’Connor et al., 1988; Strain et al., 1993, 1999; Ling et al., 

1988; O’Connor & Kosten, 1998). 

Enhanced efforts to train physicians in the care of patients 

with SUDs resulted from the increase in substance abuse 

during the 1960s and continued progress in understanding 

the biomedical basis of these disorders. 

One of the earliest meetings called to discuss deficiencies in 

the traditional medical school curriculum and the need for 

better professional training was sponsored by the National 

Council on Alcoholism in 1970 (NIDA, 1998). Early efforts by 

the AMA and the Medical Society on Alcoholism also were 

directed toward increasing physician education about SUDs 

(Lewis et al., 1987). Later, Federal funding for the Career 

Teacher Program in the Addictions provided faculty support 

to 59 medical schools and represented a successful effort to 

increase the number of academic physicians who could teach 

other physicians about SUDs (Fleming, 1994). One result of 

this program was the creation in NIAAA and NIDA of offices 

to administer efforts to improve alcohol and drug abuse education for health professionals (NIDA, 1998). In addition, two 

prominent research societies, the Research Society on Alcoholism and the Committee on Problems of Drug Dependence, 

have provided a national and international forum for sharing 

current research findings. 

A landmark conference held at the AMERSA Ninth Annual 

Meeting in 1985 addressed the issues of the minimal alcohol 

and drug abuse knowledge and skills for physicians. The 

conferees concluded that information on SUDs should be 

routinely integrated with preclinical course work and repeated 

during subsequent years (NIDA, 1998). 

Concurrent with these early programs were efforts to provide 

resources and faculty development, including Project CORK 

(Lewis et al., 1987) and Project ADEPT (Dube et al., 1989) and 

efforts by members of the Society of General Internal Medicine and the Society of Teachers of Family Medicine, the 

Ambulatory Pediatric Association, the American Psychiatric 

Association, the American College of Emergency Physicians, 

and the American College of Obstetricians and Gynecologists (ACOG) (Graham et al., 1997). Seven-year follow-up of 

one of these programs demonstrated ongoing success in 

promoting publications, presentations at national meetings, 

and clinical teaching by the fellowship participants (Graham 

et al., 1997). 

More recently, Federal support for faculty development in 

substance abuse education and training has come through 

the Federal Medicine Grants Program and the Faculty Development Program, established in 1989 by CSAP, NIAAA, and 

NIDA. Between 1989 and 1995, the Faculty Development 

Program provided grants to 14 medical schools supporting 

69 faculty fellows in pediatrics (26 percent), internal medicine (22 percent), psychiatry (19 percent), family medicine 

(14 percent), and obstetrics/gynecology (nine percent). A 

recent evaluation of this program found that it produced significant increases over the six-year period in faculty activity 

in SUDs, as measured by faculty time, publications, grants, 

and course work (Cosmos Corporation, n.d.). For instance, 

faculty fellows with substance abuse-related grants increased 

from eight percent at year one to 26 percent at year five. Similarly, the percentage of Faculty Development Program project 

directors who were awarded new substance abuse-related 

grants increased from 15 percent during year one to 55 percent 

at year five (AMERSA, 2002b). 

12 OFFICE OF NATIONAL DRUG CONTROL POLICY

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Another recent model of successful faculty development is 

represented by Project SAEFP (Substance Abuse Education 

for Family Physicians) in which 165 faculty participated in a 

five-day course using learner-centered teaching techniques. 

An evaluation of this program revealed a two- to threefold 

increase in substance abuse teaching activities by faculty with 

residents and medical students 12 months after the completion of the course (Fleming et al., 1994). 

In summary, faculty development programs designed to bring 

about substantive increases in the number of faculty who are 

trained to provide clinical teaching in the area of SUDs have 

repeatedly demonstrated success in achieving these goals. 

Faculty participants have increased their teaching; maintained 

continued scholarly work, including manuscripts and presentations at national meetings; and secured grant funding to 

continue research and education in the field of SUDs. 

DEFINING THE CORE COMPETENCIES 

The critical core competencies for physicians include a firm 

understanding of the basic biomedical sciences (e.g., molecular 

biology, genetics, anatomy, physiology, pharmacology, pathology) 

and the clinical sciences (e.g., patient interviewing, physical 

diagnosis, diagnostic reasoning, clinical epidemiology, and 

psychosocial counseling techniques). All of these competencies have direct application to the care of patients with SUDs 

(Fiellin et al., 2002). These competencies encompass knowledge and skills in the following areas: 

1. Screening, Prevention, and Brief Intervention. 

Physicians should know how and when to screen patients 

for SUDs and how to perform preventive counseling and 

brief interventions, as appropriate. 

2. Co-Occurring Medical and Psychiatric Disorders. 

Physicians should understand the medical and psychiatric comorbidities and complications of substance use disorders. They also should be able to evaluate patients with 

such co-occurring disorders and complications and refer 

patients to specialized treatment services that match the 

patients’ individual treatment needs. Physicians also 

should be prepared to provide ongoing medical monitoring and to address the needs of special populations, such 

as adolescents and older adults. 

3. Prescribing Drugs with Abuse Potential. 

Physicians should understand and be prepared to address 

the clinical, legal, and ethical considerations involved in 

prescribing medications with abuse potential, so as to minimize the risk of inducing or perpetuating prescription drug 

misuse or abuse. 

Each of these competencies is relevant to all disciplines and 

specialties. In addition, physician education can and should be 

tailored to specific practice situations and patient populations. 

For example, pediatricians have a special need for knowledge 

about SUDs as developmental disorders and the skills to 

perform screening, intervention, and referral. Such physicians 

also need to consider the issues raised by children and 

adolescents whose parents or other caregivers have SUDs 

and to acquire skills in screening and intervention in these 

situations. Similarly, specialists in obstetrics/gynecology need 

the knowledge and skills to address substance-related 

problems in pregnant and parenting women. 

Because primary care physicians serve diverse populations 

of patients in terms of gender, socioeconomic status, and 

culture, they also must be culturally competent in communicating with patients and their families. 

Screening, Prevention, and Brief Intervention. 

Physicians should know how and when to screen patients for 

unrecognized SUDs and how to perform preventive counseling and brief interventions, as appropriate. 

Screening for diseases is warranted if the following conditions are met: the disease has a significant prevalence and 

consequences; effective and acceptable treatments are available; early identification and treatment are preferable; and 

there are effective screening instruments available that are 

easy to administer. Strong research evidence supports the 

fact that SUDs meet all of these criteria; therefore, screening 

for SUDs is indicated although not often implemented 

(Fleming, 2002). 

Screening for SUDs may involve (1) direct questioning by a physician or other health care professional; (2) self-administered 

questionnaires, completed by the patient with pencil and 

paper or computer; and (3) laboratory tests. Many of these 

methods have excellent psychometric properties that are 

comparable to a single measurement of blood pressure as a 

screening test for hypertension, a fasting blood glucose test 

to detect diabetes, a mammogram to identify early breast 

cancer, or a prostate-specific antigen test to detect prostate 

cancer. Less information is available on screening for drug 

problems. While evidence for the effectiveness of various 

screening methods is not as strong as for alcohol, a number of 

instruments and methods are available. The overall reliability 

and validity of screening methods to detect alcohol and drug 

use vary by the method of administration of the test, the 

clinical setting, and the population of interest. Consumption 

questions that focus on frequency, quantity, and bingeing are 

widely recommended as initial screening questions for use in 

clinical settings (NIAAA, 1998). 

Physician training should include attention to the rationale, 

utility, operating characteristics, and use of various screening methods, including the importance of raising the topic 

during history-taking and the appropriate use of formal 

screening instruments (e.g., CAGE, AUDIT), quantityWASHINGTON, DC • DECEMBER 1-2, 2004 13

OVERVIEW OF MEDICAL EDUCATION IN SUBSTANCE ABUSE


frequency questions, and biological markers (e.g., MCV, AST, 

ALT, carbohydrate-deficient transferrin). 

Similarly, physicians should be able to provide preventive 

counseling to patients at risk for SUDs and brief interventions to those who screen positive for such disorders, using 

techniques for which effectiveness has been demonstrated in 

outcomes studies. Prevention of harm from the use of psychoactive substances can help decrease the impact of SUDs 

on the individual and society. For example, reducing alcohol 

consumption among pregnant women can reduce the incidence of fetal alcohol syndrome and the more subtle fetal 

alcohol effect. 

In addition, preventive counseling and brief interventions 

have been shown to be effective in decreasing progression to 

more severe alcohol or drug problems, which typically are 

less amenable to treatment. Brief interventions are timelimited, patient-centered counseling strategies that focus on 

changing behavior and increasing medication compliance. 

Brief intervention is not unique to the treatment of SUDs; in 

fact, this strategy is widely used by physicians to address other 

behaviors. For example, brief interventions are used to help 

patients change dietary habits, reduce weight, stop smoking, 

reduce cholesterol or blood pressure, and take medications 

as prescribed (Fleming, 2002). 

Brief intervention is useful in three clinical situations. First, it 

can reduce alcohol use and the risk of alcohol-related problems in nondependent drinkers who are consuming alcohol 

above recommended limits. The goal of brief intervention with 

this population is to reduce consumption or negative consequences, not abstinence. Second, brief intervention may be used 

to facilitate medication compliance and abstinence (noncompliance is a major issue with patients receiving medication 

for alcohol problems and co-occurring psychiatric disorders). 

Finally, brief intervention may be used to facilitate the referral of persons who do not respond to brief counseling alone. 

Services research shows that most patients who are referred 

for an assessment or counseling either do not schedule an 

appointment or fail to keep the appointment. Brief intervention 

can greatly facilitate this process and increase the probability that the patient will successfully follow through with the 

referral (Fleming, 2002). 

While the full range of risk factors for SUDs, including specific 

genetic markers, are still being elucidated, and the determinants of progression from substance use to misuse to abuse 

and addiction are under ongoing evaluation, it is clear that 

early recognition and intervention by physicians can be 

effective in decreasing progression from less severe to more 

severe SUDs. For example, there is evidence that brief interventions can reduce alcohol consumption to below hazardous 

levels for patients who are found to be engaged in hazardous 

or harmful drinking. 

Training programs should devote specific attention to building physicians’ knowledge and skills in these areas. For example, 

a required curriculum in screening, preventive counseling, and 

brief treatment interventions should be integrated into the standard curricula of all medical schools and residency training 

programs. Such a curriculum should outline the components 

of screening and brief intervention. Also, training in SUDs 

should devote attention to the effectiveness of office-based 

screening and interventions in primary care settings. 

As a requirement for graduation, medical students should 

demonstrate competency in screening, preventive counseling, 

and brief treatment interventions, and licensing examinations 

should include content and questions relevant to appropriate 

strategies for identifying and intervening with individuals who 

are at risk for or experiencing SUDs. Increased curricular 

content also should be available through continuing medical 

education (CME) programs. 

This objective has been endorsed by multiple medical organizations and public agencies, including ONDCP (in the 2004 

National Drug Control Strategy), AMA (in policy statements 

adopted or reaffirmed in 1979, 1981, 1991, and 2001), the 

American Society of Addiction Medicine (ASAM) (in 1987), 

and others. 

Identification and Management of 

Co-Occurring Substance Use and 

Medical or Psychiatric Disorders. 

Physicians should be able to identify and treat or appropriately refer patients with co-occurring medical and psychiatric 

conditions and SUDs. In addition, physicians should be 

prepared to provide ongoing medical monitoring and to 

address the needs of special populations, such as adolescents 

and older adults. 

Population studies consistently report high rates of comorbid 

medical and psychiatric disorders in patients with SUDs. For 

example, the Epidemiological Catchment Area and the National 

Comorbidity Studies report that 29 to 37 percent of patients 

diagnosed with alcohol problems have a co-occurring psychiatric disorder (most commonly mood and anxiety disorders, 

attention deficit disorder, and antisocial personality disorder). 

Similarly, alcohol or drug problems — as well as the route used 

to administer drugs (e.g., injection) — are associated with significant comorbid medical conditions such as hepatitis B and 

C, endocarditis, HIV/AIDS, tuberculosis, and cirrhosis. 

Co-occurring disorders can be difficult to detect because substances of abuse can cause symptoms that are time-limited 

but indistinguishable from those seen in many other medical 

and psychiatric disorders; for example, substance withdrawal 

or acute intoxication can mimic almost any psychiatric disorder. On the other hand, treating the co-occurring disorder 

can markedly improve the outcome of treatment for the SUD. 

14 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


Also, it is important to note that addiction to more than one 

substance is common among substance users. For example, 

nearly 35 percent of cocaine-dependent individuals are 

estimated to be alcohol-dependent (Carroll et al., 1998). 

Recognition of such comorbidities is an important factor in 

appropriate treatment. 

Although at present there is little formal training in dual diagnosis for health care providers of any discipline except psychiatry, the addition of this level of sophistication in training 

and clinical care initiatives can provide an important component to clinical care and improve patient outcomes. 

To assure that physicians achieve competence in this area, a 

curriculum addressing the medical and psychiatric 

comorbidities of SUDs should be integrated into the standard 

curricula of all medical schools and residency training 

programs. Similarly, curricula on the diagnosis and management of conditions that frequently coexist with SUDs, such 

as liver disorders, HIV/AIDS, and eating disorders, should 

contain information on the ways in which the symptoms, 

progression, and management of those disorders may be 

affected by an undiagnosed SUD. 

Increased training on co-occurring disorders also should be 

available through CME. Such training programs should devote 

attention to the recognition, treatment, or referral of comorbid 

medical and psychiatric conditions in patients with SUDs. 

This objective has been endorsed by multiple medical organizations and public agencies, including ONDCP (in the 2004 

National Drug Control Strategy), AMA (in policy statements 

adopted or reaffirmed in 1979, 1981, 1991, and 2001), ASAM 

(in 1987), and others. 

Prescribing Drugs with Abuse Potential and the 

Prevention of Prescription Drug Abuse. 

An essential area of competence for physicians is the ability 

to understand and the skills to address the clinical, legal, and 

ethical considerations involved in prescribing medications 

with abuse potential, so as to minimize the risk of inducing 

or perpetuating prescription drug misuse or abuse. 

Appropriate use of prescription drugs encompasses drug 

selection, communicating the treatment program to the 

appropriate individuals (patient, family, and other health professionals), correctly executing the prescription order, and 

monitoring the treatment program to determine if changes 

are needed to achieve optimum effectiveness and safety of 

drug therapy. Therapeutic use also involves avoidance of 

undermedication (underprescribing), overmedication (overprescribing), and drug misuse or abuse (AMA, 1981). 

Undermedication occurs when the patient fails to receive 

adequate drug therapy. For example, the negative impact of 

excessive concern about psychological and/or physical 

dependence is revealed by reports that acute and chronic 

pain often is inadequately treated. Relief of suffering is a 

legitimate goal of medical practice. On the part of the physician, failure to provide such relief may result from timidity 

(“pharmacophobia”), incorrect assessment of problem severity, or lack of knowledge or faith in the value of a drug, even 

when its administration is indicated. Patients contribute to 

undermedication when they fail to convey the severity of 

their symptoms to the physician, or to use a prescribed drug 

in the amount and for the duration of time prescribed (often 

for economic reasons). Thus, the factors contributing to 

undermedication are diverse and span the fields of medicine, 

psychology, sociology, and economics. 

Overmedication is the unjustified use of a drug. Overmedication occurs when a drug is used for an indication that is no 

longer accepted medical practice (obsolete), as determined 

by drug utilization criteria and standards; when there is no 

proper indication or sound scientific basis for such use; when 

administration continues despite proven ineffectiveness in 

curing the disease, disorder, or condition or ameliorating its 

symptoms; when more effective or less hazardous drugs are 

available; when the dose is excessive; when a combination 

drug is used even though only one of its components is indicated; or when more drugs are prescribed than are required 

(polypharmacy). 

Prescription drug misuse and abuse involve the use of a drug, 

usually by self-administration, in a manner that deviates from 

approved medical, legal, and social standards. The issues of 

drug abuse and overmedication often are related. 

That a small portion of medications are inappropriately 

prescribed by practitioners or misused or abused by patients 

and others raises an important policy issue: how to make 

medically useful drugs readily available for therapeutic use, 

while limiting access to them for non-therapeutic purposes. 

This policy mandate poses challenges very different from 

those of illicit drugs, because prescription drug problems must 

be prevented or curtailed without impeding patients’ access 

to needed medical care. 

To help physicians avoid the problems described above and 

achieve the desired level of competency, the conferees agreed 

that training in the clinical, legal, and ethical issues involved 

in prescribing drugs with abuse potential should be integrated 

into undergraduate, graduate, and continuing education 

programs in all specialties. Physicians who complete such 

training should be able to demonstrate that they have the 

knowledge and skills required to prescribe in a therapeutic 

manner to their patients, including patients at risk for, 

presenting with, or with a history of SUDs, so as to minimize 

the risk of inducing or perpetuating prescription drug misuse or abuse. 

WASHINGTON, DC • DECEMBER 1-2, 2004 15

OVERVIEW OF MEDICAL EDUCATION IN SUBSTANCE ABUSE


This objective has been endorsed by multiple medical organizations and public agencies, including ONDCP (in the 2004 

National Drug Control Strategy), AMA (in policy statements 

adopted or reaffirmed in 1979, 1981, 1991, and 2001), ASAM 

(in 1987), and others. 

What Are the Principal Challenges in 

Achieving These Competencies? 

Despite general agreement that many patients seen in primary 

care settings are at risk for or experiencing a problem related 

to use of alcohol or other drugs, many primary care physicians do not feel adequately prepared to address the issue. 

For example, a survey of Fellows of the American Academy 

of Pediatrics (2001) found that only 45 percent routinely 

screened their patients for alcohol use, and many felt inadequately trained to do so. Moreover, given the limited amount 

of time they have to manage acute, chronic, and preventive 

care, as well as the volume of information that inundates their 

practices, primary care physicians report that they often feel 

overwhelmed. For example, in a survey of family practitioners, many reported that managed care contracts require 

them to see as many as four or five patients per hour (American Academy of Family Physicians [AAFP], 2003), leaving as 

little as 12 minutes for each patient visit. 

Another significant challenge is the fact that the nature of 

drug abuse research is changing our understanding of the 

disorder. In addition, regional and national drug abuse 

patterns are constantly evolving; new drugs of abuse and 

new drug use technologies emerge with striking regularity. 

Such a rapidly evolving environment demands great flexibility of those who would understand and respond to it. 

Like patterns of drug abuse, the nature of primary care practice also is evolving rapidly. Over the past decade, changes in 

health care organization and financing have required physicians in traditional areas of primary care (such as family medicine) to assume responsibility for treating conditions — such 

as chronic pain or coronary artery disease — that previously 

were the province of specialists. On the other hand, physicians 

in some medical specialties (notably obstetrics/gynecology and 

emergency medicine) have become de facto primary caregivers 

for a significant number of patients. 

Finally, there is the problem that some physicians still do not 

regard drug abuse and addiction as biologically based medical 

disorders. It is interesting to note that opiate (Pert & Snyder, 

1973) and lipoprotein (Brown & Goldstein, 1976) receptors 

were identified at approximately the same time, yet met entirely 

different reactions on the part of the medical profession and 

the public. On the one hand, the identification of lipoprotein 

stimulated a massive research effort that resulted in the 

discovery of extraordinarily effective cholesterol-lowering 

drugs (Hebert et al., 1997), which are used extensively by physicians and accepted by the public. On the other hand, despite 

our new understanding of the contributions of receptors to 

the development of addiction, until very recently there has 

been little interest in developing medications to treat addiction and poor acceptance by physicians and patients of those 

already approved. 

16 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


PERSPECTIVES OF THE


PRIVATE SECTOR LEADERS


CONFERENCE CHAIR ADDISON D. DAVIS IV. 

We are going to begin the conference with a panel 

presentation that will give us a preview of some of 

the issues we will be discussing. We have three 

distinguished panelists: Dr. Bertha Madras, Dr. Sheldon Miller 

and Dr. Mark Kraus. We have asked each of them to provide their 

own perspective on the issues we are facing and to offer their 

insights as to possible solutions. They will look at undergraduate 

medical education, graduate medical education, and continuing medical education. We’ll follow that with a general discussion, 

so that each of you has an opportunity to contribute. 

Our first speaker is Bertha K. Madras, Ph.D. Dr. Madras is a 

professor of psychobiology in the Department of Psychiatry 

at the Harvard Medical School, and chairs the Division of 

Neurochemistry at the New England Primate Research Center. At the medical school, she is the Associate Director for 

Medical Education in the Division on Addictions, chairs the 

Faculty Affairs Committee, and is a member of the subcommittee of professors. 

Dr. Madras will be followed by Sheldon I. Miller, M.D., who is 

the Lizzy Gilman Professor of Psychiatry at the Feinburg School 

of Medicine at Northwestern University in Chicago. Until two 

years ago, Dr. Miller also was chair of that university’s Department of Psychiatry and Behavioral Sciences. He is currently a 

member of the board of directors of the Accreditation Council 

for Graduate Medical Education and a member of the board 

of directors of the American Board of Emergency Medicine 

and of the executive committee of that board. His other current positions include the board of directors of the American 

Academy of Addiction Psychiatry and the editorship of the 

American Journal on Addictions. 

Our third panelist is Mark L. Kraus, M.D., FASAM. Dr. Kraus 

is a general internist in private practice at Westside Medical 

Group in Waterbury, Connecticut, and Medical Director of 

Addiction Medicine at Waterbury Hospital. He also is Assistant Clinical Professor of Medicine at Yale University School 

of Medicine, and a Fellow of the American Society of Addiction Medicine. 

UNDERGRADUATE MEDICAL EDUCATION 

Bertha K. Madras, Ph.D., 

Harvard Medical School. 

This is a unique gathering. In my view, 

the institutions and individuals who are 

represented here can mount a significant response and play a pivotal role 

in reducing the medical and social 

problems contributing to and associated with drug abuse. 

I’d like to share my experiences in developing and presenting 

an elective course on substance abuse to the fourth year 

Harvard Medical School students. The background of this 

course is very simple. Dean Tosdan, then the Dean of Harvard 

Medical School, was approached by two CEOs who had family 

members with substance abuse problems. Both came to him 

with very profound complaints that the physicians who cared 

for their family members did not help their family members 

deal with the substance abuse problems. What they felt is 

that physicians in general are not being properly educated 

about substance use disorders. 

In response to this, the Dean developed a small committee and 

then a larger committee. Out of that came a number of initiatives, one of which was to develop a course on substance abuse. 

I was appointed to develop the course and to direct it, and to 

develop a public education program that involved a museum 

exhibit at the Museum of Science in Boston, as well as a CDROM for the public. There were other initiatives as well. 

The course is given in a one-month block during the last month 

of year four of medical training. It falls under the rubric of the 

advanced biomedical sciences curriculum. The idea is to reinforce the scientific basis of medicine for graduating medical 

school students. My charge is to present the basic biological 

principles and translate the information into medical practice. 

Although I had anticipated that most of the students interested in this course would be future psychiatrists or future 

WASHINGTON, DC • DECEMBER 1-2, 2004 17

PERSPECTIVES OF THE PRIVATE SECTOR LEADERS


addiction medical specialists, in fact, such students represented a tiny fraction of the people who signed up for the 

course. The vast majority were interested in internal medicine, OB-Gyn, surgery, emergency medicine, or just people 

who came to me and said, “I’m taking this course because I 

recognize the high prevalence of substance abuse problems 

in medical practice. I am insecure about how to diagnose 

substance abuse problems and how to manage patients with 

substance abuse problems. And I’m insecure about my 

understanding of the underlying biology and how to begin to 

explain it to my patients.” 

Initially, we developed what I would consider a very conventional course, a core curriculum taught by a cohort of at least 

fourteen of my colleagues and myself. I teach all the basic 

neurobiology. My colleagues teach screening, diagnosis, 

detoxification, and treatment of adolescents and adult populations with substance abuse problems. I present the didactic 

information about the history, legal issues, and neurobiology 

of substances. 

The course includes roundtable discussions, where the faculty 

discuss the overlap between pain control and opiate abuse, 

the risks of drug abuse to the developing fetus and child, 

gambling as an addictive behavior, research paradigms for 

investigating drugs, long-term effects of substances with 

regard to neuropsychological sequelae, as well as brain biology and cell and molecular biology. And we cover every single 

drug that we are aware of at the present time. 

The course has non-traditional features as well, which I would 

divide into two areas: student perspectives and learning 

perspectives. The most important challenge that I found in 

presenting the course was how to reduce the stigma of even 

considering this as an appropriate body of knowledge for 

physicians. 

We begin by asking the students to complete a questionnaire 

containing about 20 questions probing their attitudes towards 

substance abuse. This is done privately, to learn how they 

really feel. At the end of the course, they’re asked to bring 

their responses back to the class to see whether their attitudes have changed. Most of the students say they feel the 

course has helped them develop an understanding of addiction as a true medical problem and that in fact their attitudes 

have changed. 

We also deal with the students’ attitudes towards politically 

charged issues such as needle exchange, medical marijuana, 

and drug legalization. To do so, we use a debate format 

because it is important to have the students arrive at conclusions based on their understanding of the evidence. To the 

debate, the students bring their personal convictions about 

drugs, ranging from permissive to prohibitive. They debate 

the issues one by one. What is fascinating is that by the end 

of the debates, many students develop relatively conservative attitudes toward these issues. 

Finally, we focus on science and evidence-based medicine. 

We bring the discipline of addiction into mainstream medicine by looking at cellular and molecular biology, by looking 

at brain imaging approaches to understanding the influence 

of drugs. 

We offer unique perspectives by bringing students to a detoxification center and allowing them to interview patients who 

are undergoing the process of detoxification. Their stories 

occasionally have brought the entire class — as well as two 

instructors — to tears. 

The students also interview patients. In one case, we asked a 

surgeon to bring in a patient as well as a psychiatrist who’s a 

specialist in addiction medicine. The students heard the 

surgeon conduct a standard patient interview, juxtaposed with 

how a specialist in addiction medicine would interview the 

same individual. Then the students are given an opportunity 

to interview patients. 

We also bring in the former associate medical examiner of 

Massachusetts to present a dramatic set of slides on the 

pathology of substance abuse. Students who are not convinced that drugs have any malevolent effect on the body 

leave that class with their minds changed. 

Another core feature of the course is a discussion of the 

medical license, which is presented as a privilege. We 

emphasize that personal impairment jeopardizes the license. 

The Executive Director of the Physicians Health Service, 

which cares for impaired physicians, comes in to describe 

the program, the types of facilities that are available to help 

those who have personal problems or suspect a problem in a 

colleague. 

We bring in the Chairman of the Board of Registration in 

Medicine and discuss licensing and physician conduct. We 

also bring in a representative of the Drug Enforcement 

Administration to instruct students on the DEA vantage in 

terms of prescribing practices as well as how to stay off DEA’s 

radar screen. 

The course has been very successful. The evaluations have 

been very good, and I really enjoy the fresh perspectives the 

students have brought to it over the more than 10 years it has 

been offered. 

The most common feedback we receive from students is that 

all the members of their class should have taken the course. 

We have been discussing this with the Dean of Education at 

the Harvard Medical School. Part of the debate is whether it 

should be given in one solid block in the last year, of whether 

it should be divided across the four years to reinforce the 

message. I will leave you with that as an issue to discuss. 

18 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


GRADUATE MEDICAL EDUCATION 

Sheldon I. Miller, M.D., 

Northwestern University 

Medical School. 

From the standpoint of the future education of physicians about addiction 

issues, I see graduate medical education as a very important area for us to 

address. But first, because the people here are from very 

different backgrounds, I’m going to risk boring a few people 

by describing the structure of graduate medical education. 

Two organizations are involved with the production of specialists in American medicine: one is the Accreditation Council 

for Graduate Medical Education (ACGME), which has under 

its aegis 24 residency review committees. Those committees 

oversee more than 10,000 residencies and more than 100,000 

residents in the U.S. The ACGME reviews and accredits the 

programs where physicians train. 

The other important organization is the American Board of 

Medical Specialties, which brings together the boards that 

govern specialty practice. These boards set the standards for 

their specialties. 

It is fair to say that the structure of every single medical 

specialty in the U.S. is determined by the boards and the 

residency review committees. It is critical to understand this 

if we hope to move forward with physician training about the 

addictions at the level of graduate medical education. 

While there have been multiple efforts in this direction in the 

past, which have not met with total success, I do want to 

remind you that there have been some very positive outcomes. These provide an example and, perhaps, a “road map” 

of how we might navigate the complex, politically interdependent process required to achieve change in graduate 

medical education. I may be a little chauvinistic here, but I 

want to focus on the specialty of psychiatry, which has 

managed to make a great difference. 

If you have looked at some of the background material for 

this conference, you’ll notice that different medical specialties have widely differing levels of addiction content. The 

specialty that stands out by virtue of the fact that 95 percent 

of its training programs have significant addiction content is 

psychiatry. That’s not a result of anybody being particularly 

insightful, but of a lot of effort that actually achieved success. 

I raise it as an example for other specialties. 

Approximately 10 years ago, a process began in the same 

way this conference started: a group of interested individuals wanted to create a subspecialty of addiction psychiatry. 

Their reason was not to create a lot of specialists to treat all 

patients with addictive disorders, although they did want to 

develop experts to care for the really difficult cases. But their 

principal reason for wanting a subspecialty was to train educators and researchers, because medicine is a field that listens 

to its own subspecialists. This is true of every specialty: If there 

is a subspecialty group within the organization, it has an 

important voice, which simply doesn’t exist in organizations 

that do not have such subspecialties. So those of us who were 

involved felt it was very critical to create such a body. 

A lot of effort went on within the professional organization 

— in this case, the American Psychiatric Association. There 

also were very intense meetings with the American Board of 

Psychiatry and Neurology, which was the only avenue through 

which a subspecialty could be created. That went on for 

several years. We met...We talked...We researched...We 

talked...We met...We were disappointed...We were 

encouraged...All of it happened. And then, finally, it became 

clear that with just the support of the American Psychiatric 

Association — not enthusiastic support, but just some support 

rather than hostility — the American Board of Psychiatry 

and Neurology would be willing to create a subspecialty of 

addiction psychiatry. 

The moment that happened, the Residency Review Committee for psychiatry — which is the other side of this equation 

— became energized, because suddenly a whole new series 

of requirements had to be written. It quickly became clear 

that such requirements could not be written unless the issue 

was also addressed in the core requirements for the specialty. 

So the creation of the subspecialty not only led to what we 

were seeking, which was teachers and researchers, it also 

created an impetus for the field to recognize that there cannot 

be a subspecialty in the addictions in the absence of a core 

body of knowledge in the primary specialty. As a result, 

psychiatry developed requirements for the addiction content 

of core curricula, as well as a requirement for the amount of 

time spent in clinical experience for every single graduating 

psychiatrist. 

There still aren’t enough addiction psychiatrists that every 

program has one, but many medical schools around the country do have such subspecialists. Nevertheless, curricula have 

been developed. And even in those programs that do not have 

a subspecialist in addiction psychiatry, there is a body of 

educational material to support the program requirements. 

One of the advantages of having these requirements adopted 

by the board and the residency review committee is that if a 

training institution fails to satisfy the requirements, it may 

lose its residency program. So meeting the requirements no 

longer is optional; it is mandatory for every graduating 

resident. That would be the ideal for all medical specialties. 

I offer this as a model and as a challenge to other specialties, 

so that their boards, their residency review committees, their 

WASHINGTON, DC • DECEMBER 1-2, 2004 19

PERSPECTIVES OF THE PRIVATE SECTOR LEADERS


professional organizations, might come together and hopefully do some of the same things. Obviously, the exact content 

is going to differ for each specialty, but there is a core body 

of knowledge that won’t be different and thus should be available to every graduate physician as they go through their 

specialty training. 

Let me be clear: what we achieved in psychiatry required 

considerable time and effort, but it is very doable. The group 

of people at this conference have the expertise and authority 

to achieve similar progress in other specialties. In many ways, 

it is easier now, because the whole field has moved forward. 

The stigma is still there, but it isn’t quite as bad as it used to 

be. We’ve seen tremendous strides in understanding the 

science underlying the addiction process. As a result, we ought 

to be able to make significant progress in graduate medical 

education. 

CONTINUING MEDICAL EDUCATION 

Mark L. Kraus, M.D., FASAM, 

Yale University School of 

Medicine. 

We’ve heard from an expert in undergraduate medical education, and 

we’ve heard from a leader in graduate 

medical education. One of the lessons 

I took from both is that the teaching 

of the addictions in medical schools and residency programs 

can be strengthened, and that progress is possible. Meanwhile, the majority of our attending physicians — the population I represent — have not received any formal training in 

screening and brief intervention for substance use disorders. 

Many have prejudices towards this population, not believing 

at all that substance use disorders are brain diseases, but just 

willful misconduct. 

Moreover, today’s private practitioners are putting in very 

long hours, because medical economics dictate the reality of 

“volume medicine” in order to cover the overhead costs and 

soaring medical malpractice premiums. There is precious little 

time to attend continuing education programs at their hospitals, as they used to do, and even less time to travel to conferences because of the obvious costs and loss of income that 

entails. 

As a result, computer-based CME programs have gained 

popularity. But after a long day, or night, sitting in front of a 

computer to take a clinical course on addiction medicine may 

be the last thing such a physician would want to do. 

Given these realities, how can we persuade these private practitioners to achieve the core competencies we’re advocating: 

do we use the “carrot” of compensation or the “stick” of 

mandates? 

Whatever training we offer as training in the core competencies 

for this group of physicians must be efficient: time-efficient, 

cost-effective, and clinically practical. 

We have tremendous leaders at this meeting. We have people 

who have done serious work on this problem. We even have 

scientific evidence that supports what we’re saying. Yet, 

despite all of these things and all the wonderful work that’s 

come before us, the change we’re seeking hasn’t occurred. It 

just hasn’t happened. We must ask ourselves and our organizations and our associations and agencies, why not? And how 

can it be righted now? How can we actually achieve progress? 

It’s our responsibility...our responsibility. 

When we leave this room, it’s our responsibility to make sure 

change happens. I hope that each and every one of you leaves 

this room today not thinking that it can’t happen, but saying 

that it will happen. Dr. Miller said it well: If it isn’t going to 

happen here, it’s never going to happen at all. 

GENERAL DISCUSSION 

David C. Lewis, M.D., Chair, 

Physicians and Lawyers for 

National Drug Policy. 

Dr. Kraus is right: there has been a kind 

of repeat performance every decade 

since the 1970s. The first occurred at 

the Rockefeller University in the early 

1970s. I happened to be there as a 

youngster, accompanying the chair of the Department of 

Medicine at Harvard, who brought me to listen. That conference decided that medicine — mainstream medicine — 

should play a larger role in treating the addiction. 

The next effort, in the 1980s, was at an AMERSA conference 

at the Annenberg Center, where competencies were defined 

for each of the specialties to guide curriculum development. 

In the 1990s, there was the Macy Conference, which I chaired, 

and which addressed the knowledge needs of primary care 

physicians. 

So, with all this effort, you ask: Why didn’t something happen? Well, the culture wasn’t right. So solutions have to involve 

changing the culture, and finding approaches that are attuned 

to the culture. 

Each of past the conferences, as this one will, devised very 

specific approaches to changing the educational system. We 

can talk about carrots and sticks, but I think unless such 

changes are presented at the highest levels of the public health 

system in a forceful and continuous way — in the same way 

that we developed a real understanding of depression and 

mental health as disorders that could be treated in the mainstream of medicine — we’re not going to get there. 

20 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


No matter what we do here, I think we also have to make 

recommendations to the greater society — the greater culture 

— as to what we can do as health professionals to educate 

the public. And that must involve the government officials 

here as well as the health officials. 

Beverly Watts Davis, Director, 

Center for Substance Abuse 

Treatment. 

Dr. Lewis, I think you’ve made a great 

case for why prevention has to play a 

very primary role in what we do. It’s 

what you describe as a strategy, a 

universal strategy, in communities that 

are trying to change norms and attitudes and behaviors. 

Physicians have an incredible ability to make that happen. In 

prevention, we’re hoping that medical students receive better 

training in substance abuse prevention, which should be easy 

because it fits within their norms. 

We can continue to treat people for alcohol and drug problems, but unless we begin to change the culture in which 

people live, we will always be left to treat these disorders 

rather than preventing them. Our hope is that we will be able 

to weave prevention into our recommendations for medical 

education — there are curricula that actually have begun to 

do that in medical schools. I hope you will take a look at 

prevention as an essential part of medical education. 

Lawrence S. Brown, Jr., M.D., M.P.H., FASAM, 

President, American Society of Addiction Medicine. 

Sometimes it seems to me that we avoid the most difficult 

factors that influence medical education. One of those is the 

influence of professional peers and teachers who say that 

this is or is not a good thing — that we have too many competing priorities to address alcohol and drug problems. 

So I think we need to look at what influences the content of 

undergraduate, graduate and postgraduate medical education and medical practice. Because if we don’t do that, we’re 

going to continue to miss an opportunity to influence change. 

Winston Price, M.D.,


President, National Medical Association.


Attitudes are influenced tremendously by the individuals who 

sit at the table. While it is encouraging to see a mix of individuals here to address the issue, we all know that the individuals 

who sit around the table to develop curricula or to decide 

what becomes mandatory for the educational process do not 

reflect all of America’s populations. And so they lack some 

important perspectives about how substance abuse impacts 

the everyday life of various communities. 

Even if you accept the fact that there are no socioeconomic 

or ethnic boundaries with respect to substance abuse, I think 

that medical students and residents are influenced by the 

social mix of individuals that they see on the floors. And when 

the majority of individuals that they see affected by substance 

abuse are not the individuals who are their peers in medical 

school or residency training, they’re going to have a different 

view of what’s important. 

I can assure you that in municipal hospitals throughout the 

United States, and particularly in the African American and 

Latino communities, there is an inadequate mix of individuals taking care of the neediest patients, many of whom need 

substance abuse prevention or treatment. Until we address 

that social issue — until medical schools, residency programs, 

and faculty represent the true mix of America — we’ll continue to sit around tables with very learned individuals trying 

to come up with solutions. So I hope that is factored into the 

mix as well in order to come up with realistic solutions. 

Richard Suchinsky, M.D.,


Associate Director, Department of Veterans Affairs.


I’d like to go back to Dr. Madras’ program at Harvard, which 

is remarkable achievement. What impressed me most is that 

it gives medical students an opportunity to interview patients 

in depth and to obtain a detailed history. That’s something that 

usually does not happen. The opportunity for a physician, 

particularly a primary care physician, to be able to spend 

enough time with a patient to get a detailed history is beyond 

the life I know. Dr. Kraus alluded to that as far as post-graduate 

education is concerned. But in the actual practice of medicine, unless you are a psychiatrist who is actively involved in 

doing intensive psychotherapy, the chances of your being 

involved in a practice situation that allows you to do anything in-depth with a patient as far as addiction problems 

simply doesn’t exist. 

In fact, in most public institutions, even the role of the psychiatrist is seen as writing prescriptions. Any time he or she 

spends talking to the patient is considered wasted time. Tremendous forces are impinging on the profession right now, 

and they work against being able to intervene effectively with 

substance use disorders. 

William O. Vilensky, D.O., R.Ph., J.D., Representing 

the American Osteopathic Association. 

I have a rather unique perspective on this discussion. Twentythree years ago, the New Jersey State Medical Board retained 

me as a consultant in a case involving two physicians who 

were overprescribing amphetamines. Both received harsh 

penalties, including license suspensions and fines in the range 

of $25,000 to $50,000. That’s tantamount to the loss of their 

practices. 

WASHINGTON, DC • DECEMBER 1-2, 2004 21

PERSPECTIVES OF THE PRIVATE SECTOR LEADERS


Andrea G. Barthwell, M.D., FASAM, former Deputy 

Director for Demand Reduction, Office of National 

Drug Control Policy. 

Earlier this year, I was at a conference and heard Dr. Sheila 

Blume remark that we use “addict” or “alcoholic” as a descriptor, not a diagnosis. When we say someone is a 43-year-old 

alcoholic, we’re using that label to describe who he or she is. 

Then we don’t feel obligated legally, morally or ethically in 

the same way we would if we described the patient as a 43­

year-old diabetic. 

We will not have a significant shift in the way in which we 

approach education at all levels of training, or even in the 

provision of care, until we have shifted these terms from being 

descriptors to diagnoses. That really is the nature of our task 

here. People reject the call to leadership all the time, but even 

when it’s rejected, the responsibility doesn’t go away. As 

physicians, we have to assume that responsibility to lead. 

We know that budgets are tight. There’s no new money on the 

table for this. No one is clamoring for this content in medical 

education. Few doctors accept this role. The drug addiction 

treatment enterprise — not addiction medicine but the drug 

addiction treatment enterprise — is not welcoming. And even 

when physicians do care about this issue, we’re generally 

characterized as indifferent to it. 

But we physicians are constantly being required to adapt and 

adjust to new conditions, new paradigms, new settings. We 

can do this. What’s needed is to find a way for physicians to 

contribute that’s consistent with our skills, interests, abilities, 

and settings. We’ve got to start early and we’ve got to provide 

information at all levels of training and practice. And we’ve 

got to work to create a new standard of care, or the situation 

is not going to change. We’ve got to stay engaged for the 

long haul. For example, we have to find individuals who are 

willing to cultivate long-term relationships with legislators 

and other individuals. And we have to use our combined 

authorities to advocate for funds, to educate for change, and 

to communicate the need to do this. 

But we’re in a very unique situation here, because this is a 

White House sponsored event. We have attention at the top. 

We have concerned members of Congress who are represented here. While it is true that we’ve had similar meetings 

before, we’ve never before had all these conditions present 

at the same time. We’ve hit the jackpot this time. 

So we need to leave here with a strategic plan or a blueprint 

for our work, and we need to work with our Federal partners 

to excite them about the potential for change. If we do that, 

whenever they can find a way to support our initiatives, they 

will do so. We have to be very clear in articulating what initiatives we want supported — what will get us to the place we 

need to be. And we have to be sure that when we go back to 

our organizations, we work together in ways that we’ve never 

worked together before. That’s my vision for this meeting. 

Afterward, I was asked what I thought of the outcome. I 

replied that I thought it was too harsh. And I said they should 

take a course on the proper prescribing of controlled substances, because doctors don’t get this kind of training as 

part of the core curricula of osteopathic or allopathic medical schools. As a result, they’re sitting ducks for the scammers 

and others who abuse or divert drugs. Plus, they don’t know 

enough about medical recordkeeping to understand how to 

properly document what they’re doing. 

The New Jersey Board of Medicine and the Deputy Attorney 

General asked me to set up such a course in New Jersey. The 

Federation of State Medical Boards heard about the course 

and invited me to address one of their annual meetings. 

The course has been successful. How do I measure success? 

Among the 650 physicians who have taken the course, there’s 

been almost no recurrence of problems. I’ve since retired, 

and the course is no longer offered, but about a year ago we 

put it on DVD, and that has been successful too. So there are 

models of successful continuing education programs [also 

see the description of the model continuing education 

program in the Resources section of this report]. 

22 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


PERSPECTIVES OF THE FEDERAL LEADERS


A number of distinguished leaders of the Federal health agencies participated in the conference and their presence 

provided momentum and direction to the work of the conference. Summaries of their remarks follow. 

JOHN P. WALTERS 

DIRECTOR, NATIONAL 

DRUG CONTROL POLICY 

In my office, we believe in the institution of medicine — we believe in 

your work and achievements, which 

are manifested in the millions of 

people who are in recovery, the vast 

majority of people young and old 

who don’t use and abuse substances — and in the communities that are reaching out and that are linking people together. 

What we’re about here is accelerating that effort. We’re all 

frustrated at the number of people who still suffer. We’re frustrated that the knowledge needed to help them is not always 

applied effectively in key sectors. I appreciate your willingness to work with us on trying to change that. Many of you 

know a lot about our work at ONDCP. Others have been less 

involved. As a brief sketch of how this fits into government 

policy, I wanted to give you the courtesy of trying to make 

that clear myself. The President has repeatedly said that what 

he wants done on this issue is a return to balance, a return to 

a focus on both reducing the demand for and the supply of 

drugs. He is aware from his time in government at the state 

level and his knowledge of what’s happened nationally that 

we have had a history as a Nation of lurching from one thing 

to the other. As Americans, we want to have something that 

we can just do and get it over with and make it better. And 

we try to grab one thing and focus on that. 

The problem is that we have to focus on the right things if we 

are to make a difference. In our field, we have lurched from a 

focus just on interdiction, to a focus only on law enforcement, and then just on prevention or treatment. What we 

learned in that process is that we have to do all of these things. 

If we take seriously the fact that this is a supply and demand 

problem, if we take seriously the health implications of the 

problem — which I think are more and more widely accepted 

— we have to be able to cut off the easy availability and the 

marketing of dangerous addictive substances, while at the 

same time treating those who are dependent and need 

services and also addressing the needs of our young people 

who are exposed to these substances while they are still 

passing through adolescence to adulthood. 

Having said that we know a lot about what we need to do is 

not to say that we don’t believe in research. At the Federal 

level alone, we are spending about a billion and a half dollars 

a year on research. One of the issues at the center of this 

conference is how we can take the knowledge derived from 

this research and make it more salient to those who need it 

and can use it more effectively. 

We have had some successes. For example, when we started, 

the President set a goal of a 10 percent reduction in drug use 

in two years and a 25 percent reduction in five years. We met 

the first goal in 2003, when the Monitoring the Future survey 

reported an 11 percent decline in teen drug use from the 

baseline year of 2001. 

This experience affirms our belief in the principle that when 

we take an issue seriously and commit to sustained action, 

we can achieve success. 

We also have tried to build into our National Drug Control 

Strategy a greater appreciation of the public health dimensions of substance abuse. Those of you who work in the field 

know this very well. But I do not believe — and the President 

does not believe — that our policies have adequately reflected 

that understanding. I think part of the challenge involves 

education as well as programs and policies. 

We are trying to educate people that there is a window of 

opportunity during youth, and that the initiation of use of 

dangerous addictive substances in the pre-teen and teenage 

years is directly related to the nature and magnitude of the 

problem we have today. The promise is that if we do a better 

job of limiting the number of young people who are exposed 

to substance abuse, we will not only stop the immediate consequences, but we can change the face of the substance abuse 

problem in the country for generations to come. 

WASHINGTON, DC • DECEMBER 1-2, 2004 23

PERSPECTIVES OF THE FEDERAL LEADERS


We’ve also used the concept of contagion in explaining some 

of the public health measures that we think apply. While we 

recognize that substance abuse is not spread by bacteria or 

other biological infectious agents, it is spread by behavior. 

When young people begin to abuse these substances, they 

bring that behavior back to their friends and encourage them 

to begin using. Because peer relationships are an important 

part of adolescent development, this kind of behavior is 

important because it forces young people to choose between 

emulating the drug-using behavior or losing their friends. 

If we are going to be effective at dealing comprehensively 

with addiction, once young people break the boundary of 

prevention, we have to look at intervening. At that point, they 

have become the “agents of infection” for this behavior with 

their peers and siblings and other members of the community. 

So we’re trying to identify areas where we can intervene. That’s 

why the President has talked about setting aside additional 

money to support random student drug testing in schools, 

where communities make that decision themselves, to use a 

measure that we believe has shown itself to be effective in 

preventing substance abuse among adults in the workplace, 

the military, and transportation safety positions. 

What it also allows us to do is to create a consensus in the 

community that we’re not going to look the other way, and 

that we are going to use some of the tools that we have used 

to change the face of victimization of childhood disease in 

this regard, in which many states require testing for tuberculosis and other infectious diseases as a condition of entering 

school. We know that the infected student needs to get care 

if he or she is to have optimal chance of recovery. And we 

know that, if left untreated, he or she will infect others. 

What testing does in the communities where I have seen it 

implemented is that the community comes together and says, 

“We’re not going to look the other way anymore. We’re not 

going to not do what we can do. We’re not going to watch 

another child be victimized.” 

We also are trying to help shape wider perceptions with a 

public education effort that many of you have seen in our 

National Youth Anti-Drug Media Campaign. In addition to 

the prevention messages that we have used in the past and 

will continue to use, this year we began to sponsor a series of 

ads focusing on intervention for young people and for their 

parents to break through the stigma and denial that is a hallmark of this disease. The terrible thing about this disease is 

that the people who suffer from it usually do not recognize 

their problem. We know that, but what are we going to do 

about it? 

We want to fulfill the vision the President offered in his State 

of the Union address, when he challenged us to provide treatment to those who suffer from substance use disorders. The 

President believes that you can’t be serious about demand 

reduction if you aren’t going to treat the people who have 

the disease of addiction. We all understand the importance 

of prevention. But the President understands that there are 

millions of people in need of treatment and in recovery. We 

know how to do this. We ought to demand from ourselves 

that we do it more aggressively and on a wider scale. 

The President asked my office to estimate the “treatment gap.” 

The Household Survey told us that, each year, there are 

roughly 100,000 Americans who seek treatment but do not 

receive it. 

Next, the President asked the average cost of a treatment 

episode. At the time, Federal data showed a cost of $2,000. 

And that’s how we came up with the $200 million request for 

the President’s Access To Recovery program: It’s $2,000 per 

treatment episode, multiplied by the 100,000 persons who 

need treatment but cannot obtain it, for a total of $200 million. 

In short, the President proposed to close the treatment gap 

unilaterally with a Federal appropriation. We’ve already received 

the first $100 million, and I’m confident we’ll get another $100 

million. 

Our plan uses vouchers not only to pay for treatment slots, 

but to purchase services for individuals. Hopefully, the plan 

will allow more people to become providers, including mainstream health organizations in addition to those who already 

are providing specialized treatment services. 

The voucher program allows us to help the states fill treatment gaps. Whether the issue is support for families with 

dependent children, or job training, or help with housing and 

other kinds of transitions, the voucher program is designed to 

fill some of those gaps to allow the existing service providers 

to deliver more comprehensive, effective care. In addition, the 

program allows states to add particular kinds of capacities to 

meet local needs. Because we’re interested in measuring 

outcomes, we also want the states to provide an evaluation 

component. 

I started out by talking about the 100,000 persons who want 

treatment and cannot find it. But what about everybody else? 

The same Household Survey that gave us the 100,000 estimate tells us that roughly 90 percent of persons with substance 

use disorders are in denial. They are convinced that they don’t 

have a problem and don’t need help. 

With our intervention ads on television, we wanted to start a 

conversation through which we can change the public’s 

understanding of our societal responsibility with regard to 

substance abuse. Not just the important matter of reducing 

stigma, but using stigma in a different direction. For example, 

we want to say that there is something wrong if you look the 

other way when you know someone is suffering from substance abuse. If you understand that this is a disease, a decent 

society does not let someone get sicker without offering help. 

24 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


This is not about minding your own business. This is not about 

a lifestyle choice. This is not about freedom in a kind of insane 

way that means self-destruction. This is about recognizing 

the presence of a disease, and that an important dimension 

of that disease is denial. One way to get help for those who 

suffer from this disease is for others to put an arm around 

them and say, “We’re not going to let you continue to get 

sicker. We’re going to support you in getting well.” We know 

that where such care is available, people do get help and do 

become important contributors to society. In fact, individuals who are themselves in recovery are some of the most 

effective at reaching out to others. 

We also are concerned about the growth in the diversion of 

prescription pharmaceuticals as sources of drugs of abuse. 

We believe that these medications can be a Godsend to those 

who suffer from chronic pain. But the growth in abuse of 

these medications is something we need to come to grips 

with. Some of that has to be done with regard to education. 

ONDCP is supporting efforts to help states set up prescription monitoring systems, which will allow physicians and 

pharmacists to see whether legitimate prescriptions have been 

written, to see whether the individual involved has been 

obtaining excessive amounts of prescription medications from 

multiple sources, and to allow us to prevent prescription drug 

abuse and trafficking. 

The same Household Survey that told us we had achieved 

declines in teenage drug use also warned us that one in 10 high 

school students reported using Vicodin without a legitimate 

medical purpose. That’s a pretty alarming rate of abuse of a 

particular prescription product. As we see the introduction of 

more powerful and necessary substances for the treatment of 

various conditions, we’ll also have to deal with the diversion 

and abuse of those drugs. I think part of that requires education and working with institutions that can be of help. 

We’re also going after those who divert drugs through Internet 

purchases of pharmaceuticals. If you have an e-mail account, 

I’m certain you have been offered controlled substances without the controls. We are working to shut down such sites and to 

bring those who operate them to justice. We are not opposed to 

Internet marketing of over-the-counter and prescription drugs 

if it’s legal. But obviously if you’ve seen some of these e-mails, 

the intention is to suggest that you can do something that you 

shouldn’t be doing if you simply click on their link. 

We already know, as you know, that individuals who abuse 

alcohol and other drugs are more likely to be victims of 

accidents and violence, and to experience chronic illness. 

We know that these individuals require a variety of care, 

much of which is supported by public resources. They need 

support in the workplace, in the family, and in their faith 

communities. They need support through drug courts and 

diversion programs. They also need help from the health 

care community and medical institutions, which have an 

opportunity to reach out. 

We know that, of the estimated seven million people who 

need addiction treatment, about 23 percent are adolescents. 

Many of these young people regularly see pediatricians and 

family physicians, or they end up breaking arms and legs and 

coming to emergency departments. If we fail to screen them 

and get them the care they need, an enormous number of 

lives will be progressively damaged as time goes on. 

What do we have in mind? And what would we like the medical community to consider, based on our conversations with 

many of you and the conversations we hope to have during 

this meeting? 

First, we’d like to find better ways to use medical institutions 

to help us address substance abuse. Medical schools and 

organizations already provide enormous support for research, 

for prevention, for intervention, and for treatment. With our 

partners at the Department of Health and Human Services, 

we recently awarded a series of grants to support the teaching of screening, brief intervention, and referral techniques 

in major medical centers across the country. 

It’s a small trial. I recently visited one of the grant recipients 

— Ben Taub Hospital in Houston — where staff will screen 

every patient coming through the shock trauma center, which 

sees about 250,000 patients a year. Every one of them will be 

screened. Those who need substance abuse treatment will 

be referred to appropriate levels of care. 

Over the course of the award period, Ben Taub Hospital will 

expand the screening beyond its shock trauma center to its 

satellite health clinics, resulting in the screening of roughly a million people a year. We believe that’s the future, and we’d like to 

see that happen in more places. It requires a linkage. It requires 

support for care. It requires applying the research and knowledge we have that intervention is inexpensive and effective. 

Second, we are asking for your help in addressing the need to 

improve the initial preparation of medical professionals, as 

well as their ongoing education. Most people that I talk to in 

medicine sooner or later lament that the level of training in 

and understanding of substance use disorders is too limited. 

As a result, many physicians do not have significant exposure to teaching about the identification and management of 

substance use disorders during their undergraduate and 

graduate education. For many, their continuing medical education does not include systematic exposure to professional 

information that would help them acquire the knowledge and 

skills they need to help their patients who are at risk for or 

suffering from these disorders. 

I know that some of the obstacles to changing this situation 

involve more than lack of knowledge. Some are based on the 

idea that, if I turn over this rock and find what I expect to 

WASHINGTON, DC • DECEMBER 1-2, 2004 25

PERSPECTIVES OF THE FEDERAL LEADERS


find, what am I going to do? How do I refer people? How do 

I deal with a non-compliant patient when I understand that 

denial is a central feature of their disease? Well, that’s a part 

of education. As you know better than I, substance use is not 

the only area where this phenomenon exists. But we have to 

address it. 

In this meeting, we hope to build on what you’ve already done. 

We know that a lot of work has been done. For example, the 

American Medical Association’s policy statement on the 

physician’s responsibility for dealing with substance abuse 

was adopted in 1979 and disseminated through grants from 

the Department of Health and Human Services. The 1994 

Macy Conference on Training Primary Care Physicians About 

Substance Abuse — chaired by Dr. David Lewis, who is with 

us today — took additional important steps. Project Mainstream 

— which represents a collaboration between the Association 

for Medical Education and Research in Substance Abuse, the 

Substance Abuse and Mental Health Services Administration, 

and the Health Resources and Services Administration — 

also was a critical step in moving this process along. In 2002, 

Project Mainstream published a series of detailed objectives 

for physician knowledge and skills in addressing substance 

use disorders. 

Our task is to implement this important work. And we’d like 

your advice on how we can do that and do it as aggressively 

as possible. 

I’ve talked longer than I intended to, but I wanted to give you 

a sense of what we see that we’re trying to do, how we’re 

trying to bring the parts of the Strategy together. We’re not 

just doing a bunch of independent things; we want them to 

add up to something. We’re after a kind of institutional integration, and we believe it’s possible. More important, my boss, 

the President of the United States, believes it’s possible. And 

he expects us to do it. 

NORA D. VOLKOW, M.D. DIRECTOR, NATIONAL 

INSTITUTE ON DRUG ABUSE 

Untreated addiction has devastating consequences. It has been estimated that abuse of alcohol and 

legal and illegal drugs costs this 

country $486 billon a year — $486 

billion! The costs are so large because the consequences affect individuals in a wide variety 

of ways, including the disruption that the process of addiction produces in behavior and in the life of the person, as 

well as the medical consequences across the whole body of 

the individual, and the social effects for the individual and 

society — all of which directly affect the economy. 

We are here to talk about how we can engage the medical 

community in general to help us deal with the problem of 

addiction. One of the problems has been the belief for many 

years that drug addiction was a person’s bad choice in terms 

of making the decision to do something by their own will to 

take drugs. However, it is now clear that this is not the case. 

While choice is involved the first few times an individual 

decides to take a drug, once that person becomes addicted, 

it’s no longer a choice. 

I always put in parallel the paradigm that no one chooses to 

become addicted, just as no one — no one — chooses to 

develop lung cancer. Of course, the person does initially 

choose to smoke and then may end up with lung cancer, but 

it is not a “choice.” The same process applies to addiction. 

With technology such as imaging, it has become evident that 

drug addiction — like any other medical disease — involves 

very specific changes in the function of an organ: in this case, 

the brain. The brain is much more complex in its functioning 

than any other organ. This is illustrated in Figure 1. I am 

showing you images of a normal person and of a person who 

has suffered from a myocardial infarct. No one will doubt 

that a myocardial infarct is a disease; you can do imaging 

and see exactly where the damage to the heart is. 

Figure 2 shows a healthy heart. You see the consumption of 

sugar; that is what the red is all about. When the heart is 

damaged, the damaged tissue can no longer consume glucose 

sugar. This is how you can actually and very accurately depict 

what the abnormality is. The result with the heart is very 

easy to predict. The heart just pumps; it’s a pump. When you 

have damage to the tissue, it no longer pumps, and the blood 

is not distributed throughout the body. 

The brain is much more complex. But just as you can document exactly where the abnormality is with the heart, you 

can do that in the brain of an addicted person. And that’s 

what you see in Figure 3: this is the brain of a normal individual and this is the brain of an addicted person. In the brain 

of the addicted person, we see a very significant decrease in 

function in glucose consumption. 

It so happens that this area of the brain is the area that 

ultimately allows us to exert inhibition of our actions. It’s like 

the brain of our system. So when we are faced — and we all 

are faced on a daily basis — with things that we want to do 

but know we shouldn’t do, our ability to control our urges is 

basically a function of how well this area of the brain is 

functioning. 

Well, guess what? This area is not functioning well. It’s as if 

you’re driving a car and you see a cow in the middle of the 

road. You want to brake, because you don’t want to hit the 

cow, but your brakes are not working and you are going to hit 

the cow. That’s exactly the same process in terms of what 

26 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


occurs in the brains of individuals who are addicted, because 

one of the targets is the area of the brain that allows us to 

assert inhibitory control. 

This could explain, for example, why a drug addict tells you, 

“Doctor, I don’t want to take the drug. I want rehabilitation to 

work. I promised my wife I won’t do it. I promised my children I won’t do it.” The patient then leaves rehab, and within 

24 hours, he’s taken the drug. And the patient says, “I didn’t 

even realize it.” 

This phenomenon can be very difficult to understand because 

when we’re not addicted, we are able to control our actions. 

It is very difficult to comprehend that someone cannot do so, 

and this has caused difficulty in conceptualizing drug addiction as a disease rather than a wrong choice. We all are used 

to making choices, and we don’t understand what it means 

to have an area of the brain that allows us to make choices 

disrupted by the effect of exposure to a drug. 

Another aspect that is extremely important in terms of the 

involvement of the medical community is that drug addiction is not just a disease, it is a developmental disease. That 

is to say, it is a disease that begins early in development of 

the individual — usually during adolescence and, unfortunately, sometimes during childhood. This is illustrated in 

Figure 4, which plots the age at which young people develop 

addiction to marijuana. As you can see, the age when the 

diagnosis is first made peaks around 18 to 21 years of age. 

Even though an individual can become addicted at almost 

any age, the probability of becoming addicted decreases 

dramatically after 25 years of age. 

Why is this so? It is likely to be a function of multiple variables, 

including the fact that during the developmental period, the 

brain is not yet fully formed. And areas of the brain, such as 

the orbital frontal cortex and the frontal cortex, are not fully 

developed and will not develop fully until the early twenties. 

Thus, an area that allows the individual to control behavior 

and exert inhibition and judgment is not properly formed. 

The other aspect that is very important for us to understand 

is that the effect of a drug on an adolescent’s brain, in terms 

of the plastic changes produced, are different from the effects 

of the same drug in an adult. Although this area has not been 

properly investigated, recent animal studies are showing that 

when nicotine is administered during adolescence, it produces 

long-lasting changes that are not seen when the same dose 

of nicotine is administered to an animal that no longer is an 

adolescent. 

Moreover, the changes in the adolescent animal are associated with a higher propensity to administer nicotine. Of 

course, this could explain why adolescents become addicted 

to nicotine much faster than do adults. The research shows 

that adolescents require a much shorter period of time and 

much lower doses of cigarettes to become addicted. The 

reason I am highlighting this fact is because it brings forth a 

unique opportunity for the clinical community — especially 

pediatricians — to do very early interventions, not only to 

detect early drug use but also to make an early diagnosis and 

to guide the patient to proper treatment. 

What do we know about why we become addicted? This has 

become a very important aspect of our research because it 

provides us with targets, both for prevention and for treatment. In fact, we know a lot. Figure 5 illustrates one of the 

processes that are very important in terms of triggering the 

changes in the brain that are produced by chronic exposure 

to drugs, leading to addiction. 

That is to say, people take drugs because of chemistry rather 

than that the drugs make them feel good or help them experience new things. Drugs have the ability to produce these 

sensations because they increase levels of the chemical 

dopamine. All drugs of abuse — both legal (like nicotine or 

alcohol) or illegal (like marijuana or cocaine) — increase the 

level of dopamine in the brain. 

Now, dopamine is not present in the brain to make us feel 

good when we take a drug. Dopamine is in the brain to signal 

events that are salient to our survival. So when an action is 

extremely important to survival, dopamine serves as a liberator. Think for a minute about the things that actually are 

important for survival. The first is food. When an individual 

sees food or eats, the level of dopamine goes up. That’s the 

way the brain signals that this is salient and that the action 

should be repeated. Sex is associated with an increase in 

dopamine and that, in turn, motivates the behavior to seek a 

partner and to ensure that the species will procreate. 

As primates, social interactions are among our most important drives. They are extremely important because for our 

survival we need one another. That enhances dopamine. It 

so happens that drugs directly activate the system through 

which nature assures that we will repeat behaviors. But the 

drugs do this in a way that is qualitatively and quantitatively 

different than other dopamine enhancers. 

Look at Figure 6, and what do we see? First, that these stimulant drugs will overwhelm any natural reinforcer. The natural 

reinforcer has no chance to compete with a stimulant that 

will be perceived as salient, as a drug is. But our brains and 

our biological systems try to maintain a balance, which in 

medicine we call homeostasis. A change like those induced 

by drugs leads to adaptations as the brain tries to compensate. This is what initiates the process of drug addiction: the 

adaptation in an effort to achieve balance. 

So what do we see then in the brains of people who are addicted? 

When you look at the systems that are regulating the signaling of dopamine (Figure 7), there is a cell transmitting 

WASHINGTON, DC • DECEMBER 1-2, 2004 27

PERSPECTIVES OF THE FEDERAL LEADERS


dopamine to another cell. This transmission is modulated by 

receptors. When people become addicted, the receptors shut 

down as part of the body’s effort to maintain balance. We see 

this with cocaine, methamphetamine, heroin, and alcohol. So 

one of the brain’s adaptations that triggers the whole process 

of addiction is an adaptation brought about because of 

increases in dopamine, which leads to the very significant 

reduction in receptors. That reduction, in turn, affects the 

way the individual responds to natural stimulants. This is one 

of the processes that ultimately lead to the compulsive use 

of drugs. But drugs not only produce addiction, they also 

affect the body in other ways. 

Director Walters asked how we can make the process of 

addiction relevant to physicians — to pediatricians, neurologists, oncologists — to physicians in every specialty. I believe 

the way to make it relevant is to educate physicians about 

the effects that drug abuse has on other medical diseases 

and conditions in the patients they are treating. 

That information is very well recognized for cancer. No one 

doubts that smoking, whether one smokes nicotine or cannabis, increases the risk for a wide variety of cancers. Much 

less is known about the involvement of drug abuse in other 

diseases, and that is extremely frustrating. For example, we 

know that drugs have a negative effect on pulmonary function. But when I looked for studies of the effects of drug abuse 

on asthma, which is a problem that is escalating in children 

throughout the United States, I couldn’t find a single article 

in PubMed that examines asthma and substance abuse. 

You may say that’s because it’s not relevant. But of course it’s 

relevant. Smoking is likely to affect the prognosis of these 

patients. Moreover, when we give medications to treat asthma, 

many of the medications have similar pharmacological targets as drugs of abuse such as cocaine and amphetamines. 

So why are there no studies? 

My perspective is that we ought to link the consequences of 

drug abuse to other medical problems. Then it will become relevant for a pediatrician to ask a kid who has asthma whether he 

has ever tried drugs. Why? Because it will determine the prognosis and the way that child will respond to asthma medication. 

The same thing pertains to a wide variety of medical disorders. 

For example, there is increasing evidence that drug abuse may 

trigger the expression of psychiatric disorders. We’re faced right 

now with a remarkable increase in the number of children and 

adolescents who are being referred for the treatment of psychiatric problems, at the same time we’re seeing an increase in the 

use of neurotoxic drugs. We also know that drug abuse contributes to infectious diseases and that, in young people, one of the 

main causes of myocardial infarction is abuse of stimulant drugs. 

Learning disorders and obesity are conditions that seem 

totally disparate, but all are on the increase, and drug abuse 

is a contributing factor. Mothers who smoke during pregnancy 

have children who are two to three times more likely to be 

obese in childhood, adolescence, and as adults. This is something that we didn’t even know until recently. Cerebral vascular 

accidents (strokes) are related to intake of drugs and alcohol, 

and we didn’t know that until recently. We don’t really know 

the magnitude of the impact of drugs on rates of traumatic 

injury. We know that it’s quite large, but we really haven’t 

looked at it carefully. 

To me, one of our priorities should be to present this evidence 

in ways that physicians — whether or not they believe that 

drug addiction is a disease — cannot ignore. Addicted 

individuals take drugs because they enter their brains and produce increases in dopamine. But the drugs don’t affect only 

the brain: they go all over the body and produce direct effects 

on multiple organs. That is why we, as physicians, must ask 

questions. We can no longer keep our eyes closed when it is so 

obvious. Figure 8 illustrates exactly how obvious it is. 

Figure 8 depicts a whole body image of a normal person, 

showing an enzyme that is important in protecting the body 

from toxins. There are very high concentrations of the enzyme in 

the brain, the kidneys, the liver, and to a certain extent, the heart. 

You also see it in the lungs, though the signal is not as strong. 

Figure 9 is a whole body image of a smoker. You can see the 

dramatic reduction in the enzyme. Basically, there’s none in 

the brain, and almost none in the heart. Look at the kidneys. 

We could not detect any in the lungs. And this, of course, 

provides an example of why cigarette smoking increases the 

damaging effects of toxins and affects overall health. 

Smoking also has another aspect, and that is related to the 

effects of drug use during pregnancy. This has been very well 

recognized for alcohol, but much less so for other drugs. We’re 

concerned about mothers who use cocaine or marijuana or 

other drugs during pregnancy. We also should be concerned, of 

course, about mothers who smoke. Why? Because at least 11 

percent of pregnant women smoke. Eleven percent! The 

epidemiologic data tell us that women who smoke have 

children who have lower birthweights, have higher rates of 

prematurity, are much more likely to die of respiratory 

syndrome, and have a much higher risk of conduct disorders 

and early experimentation with tobacco. Smoking is the main 

risk other than genes for development of childhood ADHD. 

Children of mothers who smoke during pregnancy have, on 

average, lower IQs and are at higher risk for obesity. 

This is another area where the medical community could play 

an extremely important role, by conveying this information 

to, and doing a complete evaluation of, the woman who’s pregnant. That would be doing prevention, not just for drug abuse 

but for a wide variety of medical problems in both mother 

and offspring. 

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Infections: here’s another connection that’s well known. Over 

time, injection drug use has contributed to 30 percent of the 

cases of HIV/AIDS, and continues to do so. But we’re seeing 

another contribution of drugs, and that is sexual transmission among individuals who are under the influence of both 

legal and illegal drugs. Here, we see not only the drug’s effect 

in altering mental state so that individuals make decisions 

they wouldn’t otherwise make, but also the effects of drugs 

combined with infectious agents. 

This effect is illustrated in Figure 10, which depicts a normal 

brain. This image measures a marker that shows whether the 

dopamine-producing cells are functioning. The other image 

is of a person with HIV, and there is an obvious reduction in 

the markers for dopamine-producing cells. The change is not 

radical, but it is clearly present. Look at the person with HIV 

who is also taking drugs, in this case cocaine, and you can 

clearly see the that the damaging effects of HIV are intensified by the drug. 

This combination of drug and infectious agent is beginning 

to be recognized as producing not oxnly an additive effect, 

but perhaps even a synergistic action. And that’s another 

reason that physicians can no longer ignore the importance 

of drug abuse. 

There are many other examples I could put forward, but I’m 

not going to belabor the point. I just wanted to illustrate how 

obvious this is, but that we have not been able to transmit 

this information to the medical community. 

Now, I want to concentrate on another big challenge 

confronting us. Director Walters alluded to it. We have developed medications and behavioral interventions that are useful 

in treating addiction, yet many people are not seeking treatment. Of the 21.6 million Americans who are addicted to or 

abuse any illicit drug or alcohol, only 10 to 15 percent are 

seeking treatment. So 85 percent of the population that is 

addicted to drugs or alcohol are not seeking treatment, and 

that is a challenge in terms of what we can do to bring them 

into treatment. As Director Walters pointed out, the medical 

community has a unique opportunity to intervene to help 

these individuals overcome their denial and admit that they 

have a disease and need treatment for it. The involvement of 

physicians could have a major impact on this serious problem. 

Finally, Figure 11 shows another area where we need medical 

community involvement. One of the areas where we’re seeing 

increasing drug use involves prescription drugs, particularly 

opiate analgesics. And that requires engaging the medical 

community in yet another aspect of drug abuse prevention 

and treatment. 

So the challenge is: How do we engage the medical community so that medical students and residents are trained in the 

recognition and evaluation of drug abuse and addiction? If 

we take advantage of the extraordinary infrastructure of 

medical education, not only the drug addiction community 

will be served, but also the medical profession in general. 

And with that, I want to thank you for your attention. 

QUESTION (From Dr. Jeffrey Samet): 

You mentioned medical schools as a key ingredient. 

I think it’s terrific that a mechanism would be developed for 

improving the training of medical students and residents 

about alcohol, or about drug abuse, but one must remember 

that alcohol and drugs frequently go together, so perhaps there 

should be some kind of blending mechanism to support that. 

Because truth be told, real patients use both at the same time. 

ANSWER (Dr. Volkow): 

What you’re saying is something that has been obsessing me 

very much as a clinician: the notion of training clinicians who 

are able to deal with both drug addiction and alcoholism. 

Because to have it separated is the most inefficient way that 

we can spend our dollars. 

I think that one of our targets is to help develop a curriculum 

to train clinicians (as well as nonclinicians, who account for a 

very large percentage of those who provide treatment) to be 

able to deal with both drugs and alcohol, so that we don’t 

have to send patients to different places for care. I think that 

would be an extremely important initiative to put forward. 

QUESTION (From Dr. Winston Price): 

Within certain populations, substance abuse is a disease of 

society. As a pediatrician, I have adolescent patients who are 

substance abusers. When I say, “You realize what this will do 

to your body, what this will do to your family,” their response 

is, “This is better than the situation I’m going back to in my 

community.” That’s more damaging to them than the substance abuse. 

ANSWER (Dr. Volkow): 

You are touching on an extremely important aspect of addiction, and that is the involvement of the environment both in 

terms of obvious factors such as drug availability and more subtle 

factors such as stressors, whether they are acute or chronic. 

Through research, we’re starting to understand that environmental factors, such as lack of physical contact with parents, 

can leave children more vulnerable to stressors, which then 

facilitate the acquisition of drugs. 

It’s clearly a complex interaction. Now, how do we deal with 

it in terms of both prevention and treatment, in terms of 

recognizing what are those variables so that you can do 

interventions that counteract the deleterious effects? What 

we’re doing in research is trying to understand how these 

environmental factors produce changes that facilitate the 

acquisition of drugs. 

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PERSPECTIVES OF THE FEDERAL LEADERS


Unfortunately, if a child is born into a family structure where 

the parents are not there, we’re not going to be able to erase 

that. But we can provide an infrastructure that helps to compensate. We’re dealing here with a chronic disease, and the 

extent to which a person is going to be able to stay clear of 

drugs is going to be partially mediated by the environment in 

which he or she is situated. Hence the importance of 

community involvement. 

QUESTION (From Dr. Mark Kraus): 

The emphasis seems to be on medical school and residency 

training and education. Yet the population is being taken care 

of by attending physicians, and they’re the ones who haven’t 

had a lot of training. What can NIDA and NIAAA do to support clinical knowledge transfer to the attending population? 

ANSWER (Dr. Volkow): 

At NIH, our mission is to support research. Our mission 

also is to provide knowledge. Now, how can we help with 

what you’re asking, because we do have an obligation to 

help? We can start by providing the knowledge. For example, 

I brought up the issue of prescription drug abuse. In this 

country, we really do not know how to treat chronic pain. 

As unbelievable as it may be, the long-term use of opiates for 

the treatment of chronic pain has not been properly investigated. Thus, you see an extremely important opportunity for 

us to develop the research and, from that, the guidelines for 

how to treat pain patients properly to minimize the risk of 

addiction. That’s an example of where we can help by 

providing knowledge. 

We also are partnered with SAMHSA, which has the authority 

to develop training for clinicians. We’ve partnered with them 

to ask what is the best strategy to bring research information 

to attending physicians so that it is incorporated into practice? 

We can translate that into a services research question. 

Another way we can help is by developing strategies to 

incorporate new knowledge into the repertoire of attending 

physicians in such a way that the knowledge is utilized, 

because the information is there, but clinicians are not using 

it. And that is a research question: Why are they not using it? 

What active ingredients do we need to identify to optimize 

the chances that it will be used? That’s the way I think NIH 

can and should participate. 

QUESTION (From Dr. Norman Wetterau): 

I’m involved with the American Academy of Family Physicians. I want to thank Dr. Volkow for your letter of support 

for a resolution that was before our Congress of Delegates, 

calling for more physician education about alcohol and drugs. 

I want to thank you and to let you know that the resolution 

did pass, and we have representation at this meeting and are 

looking forward to doing things. 

TING-KAI LI, M.D. DIRECTOR, NATIONAL 

INSTITUTE ON ALCOHOL 

ABUSE AND ALCOHOLISM 

As everyone in this room knows, 

alcohol abuse and dependence and 

drug addiction go together in the 

general population, as well as in the 

clinical population. What I’d like to 

do today is to give you a view from NIAAA and discuss how 

our work relates to what you hope to accomplish by the end 

of the day. 

Let me start with a brief synopsis: the National Institute on 

Alcohol Abuse and Alcoholism was established in 1973. Its 

mission was primarily to provide treatment or prevention 

services, training, outreach, and education. Research was 

really a relatively minor component. In 1992, the research 

institutes — NIMH, NIDA, and NIAAA — were transferred 

to the National Institutes of Health, while the service delivery functions were assigned to the newly created Substance 

Abuse and Mental Health Services Administration (SAMHSA). 

Our current mission at NIAAA is to support and promote the 

best science on alcohol and health for the benefit of all, by 

doing the following: 

1. Increasing our understanding of normal and abnormal 

biological functions and behavior related to alcohol use; 

2.	 Improving the diagnosis, prevention, and treatment of 

alcohol use disorders; and 

3. Enhancing the quality of health care. 

To understand alcohol drinking and its effects requires crossdisciplinary approaches in research. These range from studies 

on molecules and cells through animal models, from human 

laboratory studies, to population-based studies. At the same 

time, in order to develop efficacious and effective treatment 

and prevention strategies, we need multidisciplinary 

approaches. Which also requires multidisciplinary collaboration among investigators. 

Quality care requires translation and dissemination of new 

knowledge to health care professionals and the public at large. 

NIAAA has had active partnerships to sponsor career development and faculty development programs for 20 years. 

NIAAA has continued to support education of health professionals and the career development of educators and clinical 

investigators in a number of health professional schools. 

Here are some examples of recent activities in the health 

professions education that NIAAA conducts. First, we’ve collaborated with the Research Society on Alcoholism to develop 

a multidisciplinary curriculum for young biomedical scientists, 

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which is a cross-disciplinary training exercise. Second, we’ve 

developed curricula for social workers, emergency department 

and primary care physicians, as well as pastoral counselors. 

(Some of the people involved in these programs are here at 

this conference.) Finally, we’ve developed and are further 

improving a health practitioner’s guide for screening and brief 

intervention with patients who have alcohol problems. 

We also continue to support dissemination of new evidencebased knowledge. And we are continuing to make presentations at universities and professional societies and to support 

publications, such as Alcohol Alert. Then there are publications about research, reviews, and other commentaries in 

professional journals. And we do have a small but active outreach program that offers brochures and pamphlets targeted 

to health care practitioners and the public. 

We support grants for research and training. The “R” series 

are for research, and the “K” series are for career development. There’s one in particular that is underutilized, but it’s 

on the books. It’s a KO7 award for scientists and educators, 

which is meant for development and training of young faculty. 

We also have a contract arm that does research translation, 

research dissemination, and the printing of materials. 

Now, with all of that, where are we in terms of the quality of 

care for alcohol use disorders? This is really the topic of 

today’s discussions. The answer is seen in a recent paper by 

McLellan and coworkers (Figure 1), who took 10 different 

acute and chronic conditions and developed what they 

considered to be perfect quality of care, which was given a 

score of 100. Then they reviewed cases and assigned scores 

to the care actually delivered. Figure 1 shows the scores for 

various disorders. Breast cancer, low back pain, and depression score fairly well, but even the best is only 80 percent. 

Where is alcoholism treatment? It’s dead last. On the quality 

scale, alcohol treatment scores a 10. 

So something isn’t working, but what is it? The accepted barriers to high-quality alcohol prevention and treatment include 

attitudes, values, beliefs, and perceptions on the part of health 

care professionals and the public at large; stigma; and the 

belief that alcohol and drug addiction are moral failings and 

not diseases. On the whole, we don’t understand the burden 

of alcohol and drug use disorders. There is bias on the part 

of physicians because their training relies on inpatient clinical 

populations. 

Another factor is the lack of knowledge that treatment and 

recovery are successful. And then, of course, there is the lack 

of skills in prevention and intervention: if you don’t have the 

skills, you can’t use the skills. There also is a lack of knowledge about what resources are available in the community. 

And finally, as Tom McClellan has pointed out, there is a weak 

and insufficient treatment infrastructure. So there are multiple 

factors contributing to the problem. 

From NIAAA’s perspective, what kind of new knowledge 

might influence physicians’ attitudes and beliefs about the 

quality of care of alcohol problems? First, physicians need 

to understand and be very aware of the impact of alcohol 

use disorders on personal health, public health, and the 

economy. Second, they need to recognize the prevalence of 

alcohol use disorders in adolescence and how it plays out 

across the lifespan. Third, physicians need to understand that 

there is a relationship between the quantity and frequency of 

drinking and the risk of harm. Fourth, they need to know 

about treatment success rates from the recent literature. 

Finally, they need to understand something about recovery 

in the general population and not just clinical populations. 

It’s also important for us to recognize how the public in general 

consumes alcohol. Alcohol is illegal for underage populations, 

but it is legal for adults. One-third of the population does not 

drink at all, while two-thirds do. Three times more males drink 

than females; there’s an interesting scientific question as to 

why this is so. It may not be entirely cultural; there may be 

some biological explanations as well. 

We also know that 60 percent of alcohol is consumed by 10 

percent of the population. You might say that the 10 percent 

is the target population we should look at. However, a much 

larger part of the drinking population is at risk for alcoholrelated problems. Figure 2 contains data from a recent 

epidemiologic survey, and shows something about drinking 

patterns and how they relate to problems. The major problem is exceeding the daily limit, which is four drinks per day 

for men and three drinks per day for women. Those who 

exceed these limits, even on an infrequent basis, are at 

increased risk for alcohol abuse and addiction. Drinking a lot 

of alcohol in a short period of time impairs mental capacities 

and motor function. When it happens infrequently, there is a 

very modest increase in dependence. When it happens more 

often (once a week or more), the risks go up, so that one in 

four persons in this category have problems. These data 

provide a pretty good guide in terms of screening and brief 

intervention and where a physician should be looking. 

Dr. Volkow spoke of the importance of concentrating on the 

developmental trajectory of substance abuse, including 

alcohol. The data in Figure 3 are from the same database. 

When we look at the age of first use of alcohol, we see two 

peaks. The larger peak corresponds with the age when young 

people attain the legal age or go to college. But there is another 

good-sized peak of people who start to use alcohol very early 

in life. 

Those who do this become alcohol-dependent faster. If you 

first start drinking at age 13 rather than age 20, you have an 

almost fourfold greater risk for developing alcohol dependence. 

The risk is further increased if you have a family history of 

alcoholism. One reason is that underage individuals drink 

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PERSPECTIVES OF THE FEDERAL LEADERS


differently than adults: they drink less frequently, but they 

drink more per occasion. As a result, the data show that the 

onset of alcohol dependence is concentrated in the 18- to 

25-year-old age group. There are important public health as 

well as medical implications in this kind of developmental 

trajectory. 

In the hospitals and clinics, we’re used to looking at alcoholism as a chronic relapsing disorder, which it is in adults. But 

that is not addressing the underlying problem, which occurs 

at a much younger age. We don’t see that in the hospitals, but 

we do see it out in the community, and this is a problem we’ll 

need to address. 

There are some other facts that are not widely known that 

suggest health professionals have a powerful role in motivating high-risk drinkers to enter and successfully complete 

treatment. Studies show that heavy drinkers are more than 

twice as likely to reduce or moderate their drinking after a 

screening and brief intervention. This finding applies to both 

men and women. 

It’s also important for physicians to understand that although 

alcoholism is a complex disease, the relapse rate in treated 

individuals is not very different from that seen with other 

common diseases such as hypertension, diabetes, and asthma. 

Treatment success rates for alcohol dependence are in the 

range of 30 to 60 percent, depending on whether the outcome measure used is continuous abstinence, or reduction 

in the number of drinks per day, or improved social functioning (the 30 percent figure is for continuous abstinence). 

Finally, Figure 4 shows data yet to be published (it’s in press). 

It is based on people who have been dependent and looks at 

how they’re doing 5 and 10 and 20 years later. This is a crosssectional study, of course; what we need are longitudinal 

studies. But this is an interesting profile: over the years, the 

number of people who are dependent goes from about 55 

percent all the way down to less than 10 percent. Some are in 

partial remission, and some have become abstainers. Some 

even are asymptomatic drinkers. 

To understand the factors that contribute to these data is 

vitally important for us in terms of treatment and prevention 

strategies. The data also represent important information for 

physicians and other health professionals. 

Now, how do we overcome the barriers to high-quality care 

to prevent and treat alcohol problems? I would submit that 

current research and education initiatives are necessary but 

not sufficient. So from the NIAAA perspective, we have a 

proposal: NIAAA would be supportive of a collaborative 

program for the development of core faculty in schools of 

health professions education. The programs would have a 

career and a scholar-investigator component. We see this as 

a way to develop faculty who are knowledgeable about this 

area, and who are able to invest in both teaching and research. 

A career clinical scholar and investigator would be a key member of the core faculty who is responsible for education, for 

conducting research on education and health services 

research, and for mentoring the next generation of clinical 

scholars and investigators. 

We believe that the KO7 mechanism, which already is on the 

books, is ideally suited for both career development of young 

clinical investigators and the mentoring component of such 

a program. We are willing to invest in this over the next nine 

years in a collaborative manner, but it will require buy-in from 

the schools of medicine and other health professions. 

In summary then, I want to say that, throughout its history, 

NIAAA has supported health professions education through 

a variety of mechanisms. This proposal to further invest in 

the goal of high-quality alcohol prevention treatment and care 

can be done best in collaboration with the professional schools 

and with other Federal agencies and private sector organizations. We look forward to your discussion of the proposal 

and to your collective response. Thank you. 

JEFFREY RUNGE, M.D. ADMINISTRATOR, NATIONAL 

HIGHWAY TRAFFIC SAFETY 

ADMINISTRATION 

Here is what brings us together: If 

you go to the CDC’s Web site, you 

will find a file that shows the 10 leading causes of death in the United 

States. Under the World Health 

Organization’s conventions, CDC lumps all unintentional injuries into one group. This always bothered me, and I wanted 

to separate out motor vehicle crashes. I could never do that 

until I actually had a staff to do it; I now have that staff and 

they have done it. 

Figure 1 shows what happens when you separate out motor 

vehicle crashes from other causes of injury: Of the 10 leading causes of death in the United States by age, motor vehicle 

crashes rank number 1 from the toddler age group (just over 

age 2) through 34 years of age. They are overtaken by cancer 

and heart disease as a cause of death only in the 35 to 44 

age group. 

When I talk about traffic injuries as a public health problem, 

people agree emphatically, as they do when we describe AIDS 

as a public health problem. But these data show the situation 

graphically. We are consuming our young with motor vehicle 

crashes, and the cause boils down to three things: impaired 

driving, failure to wear a safety belt, and speeding. 

What I’m going to focus on today is impaired driving and the 

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strategy we have chosen to address it. The reason that we 

are here, obviously, is because we are concerned about a segment of the impaired driving population that will not respond 

to prevention messages. They will not respond to social 

norming. They do not respond to anything except their physicians and, we hope, addiction treatment. But to treat them, 

we have to find them. 

This is the fifth meeting that I’ve been involved with, and that 

NHTSA has been involved with, on screening and brief intervention in primary medical practice. In 2000, NHTSA sponsored a meeting on developing best practices for emergency 

care of the alcohol-impaired patient. The meeting occurred 

before I arrived at NHTSA, but I was very much involved in 

the community. In 2001, the CDC and NHTSA sponsored a 

meeting on alcohol problems and emergency department 

patients; the proceedings are available on CDC’s Web site. In 

May 2003, we sponsored a meeting on crossing barriers in 

emergency care of alcohol-impaired patients. In February 

2004, we gathered medical leaders together to talk about 

screening and intervention. Sooner or later, we’ll have to quit 

having meetings and start doing something. 

Figure 2 is not a very sophisticated pie chart. It attempts to 

show predicted savable lives. In other words, if we take out 

motor vehicle crashes that occur at greater than 50 miles per 

hour at impact, and if we take out nonsurvivable crashes and 

just look at preventable deaths and survivable crashes, what 

are the factors that could result in their prevention? 

There is obviously some double-counting here. But when you 

make it ridiculously simple, about a third of lives lost are 

attributable to impaired driving; about a third of lives lost are 

from failure to use safety belts; and about a third of lives lost 

are from all other causes, such as pedestrian safety, child 

safety, intersection crashes, off-road crashes, isolated without 

belts, and alcohol use. When you’re trying to set priorities for 

a government agency, a picture this clear is very useful. For 

us, it’s on the behavioral side, not the vehicle safety side. We 

also regulate the motor vehicle industry, but on the behavioral side, use of safety belts and prevention of impaired 

driving are the focus of our work. 

There has been some relatively good news over the last year. 

Don’t be misled by this histogram. It starts at 40,000; it does 

not start at zero. If it started at zero, you wouldn’t be able to 

see much of a difference here. But the good news is that we 

had the first decline in overall fatalities that we’ve had in 

quite a long time. The exposure that people have to death 

from motor vehicle crashes in the United States has increased 

about two percent per year since we started keeping records 

in the 1960s. So the rate has been going down fairly consistently, even as the absolute number of drivers killed has 

increased. In 2003, however, we saw the first actual decline 

in a long time. 

It’s easy to see [on the histogram] that 939 fewer people died 

in crashes in passenger vehicles in 2003 than in 2002. At the 

same time, safety belt use rose to 80 percent. There’s an 

obvious conclusion here. Let’s look at alcohol-related crashes. 

You can see that the rate has come down since 1982, and 

sort of flattened out in the mid-1990s. Last year, we actually 

had the largest decline since 1992. 

Something happened in the 1980s that was a sea change. You 

don’t hear “one for the road” at a party much anymore, or at 

least at the parties I attend. If you think about it, it became 

socially normal to drive sober and socially abnormal to brag 

about how drunk you were when you drove home. A norming 

process took place. 

Unfortunately, the people who are represented by this part 

of the histogram aren’t affected by these social trends. We 

know who they are, and they really are the reason that 

you’re here. 

For those of you who don’t like pictures, Figure 3 shows the 

numbers of alcohol-related crashes. Again, I have to point 

out that we use the best methodology in the world for estimating alcohol-related fatal crashes. We take all the knowns 

that are reported by the police, the toxicology reports from 

the police, and then we impute the real number, because we 

have blood alcohol and drug screens for such a small number of the fatal crashes. 

We actually do an imputation of what we believe the number 

to be, and it is based on surrogates; for example, the proportion of crashes that are known to be alcohol positive occur at 

night, single vehicle, rural roadway. When we look at a 

percentage of single vehicle, nighttime, rural roadway crashes, 

we know that, with reliability over many years, they are going 

to be alcohol related. This is how the number is arrived at, 

although this is not a census like our Fatality Analysis 

Reporting System, FARS, is: 42,825. You can believe that. But 

this is the best estimate, and it’s pretty tight, we believe. 

As I said, we saw the first decline in 2003 (Figure 4). What’s 

most impressive about this figure is that in the BACs between 

.02 and .079, it only represents about 2,300 of the 17,000. 

Everybody else — 14,630 — is over .08. 

Let’s look at age for a minute. Part of the problem with being a 

government official is that we have to make some choices, 

because we don’t have enough resources to do everything we 

would like to do. We have to focus resources on the places 

where we can do the most good. It doesn’t take a rocket scientist 

or even a simple emergency physician from North Carolina to 

figure out where the risks are, using this histogram. 

Clearly, we are killing our young people in alcohol-related 

fatal crashes. The peak level occurs among new drinkers, who 

also are relatively inexperienced drivers, followed closely by 

21- and 22- and 23-year-olds and, sadly enough, 19- and 20­

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PERSPECTIVES OF THE FEDERAL LEADERS


year-olds. What the 21-year-old drinking law did was to save 

thousands and thousands of teenagers. 

This is the crux of the issue for screening and intervention. 

Figure 5 shows a histogram of alcohol levels of alcoholpositive drivers who were involved in alcohol-related crashes. 

In 2003, the median and the mean BAC levels were .16, so 

fully half of the drivers who were involved in fatal alcoholrelated crashes had blood alcohol levels higher than .16. 

Here is my point: When we’re trying to look at who to target, 

we have to employ different strategies for different parts of 

the population. These are sick people, and they need a doctor. 

Interestingly, most of them have a doctor, and most of them 

interface with the medical profession in the emergency 

department, if nowhere else. But what do we do about it? 

As I mentioned before, there is double counting. People who 

drive impaired don’t buckle their safety belts. People who don’t 

buckle their safety belts drive impaired. And so fully 70 percent 

of the fatal crashes that were alcohol-related involved unbelted 

drivers, as compared with a little under half of crashes that 

were not alcohol-related. What we’re seeing is a population of 

risk-takers, and that bit of information may stimulate some 

ideas about how to approach them and what questions to ask. 

Whenever I talk about what we are going to do about impaired 

driving, I am asked if it is an insurmountable problem. The 

answer is no; it is not an insurmountable problem. But we 

have to break up the problem into its constituent parts. We 

did have a problem in the 1980s with people who were socially 

responsible, who were socially normal, and who would drink 

three, four, five drinks; have one for the road; hop in the car; 

and go home. And if they had a crash, it was considered an 

“accident.” Those days are gone. 

But we also have new drivers every year. And we have new 

drinkers every year. So we have a need for high-visibility 

enforcement, coupled with advertising messages targeted at 

males ages 18 to 34, to give them the sense that it is not okay 

to drink and drive, that they will be arrested and put in jail, 

and it’s going to ruin their lives. That is the purpose of a highvisibility enforcement campaign. 

Those who fail to be deterred by this message will fall into 

the court system if they are apprehended. However, we also 

have a huge problem in the court system. We have judges 

who don’t know the law. We have wet-behind-the-ears 

prosecutors in many jurisdictions. The more experienced 

prosecutors are assigned the robbery and rape cases, leaving 

the less experienced attorneys to try these complicated DWI 

cases. To address this, my agency is collaborating with our 

partners in the Department of Justice, the state Attorneys 

General, and other officials, to develop a cadre of resource 

prosecutors in every state, who can assist the district court 

prosecutors with this very complex law. 

Another approach uses DWI courts that are based on the 

drug court model, which we know works. We funded a study 

in the late 1990s that looked at the drug court model, meaning a judge orders the offenders to appear monthly and 

assigns social workers to go to their job sites, obtain urine 

specimens, and interview their families. Usually, sobriety is a 

condition of staying out of jail, and if individuals in the 

program flunk out, it is not good for them. So the success 

rate in DWI courts is very high. We hope to replicate this 

approach across the country. 

Before we ever get to that point, however, we need physicians 

to ask the simple questions as part of the routine medical 

history, particularly with patients in the high-risk populations, 

such as males ages 18 to 34. 

How many of us actually ask these questions: How many 

drinks does it take before you first feel the effects of alcohol? 

Has your family been worried about your drinking? There 

are many, many, many screening tools that all of us are familiar 

with, such as CAGE and TWEAK. Dr. T.K. Li, who directs the 

National Institute on Alcohol Abuse and Alcoholism, is working on defining a single question that may be the only question 

a doctor has to ask. He thinks the question might be, “How 

many drinks do you drink at a sitting when you drink?” Above 

four is a pretty good predictor for alcohol use. 

So we’re after something that won’t require extra time in the 

emergency department and other high-volume locations. 

Emergency physicians often see 15 patients an hour. They 

don’t have time to go through the AUDIT with every patient. 

But part of this whole discussion is that if we can communicate, if we can all agree that this is a big enough public health 

problem and that we have to start this process for alcohol 

and drugs, then maybe you can tell us what to do, how to do 

it, and how to normalize this among physicians in the community. We really need something that will make doctors feel 

good and comfortable about asking the questions. 

And the second piece of this is, then what? You have screened 

your patients and found that they are at high risk for alcohol 

abuse. Then what? What do you do? We have to make it comfortable for doctors to screen their patients, but we also have 

to make doctors believe that they’re going to have success 

both if they send their patients somewhere or if there’s 

nowhere to send them, to deal with the issue themselves. 

You don’t need to be sold on that. 

Some key issues are shown in Figure 6. Pretty good data coming out indicate that 40 percent of the people don’t drink at all, 

so when you ask a screening question, you go to the next thing. 

Some at-risk drinkers here, believe it or not, will respond to the 

advice of their doctor. I know that you doctors in the audience 

don’t believe that, but people actually do respond to our 

advice. And I’m sure you’ll have experts who will give you 

34 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


the literature citations. Even if you’re great at a brief intervention, doing a screening and giving advice and following 

up may, in fact, work for a good portion of this population. 

How do we get to this issue of alcohol screening? In medical schools. When I was in medical school, a professor told 

me that the curriculum content at my medical school was 

twice what he had to learn at his medical school. And that 

was in 1977 when I started. In 2004 I can’t imagine the curriculum content that has to be packed into the same amount 

of time. So the chances of getting alcohol screening into a 

four-year medical school curriculum I’m not very sanguine 

about, frankly. 

I am not sure when this training has to happen. I think I heard 

about it one time in my freshman behavioral science class, 

sort of between the lecture on the angry patient and the medical marriage and the human sexual response or something 

like that. It was not a big feature of my medical school, and I 

doubt that it is now. But, clearly, training is important. 

The insurance laws build in a disincentive for physicians to 

gather alcohol data on their patients because they’re afraid 

of not being able to bill for services are a reality. We’ve been 

working on that. A couple of states, North Carolina being 

among them, have a law prohibiting that. One of the reasons is because I sent Commissioner Jim Long a bill for 

$156,000 for a patient who fell off a ladder, spent a month in 

the ICU, and had multiple surgeries. Workers Comp refused 

to pay the patient’s bill. Representatives interviewed the 

patient’s co-workers, who said the patient had been drinking 

beer at lunchtime. I’m happy to say that denying a claim for 

this reason is against the law in North Carolina now. Maryland, North Carolina, and Vermont, I believe, have adopted 

laws that say it doesn’t matter if a person is using alcohol, 

insurance is still responsible. 

So it is possible to be reimbursed. The National Association 

of Insurance Commissioners has a model bill, and I would 

encourage you to look at it. How do you bill for these 

services? I’m not sure. There’s a CPT code for it, but in emergency medicine we can’t use it. If we do screening intervention, it might bump us up a level of service. We can’t use the 

CPT code, because nobody will pay. 

There also are issues with accreditation. The American 

College of Surgeons Committee on Trauma is talking about 

having screening intervention protocols as part of trauma 

center designation, which I think would be absolutely fabulous. Maybe JCAHO wants to look at this as best practice. 

We don’t have all the answers, but we do know that screening 

is an important problem. Having looked at your name tags, I 

think people in this room can help us navigate our way to 

making brief intervention standard practice in the United 

States among physicians and other health care providers. 

VICE ADMIRAL 

RICHARD H. CARMONA, 

M.D., M.P.H. SURGEON GENERAL OF THE 

UNITED STATES 

You know, the President has made it 

very clear to me that substance abuse 

prevention and treatment are a very 

high priority for us. I know I’m preaching to the choir when I 

say that to you. But I think that coming from a President of the 

United States who is willing to raise this to an issue of national 

health policy, it is very, very important. And of course, the sole 

purpose of Director Walters’ job is to do something about this 

dilemma. So the commitment of our government is there. 

As you know, my personal involvement is that both my parents 

were alcoholics and had problems with substance abuse. I got 

to witness those things as I grew up, and I saw how it disintegrates families. Personally, I saw the difficult decisions that 

people who are addicted have to make when they have only a 

few dollars and have to decide whether to buy food or the 

drug or alcohol. Of course, the children suffer, and it creates a 

great deal of instability in families. 

It’s interesting: When I think of myself growing up, I remember how wonderful and kind and caring my parents were, but 

they were very consumed by their problems, their addictions. 

And yet, they always tried to care for us. They always tried to 

do the right things for us. In fact, my mother used to give me 

lectures about not using drugs and not drinking in the streets 

with my friends. And yet, they were burdened by it themselves 

and couldn’t get out from under it. 

So for me, this is not just an academic discussion. It’s something that I really experienced and I feel very passionate about, 

something that we really need to do something about. 

When we hear the term “substance abuse,” most Americans immediately think of marijuana, cocaine, heroin, and other illegal 

drugs. But prescription drug abuse and alcohol abuse also are 

harming and killing Americans of every race and socioeconomic 

group. Today, an estimated 6.2 million Americans abuse prescription drugs, compared to 1.6 million in 2000. That’s nearly a 400 

percent increase in four years. And for the 14 million Americans 

battling alcoholism, the holiday season, with its parties and 

champagne toasts, presents a steep challenge. These are people 

who are ruining their bodies, their minds and, in some cases, 

dying because of a disease that can be prevented and treated. 

Substance abuse impacts millions of American mothers and 

fathers, America’s workers, America’s future leaders, our children. 

Every parent thinks: Am I doing enough to make sure my child 

stays away from drugs? That’s exactly what we should be asking 

ourselves. What can we do? What can we do to make it better? 

What we are doing is a Surgeon General’s Communication about 

WASHINGTON, DC • DECEMBER 1-2, 2004 35

PERSPECTIVES OF THE FEDERAL LEADERS


teen driving, including the contribution of substance abuse. As 

you know, not all motor vehicle crashes are related to driving 

under the influence of drugs and alcohol, but many are. In 2001, 

23 percent of young drivers involved in fatal crashes had been 

drinking. And we’re seeing a rising trend in the number of crashes 

caused by teen drivers who lack experience and focus, or suffer 

from simple fatigue. Across our Nation, car crashes kill more 

children and young adults than any other single cause. Each 

year, more than 41,000 Americans die in motor vehicle crashes, 

and crash injuries result in more than half a million hospitalizations and four million emergency department visits. The economic burden of motor vehicle-related deaths and injuries 

also is enormous, costing the United States more than $150 

billion a year, at a time when health care presents a huge 

economic burden, which is mostly preventable. 

The same factors that contribute to younger drivers being 

involved in motor vehicle crashes account for their higher 

death rates. (We all remember the teenage years. You feel 

you’re invincible — nothing bad is going to happen to you — 

it will always be somebody else.) 

The time of day also is strongly associated with motor vehicle 

crashes involving young drivers. For example, more than half 

occur on weekends, and more than 40 percent occur between 

9:00 p.m. and 6:00 a.m. 

Before I went into public health, I was a trauma surgeon in an 

emergency department. I was on the receiving end of all of 

those victims. I remember, day after day and night after night, 

those gurneys rolling in. Interestingly enough, no matter why 

the emergency patients were admitted — domestic violence, 

gunshot wound, drug abuse — a large percentage were involved 

with some type of substance abuse, buying, selling, using. 

And just about two or three out of every four of those cases 

before me were preventable — they didn’t have to be there. 

People made bad decisions that affected their whole lives. 

I’m bringing the idea of a Surgeon General’s Communication on 

teen driving to you because I think that you have a thorough 

understanding of the role that substance abuse plays in killing 

our young people on the highways of America. This is actually 

the first time I’ve mentioned this to a peer group in any meeting. I would appreciate your professional input and your help 

in moving forward such an idea and how it might be structured 

and how we might all partner on something like this. 

To put it plainly, drug and alcohol abuse and addiction are societal issues that demand societal solutions. These problems 

undermine the public health. They create an enormous disease burden and an economic burden that is entirely preventable. The good news is that we can all be part of the solution. 

And that includes all of us and our colleagues in the health 

professions. By engaging health professionals, families, and 

support groups, we can provide assistance to people of all ages 

and from all walks of life who may be at risk, and help those 

who have already fallen victim to an addiction, help them to 

recover and go on to lead productive, drug-free, healthy lives. 

To prevent substance abuse and save millions of lives, we must 

focus on closing the gap between what health professionals 

know about substance abuse and what the rest of America 

understands. I think most of you will agree that in our country, 

we have a largely “health illiterate” society. Health literacy is 

the ability of an individual to access, understand, and use 

health-related information and services to make appropriate 

health decisions. So how does the average person deal with all 

of the great scientific information that we’re trying to give them 

to change their behavior to keep them healthy, to make their 

lives better? They simply don’t understand. The literature’s 

pretty strongly supportive of the fact that half of patients don’t 

understand the appointment slip and when they’re supposed 

to come back, and a quarter of the people don’t understand 

their prescriptions and what’s on them. This health literacy 

block is very, very significant in everything we do. 

How many times have we been annoyed with a patient 

because he or she is noncompliant? But when you ask why 

were they noncompliant, you realize: Maybe they didn’t understand. Maybe I didn’t deliver the message correctly. Maybe 

it just didn’t catch. 

How much time are we actually giving to patients today to 

engage them in conversation to make sure they understand? 

How are we ensuring that our messages are not only linguistically but culturally competent? So we waste a lot of time 

and a lot of money because we’re trying to explain something to someone who doesn’t hear us. 

What we’re looking for is ways to change behavior. That’s 

what health literacy is all about. There is a gap between those 

of us who have the knowledge and those who need the knowledge. But how do we get it to them so that they’ll incorporate 

it in their lives, change their behavior, reduce their morbidity 

and mortality, and improve their health and wellness? No 

matter what our discipline or specialty may be, that’s really 

the end product of just about everything we do: to keep people 

healthier. So we have to find ways to do a better job of delivering these very important messages. 

Improving health literacy involves giving people information 

about the safe use of prescription drugs, about staying away from 

illegal drugs, and about drinking only in moderation, if at all. We 

also must train ourselves and the next generation of medical professionals to watch for signs of abuse or addiction in our patients. 

I want to thank Director Walters and all of you, my colleagues, 

for what you are doing to prevent, treat, and eliminate substance 

abuse and increase America’s health literacy as we do so. These 

efforts will lead to a healthier, stronger America. Together we 

are facing this problem before it becomes impossible to turn 

around. Together we are asking the tough questions and applying the best science and solutions to helping Americans. I realize that it’s a very, very difficult problem that we’re dealing with, 

but we really have to do something about it. It’s the right thing to 

do, because there are people who desperately need our help. 

36 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


REPORTS FROM THE WORKING GROUPS


Through intensive dialogue in the Working Group sessions, Leadership Conference participants


agreed on the following findings, objectives, and recommendations for achieving


greater physician involvement in the prevention, identification, and management of SUDs.


UNDERGRADUATE MEDICAL EDUCATION 

Findings. 

Medical schools in the United States are accredited either by 

the Liaison Committee for Medical Education (for the M.D. 

degree) or by the Council on Predoctoral Education of the 

American Osteopathic Association (for the D.O. degree). 

These entities set standards for educational programs that 

lead to eligibility for licensure as a physician. 

In both allopathic and osteopathic medical schools, most of 

the first two years of education takes place in classrooms 

and laboratories, as students learn basic medical sciences, in 

general and then by organ system. Students also learn basic 

communication skills and how to take a patient history and 

perform a physical examination in the first two years. Most 

schools require some clinical experience in the first two years, 

most of which is observational. Much of the third and fourth 

years of medical education takes place in clinical settings, 

where students learn to apply their knowledge of basic science 

and clinical skills in caring for patients under the direct 

supervision of faculty and residents. 

Students may be exposed to substance abuse education in a 

variety of settings. During the first two years of medical 

school, substance abuse topics may be integrated into standard course work or taught as separate courses in addiction 

medicine. During the third and fourth years of medical school, 

students on required and elective clinical clerkship rotations 

may engage in specific substance abuse services. More commonly, however, educators formally or informally integrate 

substance abuse goals and objectives into clinical rotations 

such as internal medicine, family medicine, neurology, and 

psychiatry. 

Dedicated training in SUDs is rarely offered. For example, a 

1981 national survey of allopathic medical schools found that, 

while 40 percent offered elective courses in substance abuse, 

fewer than one percent provided required courses (Pokorny 

& Solomon, 1983; Lewis, 1987). A survey of 98 medical 

schools in 1986 (with an 85 percent overall response rate) found 

that the proportion of departments that offered a curriculum 

unit in substance abuse was 41/89 (46 percent) for internal 

medicine, 52/78 (67 percent) for family medicine, and 82/84 

(98 percent) for psychiatry (Davis et al., 1988), with just more 

than half (53 percent) of these offering clinical experiences. 

A 1998-1999 LCME (1999) survey found that of the 125 

accredited U.S. medical schools, training in substance abuse 

was provided as part of a larger required course in 119 (95 

percent). Only 10 (8 percent) had a separate required course, 

while 45 (36 percent) offered an elective course. 

The American Association of Colleges of Osteopathic Medicine (AACOM) surveyed colleges of osteopathic medicine to 

evaluate curricular offerings during the 1998-1999 academic 

year. All colleges reported offering substance abuse content 

in their curricula. On average, four percent of the curriculum 

time was reported as dedicated to substance abuse (Douglas 

Wood, personal communication). In a separate 1998 survey 

of 17 osteopathic medical schools by the American Osteopathic Academy of Addiction Medicine, only three of 11 

schools that responded reported offering separate courses in 

addiction medicine during the first two years of medical 

school (Anthony Dekker, personal communication). None of 

the schools required a clinical clerkship rotation in substance 

abuse during years three and four; however, most offered elective rotations for interested students. Data are not available 

on the percentage of osteopathic students electing substance 

abuse rotations. 

Objectives. 

The Working Group on Undergraduate Medical Education 

defined the following objectives: 

•	 Training in how to employ instruments and techniques 

useful in screening, preventive counseling, and brief 

interventions with patients at risk for or evidencing signs of 

SUDs should be integrated into the standard curricula of all 

medical schools. As a requirement for graduation, medical 

WASHINGTON, DC • DECEMBER 1-2, 2004 37

REPORTS FROM THE WORKING GROUPS


students should be able to demonstrate that they know 

how to screen, counsel, and intervene with patients so as 

to prevent the development of, or arrest the progression 

of, SUDs. 

•	 Training in the identification and management of medical 

and psychiatric comorbidities and complications of SUDs 

should be integrated into the standard curricula of all 

medical schools. As a requirement for graduation, medical 

students should be able to demonstrate that they know 

how to identify and manage such co-occurring medical 

and psychiatric disorders and complications. 

•	 Training in the clinical, legal, and ethical issues involved 

in prescribing drugs with abuse potential should be integrated into the standard curricula of all medical schools. 

As a requirement for graduation, medical students should 

be able to demonstrate that they understand these 

considerations in prescribing for patients, including patients 

at risk for, presenting with, or with a history of SUDs, so 

as to minimize the risk of inducing or perpetuating an SUD. 

•	 Licensure examinations should include questions that test 

the applicant’s mastery of the relevant body of knowledge 

and skills. 

Recommendations. 

To achieve these objectives, the members of Group 1 recommended the following action steps: 

1.	 Establish an expert panel or special content group to assist 

the National Board of Medical Examiners with test questions on SUDs. 

2.	 Compile and disseminate information about potential model 

curricula for teaching about SUDs at the undergraduate 

level. As a first step, ask the conferees to submit information about possible models for compilation in the project 

database and dissemination to interested parties. Ask the 

Surgeon General to convene a meeting of medical school 

leaders to discuss ways to get the curricula adopted. 

3. Work with the Federation of State Medical Boards (FSMB) 

to strengthen the language addressing the requirements 

of the medical licensing boards concerning the content of 

board examinations related to SUDs. 

4. Work with the Surgeon General and medical societies to 

draft a strong ethical statement that says physicians may 

not ignore the signs or symptoms of SUDs: “Substance 

use disorders are medical illnesses and may not be ignored 

or go untreated. We do not choose the illnesses we treat.” 

5.	 Work with medical student organizations to help them 

advocate for better education on the identification and management of SUDs (this was enthusiastically supported by 

the two medical students who were present in Group 1). 

6.	 Create a “marketing strategy” through which medical 

schools are rated on the SUDs content of their curricula, 

with the results prominently disseminated in medical and 

addiction journals (just as the rankings of U.S. colleges and 

universities are published in U.S. News & World Report). 

7. Work with NIAAA, NIDA, and the Association of American 

Medical Colleges (AAMC) to establish and fund programs 

to support the development of young medical school faculty as substance abuse researchers, teachers, and mentors. 

GRADUATE MEDICAL EDUCATION 

Findings. 

The Accreditation Council for Graduate Medical Education 

(ACGME) oversees the training of 98,220 postgraduate (resident) physicians and the accreditation of 7,731 residency 

training programs in 99 specialty and subspecialty areas. 

Although several professional organizations have called for a 

greater integration of substance abuse education into allopathic and osteopathic residency training programs, the 

impact of these recommendations has been variable. For 

example, although the ACGME was represented in the 

development of the Policy Report of the Physician Consortium on Substance Abuse Education, substantive changes in 

Residency Review Committee (RRC) standards, requiring 

expanded integration of substance abuse curriculum into residency programs, never occurred (John Gienapp, personal 

communication). 

A similar lack of impact was seen in osteopathic residency 

training standards (Eugene Oliveri, personal communication). 

Recent data indicate that there are RRC program requirements regarding substance abuse education in only five of 

the 99 specialty training programs (anesthesiology, family 

practice, internal medicine, obstetrics/gynecology, and 

psychiatry) (AMA, 1998). 

A survey conducted in 1988 with a 74 percent response rate 

revealed that the proportion of departments that offered a 

curriculum unit in substance abuse was 93/232 (40 percent) 

for internal medicine, 195/288 (68 percent) for family medicine, 38/139 (27 percent) for pediatrics, and 153/169 (91 

percent) for psychiatry (Davis et al., 1988). A recent national 

survey was conducted to determine the extent of substance 

abuse training in residency programs. This survey of 1,831 

allopathic and osteopathic residency program directors in 

emergency medicine, family medicine, internal medicine, 

pediatrics, psychiatry, and obstetrics/gynecology found that 

the percentage of programs requiring substance abuse training ranged from 32 percent (pediatrics) to 95 percent (psychiatry), yielding a combined average of 65 percent. The 

median number of curricular hours ranged from three to 12. 

The traditional grand rounds lecture was the most common 

38 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


curricular format used to teach substance abuse topics; only 

family medicine (55 percent) and psychiatry (75 percent) 

reported that a majority of their programs required clinical 

rotations. In recent surveys, the most commonly cited factors 

limiting further integration of substance abuse training into 

residency programs include a perceived lack of time, faculty 

expertise, identified training sites, and institutional support 

(Fleming et al., 1999; Isaacson et al., 2000). 

While physician training should be geared toward a broad 

range of skills, including screening, intervention, referral, and 

follow-up care, it would be desirable that some proportion of 

substance abuse training be performed in specialized settings 

in order to expose trainees to this type of care. A separate 

survey has revealed that fewer than 10 percent of the faculty 

who teach substance abuse topics perform clinical work in 

addiction treatment programs, and that teaching is infrequently performed in these settings (Fleming et al., 1999). 

Implementing screening, preventive counseling, and brief 

intervention is best approached as a systems issue (Fleming, 

2002). Clinical services and the providers who deliver them 

need to be linked in terms of both location and reimbursement. Health care settings are complex systems with multiple 

competing agendas; therefore, implementation strategies must 

involve convincing purchasers (e.g., employers and government agencies) and payers (e.g., insurance companies and 

HMOs) to provide financial support and leadership. Both the 

purchasers and the providers need to be convinced that 

prevention of and early intervention for SUDs will improve 

the health of their covered populations and reduce health care 

and social costs. Similarly, professional organizations need to 

take a more active role in persuading payers to allocate a level 

of resources to the problem that approximates the impact of 

SUDs on the public health and economy (Fleming, 2002). 

Objectives. 

The Working Group on Graduate Medical Education identified the following objectives: 

•	 Training in how to employ instruments and techniques 

useful in screening, preventive counseling, and brief interventions with patients at risk for or evidencing signs of 

SUDs should be integrated into the standard curricula of 

all residency training programs. Such programs should 

require residents to demonstrate that they know how to 

screen, counsel, and intervene with patients so as to prevent the development of, or arrest the progression of, SUDs. 

•	 Instruction in the identification and management of medical and psychiatric comorbidities and complications of 

SUDs also should be integrated into the standard curricula 

of all residency training programs. Such programs should 

require residents to demonstrate that they know how to 

identify and manage such co-occurring medical and 

psychiatric disorders and complications. 

•	 Training in the clinical, legal, and ethical issues involved 

in prescribing drugs with abuse potential should be integrated into the standard curricula of all residency training 

programs. Such programs should require residents to 

demonstrate that they understand these considerations in 

prescribing for patients, including patients at risk for, 

presenting with, or with a history of SUDs, so as to minimize the risk of inducing or perpetuating an SUD. 

•	 Specialty board examinations should include questions that 

test the applicant’s mastery of the relevant body of knowledge and skills. 

Recommendations. 

The members of Group 2 designed a two-pronged approach 

to achieve these objectives: (1) address the extrinsic larger 

systems factors outside medicine, such as factors that impede 

the identification, treatment, and referral of patients with SUDs: 

for example, insurance coverage that does not work, loss of 

treatment facilities, and carve-outs that mean doctors are not 

being paid for what we want them to do in caring for patients 

with SUDs, and (2) attack the intrinsic systems factors inside 

medicine, such as residency programs, stigma associated with 

alcoholics and other patients with SUD, and transmission of 

negative attitudes toward SUDs from older medical staff to 

younger staff. To achieve this, the members of Group 2 proposed the following action steps: 

1.	 To address the extrinsic factors, identify a sponsor and 

potential funders for a high-level think tank-type meeting 

to bring together the major purchasers and administrators 

of health care to focus on the economic implications of 

SUDs. Attendees would include private sector employers, 

such as IBM and General Motors; public sector funders, 

such as the Centers for Medicare & Medicaid Services, 

Medicaid claims administrators, state alcohol and other 

drug agencies, presidents of Blue Cross Blue Shield plans 

and of “big medicine” educational groups (e.g., AAMC, 

ABMS, and ACGME), and the Chair of the Deans’ Association of AAMC; and business and health consulting 

groups capable of offering econometric and business 

analyses, such as Leapfrog, Lewin, and RAND. 

2.	 To address the intrinsic factors, identify a sponsor and 

potential funders for a second meeting, to bring together 

representatives of the institutions of medicine to focus on 

the overarching need to set minimum standards for training all medical students and residents in the recognition 

of SUDs. Attendees would include the ACGME leadership, 

the heads of the respective American Board of Medical 

Specialties (ABMS) boards, the Chairs of the RRCs, and 

others who create and maintain the core content for each 

of the specialties. 

WASHINGTON, DC • DECEMBER 1-2, 2004 39

REPORTS FROM THE WORKING GROUPS


3. Approach the ACGME and RRCs for help in identifying 

and disseminating information about model residency 

training programs that incorporate teaching about SUDs. 

As a first step, ask the conferees to submit information 

about possible models for compilation in the project database and dissemination to interested parties. 

4. Work with the ABMS to strengthen the language articulating the requirements of the various specialty boards for 

the content of examinations related to SUDs. As a first 

step, ask the conferees to submit copies of relevant special 

board requirements for compilation in the project database and dissemination to interested parties. 

5. Compile and disseminate information about available 

fellowship opportunities in addiction medicine and addiction psychiatry. As a first step, ask the conferees to submit 

information about fellowship opportunities for compilation in the project database and dissemination to interested 

parties. 

6. Compile and disseminate information about sources of 

available funding to support modification of residency 

training curricula to include greater attention to substance 

use disorders. As a first step, ask the Federal agency and 

foundation representatives to submit information on funding sources, for compilation in the project database and 

dissemination to interested parties. 

CONTINUING MEDICAL EDUCATION 

Findings. 

Continuing medical education is a system that provides 

resources to physicians engaged in individualized “learning 

projects.” Such projects are designed to support an individual’s 

continuous and personal professional development agenda, 

which reflects his or her scope of practice (e.g., clinical, educational, administrative, leadership). Some of these activities 

have been identified by the AMA as credible and valid learning activities deserving of Category I Credit in the Physicians 

Recognition Award of the American Medical Association. This 

system of recognizing continued learning is administered by 

the Accreditation Council for Continuing Medical Education 

(ACCME). 

Continuing education is effective in changing practice behaviors if it is framed correctly. Each type of activity is suited to 

a particular learning need. For example, didactic lectures and 

books transfer data and information. Supervised work and 

coaching support the development of skills. Reflection and 

small group work facilitate the transition to competence. This 

is why CME that is effective in promoting change in practice 

always involves multiple steps and modalities spread over 

time, and includes feedback as well as reminders in practice. 

The common features of all CME activities are that the 

content, objectives, and elements of evaluation share the 

following features: (1) they are anchored to the learner’s practice-based questions or needs, (2) their content is valid, and 

(3) they are free of commercial bias. The CME system, through 

its accredited providers, brings form and function to these 

features by structuring or facilitating them as learning 

activities that are designed to advance the learner along a 

knowledge, competence, or performance agenda. 

The contents of accredited CME programs are derived from 

practice-based needs, whether at the level of individual 

physicians, medical communities, or larger physician populations. Physicians are involved in CME programs to fulfill 

their learning goals. Not all learning requires an accredited 

provider-based activity, but all accredited provider-based 

activities should result in, or at least be designed to promote, 

learning. The presence of a method to assure that all three 

features are present in a learning activity is the value that the 

CME accreditation system brings to the learner. 

Objectives. 

The Working Group on Continuing Medical Education identified the following objectives, which it designated “strategic 

imperatives”: 

*	 Mainstream education about SUDs by teaching them in 

the same way that knowledge and skills in addressing other 

chronic disorders are taught. 

*	 Overcome stigma by engaging experienced physicians who 

are experts on SUDs in mentoring younger/novice physicians. Also, encourage colleagues and organizations to 

present positive public messages about SUDs and to avoid 

implicitly negative language and messages. 

*	 Engage health care purchasers and payers in addressing 

reimbursement and coding issues (as represented by parity 

and the Uniform Accident and Sickness Policy and Provision Laws). 

*	 Encourage all medical organizations to adopt a standard, 

clinically focused terminology, as CSAP has done over the 

years with prevention terminology. For example, in medical 

forums, refer to “relapse” rather than “recidivism,” to “opioids” rather than “narcotics,” and to “patients” rather than 

“clients.” 

Recommendations. 

To achieve the foregoing objectives, the members of Group 

3 proposed the following action steps: 

1. Work with ACGME and the various specialty boards to 

strengthen the requirements for continuing education on 

SUDs. In addition, encourage the specialty boards to 

include questions that test the applicant’s mastery of the 

body of knowledge and skills relevant to SUDs in their 

recertification examinations. 

40 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


2. Work with ABMS and the state medical boards to include questions that test the applicant’s mastery of the body of knowledge 

and skills relevant to SUDs in their licensure examinations. 

3.	 Compile and disseminate information about potential 

model CME programs about SUDs. As a first step, ask the 

conferees to submit information about possible models for 

compilation in the project database and dissemination to 

interested parties. Collaborate with ACCME to develop a 

“www.accme.gov” Web site, where approved educational 

programs could be listed. 

4. Facilitate a connection between ONDCP, other leaders of 

the initiative, and organizations that represent the CME 

infrastructure (i.e., those that provide and accredit CME 

programs). Through such a relationship, the CME providers could be engaged in promoting the concept that public 

health issues (including SUDs) should be addressed through 

their systems and members. 

5	 Facilitate a connection between Federal agency staff who 

have CME responsibilities and the group of experts within 

ONDCP and other leaders of the initiative. If government 

CME providers were to embrace the concept of partnering 

with private sector organizations, the dissemination 

strategy would be in place. For example, the National 

Institutes of Health, Centers for Disease Control and Prevention, or Federal Drug Administration could invite the 

national medical specialty societies to become partners in 

developing and presenting clinical modules on identifying 

and managing SUDs (few would decline such an offer). 

Look to the buprenorphine training courses (the curricula 

for which were developed through a collaboration between 

CSAT and selected medical specialty societies) as a model. 

6. Teach about prescribing drugs with abuse potential in the 

same way other areas of clinical knowledge and skills are 

taught. Use all the educational media available, including 

new media such as teleconferencing and online CME 

programs. Employ multiple focused interventions (in the 

same way pharmaceutical manufacturers do with the rollout of a new drug) through partnerships between Federal 

agencies and relevant private sector organizations. 

7. Work with NIAAA and NIDA to identify and disseminate 

information about sources of funding to support clinical 

research into the prevention, identification, and management of prescription drug abuse. 

8.	 Incorporate language that reflects competency in prescribing 

controlled drugs into licensure standards and certification/ 

recertification programs. Require that at the time of 

re-registration with DEA, physicians present evidence of 

CME credits and/or focused self-assessment to achieve 

this competency. 

9. Revise patient charts to move the personal/family history 

of alcohol and drug problems from the “Social History” 

to the “Past Medical History,” where it is more likely to be 

considered in the prescribing decision. Add similar cues 

to the screens of electronic medical records. 

10. Add reminders about prescribing considerations and 

cautions to the backs of prescription forms (especially 

state-issued forms). 

11. Through public-private partnerships (e.g., NIDA and 

ACOG), identify and/or develop educational materials that 

physicians can give to patients for whom they prescribe 

drugs with abuse potential. 

ROLE OF THE FEDERAL AGENCIES 

Findings. 

Conferees agreed that the Federal health agencies have an 

important role to play in physician education, acting through 

multiple mechanisms: 

RESEARCH GRANT SUPPORT. Increased grant support for 

research designed to foster physicians’ competencies in identifying and addressing SUDs will not only stimulate research 

in the field, but also provide needed support to faculty with 

critical research agendas. Examples of potential research 

agendas for these faculty include determining the appropriate health care profession to perform a brief intervention, 

determining the critical components of brief interventions, 

exploring the need to adapt screening and brief intervention 

strategies to special populations, and determining the most 

effective teaching strategies for training clinicians in screening and brief interventions. The opportunities to compete 

for research grants in these areas will help stimulate faculty 

interest, promote career development for faculty interested 

in this field, create new and useful knowledge, and add legitimacy to the field. Successful grantees will also serve as role 

models or mentors for junior faculty members. 

INSTITUTIONAL SUPPORT. Institutional support for faculty 

teaching about SUDs can be developed via funding mechanisms that are designed to foster development of curriculum 

or research efforts. Funds that are targeted toward programs 

that cut across disciplines (e.g., medicine, social work, nursing) will foster development of collaborative research and 

training efforts and help engender institutional support. 

CENTERS OF EXCELLENCE. Federally funded National 

Centers of Excellence are needed to serve as model programs 

that are focused on developing, disseminating, and implementing methods of research, clinical care, and education 

on SUDs. Such centers could participate in a network to 

develop and implement a standard curriculum for undergraduate, graduate, and postgraduate medical education. Current 

Federally supported initiatives with national infrastructures, 

such as the Area Health Education Centers supported by the 

Health Resources and Services Administration (HRSA), the 

Addiction Technology Transfer Centers supported by CSAT, 

and the Clinical Trials Network supported by NIDA, can 

provide a framework on which to build the proposed centers. 

WASHINGTON, DC • DECEMBER 1-2, 2004 41

REPORTS FROM THE WORKING GROUPS


Objectives. 

The members of the Working Group of Federal Agencies identified the following objectives: 

•	 Training in how to employ instruments and techniques 

useful in screening, preventive counseling, and brief interventions with patients at risk for or evidencing signs of 

SUDs should be integrated into the standard curricula of 

all medical schools, residency training, and continuing 

education programs. 

•	 Training in the identification and management of medical 

and psychiatric comorbidities and complications of SUDs 

should be integrated into the standard curricula of all 

medical schools, residency training, and continuing education programs. 

•	 Training in the clinical, legal, and ethical issues involved 

in prescribing drugs with abuse potential should be 

integrated into the standard curricula of medical schools, 

residency training, and continuing medical education programs in all specialties. 

•	 Federal agencies should assist in the development, dissemination, and evaluation of these curricula at all levels 

of physician training. 

Recommendations. 

The members of Group 4, all of whom represented Federal 

agencies, responded to the following question: “Assume we 

have accomplished all the competencies by the year 2010, 

what did the government do to make it happen?” They agreed 

that the Federal government could play the following roles: 

1. Bring resources and authority to the issue (as the ONDCP 

Director, the Surgeon General, the NIDA and NIAAA 

Directors, and the NHTSA Administrator did at the Leadership Conference). 

2. Elevate the visibility of the subject to the highest levels of 

the agencies, and encourage collaboration across agencies (e.g., Department of Health and Human Services and 

VA working together). 

3. Keep working to find ways to convince physicians that 

SUDs are medical disorders. Simultaneously, help physicians understand the impact of SUDs on other medical 

disorders for which they provide care (as Dr. Volkow 

advised in her presentation). 

4. Break the problem down by stage of illness. Develop 

different treatment and referral models for the early, 

middle, and late stages of the disorder, as is done with 

other chronic disorders. 

5.	 Use information that is already available (such as the 

SAMHSA Treatment Improvement Protocols and the VA 

clinical practice guidelines) to provide frameworks for the 

development of clinical models. (SAMHSA’s initiatives with 

the recovery and faith-based communities would be an 

important piece.) 

6. The VA system can begin to develop models for medical 

education, then use its clout to renegotiate contracts with 

medical schools to incorporate them. 

7.	 HRSA could provide funding for the development and 

implementation of clinical models for its target populations (e.g., for treatment in rural areas) in collaboration 

with other agencies. 

8. Work together across multiple agencies, including payers 

such as Medicare and Medicaid and other organizations 

to develop more ideas about clinical models. Such clinical 

models would, in turn, facilitate the development of reimbursement models. (Alternatively, develop guidelines, then 

let economists develop the models.) 

9. Support research into strategies that promote system 

change and provider change. Work with the credentialing 

bodies to develop and maintain incentives for change. Test 

the models’ efficacy with demonstration projects, funded 

through contracts and requests for applications. 

10. Compile and disseminate information about sources of 

available funding to support modification of medical school 

curricula and residency training programs, as well as 

development of continuing education programs, to include 

greater attention to SUDs. As a first step, ask the Federal 

agency and foundation representatives to submit information about available funding for compilation in the project 

database and dissemination to interested parties. 

The members of Group 4 pointed to nutrition and geriatrics 

as good examples of how cross-cutting ideas are incorporated into medical education, and suggested that these and 

other specialties should be studied as models. 

PUBLIC INPUT 

Recommendations. 

The following recommendations were presented by Dr. Sidney 

Schnoll, representing the Public Input Working Group: 

1. Work with NIAAA and other agencies to develop and fund 

a program (like that outlined by Dr. Li in his presentation) 

that would support the development of medical school 

faculty who are experts on SUDs. Such individuals 

become “champions” for adding addiction-related content 

to the curriculum in undergraduate and graduate medical 

education and become role models and mentors for 

students. 

2.	 Work with ASAM, AOAAM, and the American Academy 

of Addiction Psychiatry to develop a joint committee to 

develop questions on SUD-related topics for medical 

schools, the National Board of Medical Examiners, and 

other developers of certification/recertification examinations. As part of this, look at the case simulation 

materials developed by Barry Stimmel, M.D., and 

42 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


colleagues at the Mount Sinai Medical School for use in 

clinical skills testing. (Some years ago, copies of these 

materials were sent to every medical school dean in the 

United States. Unfortunately, the information is probably 

tucked away on a shelf gathering dust.) 

3.	Include the pharmaceutical industry in all plans for 

educational programs to address prescription drug abuse, 

because industry has more resources and better data than 

the Federal government and already is a major sponsor of 

continuing medical education. 

ACTION PLANS 

To sustain the momentum generated at the Leadership Conference,


the conferees recommended that the following actions be initiated as quickly as possible:


1.	 In lieu of a standard written conference evaluation, arrange 

for the facilitators to individually debrief conference participants to learn their reactions, ideas, and suggestions 

for follow-up activities. Revise the follow-up plan to reflect 

the information gathered through the debriefing process. 

[Completed] 

2. Compile the “next steps” proposed by each of the Working Groups and disseminate the resulting draft document 

to all Leadership Conference participants. Arrange a 

conference call with the chairs, co-chairs, facilitators, and 

reporters of the Working Groups to review the document 

and to identify common issues and themes. [Completed] 

3.	 Send the draft conference report to Working Group members 

for review and comment. Arrange a follow-up conference 

call with each of the Working Groups to discuss the report 

and follow-up plans. [Completed] 

4. Invite the conference participants, the Federal agencies, 

and the medical specialty societies to submit relevant 

educational programs and curricula for undergraduate, 

graduate, and continuing medical education for compilation in the project database and dissemination to interested parties. Ask the Expert Panel members to assist in 

compiling and evaluating this information. [Underway] 

5.	 Ask the Federal agency and foundation representatives and 

other conference participants to submit information on 

available program and research funding for compilation 

in the project database and dissemination to interested 

parties. [Underway] 

6. Develop articles describing the conference and submit 

them to refereed journals for publication, including the 

Journal of the American Medical Association, the Journal of 

the American Osteopathic Association, specialty journals for 

the various medical specialties, policy journals such as 

Health Affairs, newsletters, and other publications. Frame 

different aspects of the conference to address the interests of particular audiences. [Underway] 

7. Initiate meetings between representatives of appropriate 

Federal agencies and educational providers, organizations 

representing the prescribing professions, and other stakeholder groups to identify mutual goals and initiate collaboration on project development and dissemination. 

[Underway] 

8. Invite the Leadership Conference participants to identify 

opportunities to gather informally at forthcoming meetings of their organizations. Ask the participating organizations to consider helping to organize and/or sponsor such 

gatherings. [Underway, with the first gathering held at ASAM’s 

annual meeting in April 2005] 

9. Arrange meetings between ONDCP staff and representatives of Groups 1 and 2 with executives of ABMS and the 

Association of American Medical Colleges (whose leaders were unable to attend the conference because of a 

conflicting engagement). [Underway] 

There was virtually unanimous agreement among the 

conference participants that considerable progress had been 

made and that a follow-up meeting should be scheduled in 

one year to revisit the objectives, strategies, and action steps 

and to assess progress toward achieving them. In the interim, 

the conferees suggested that the Expert Panel continue to 

meet as an organizing nucleus and that task forces be 

appointed to pursue specific objectives. 

In his closing remarks, conference chair Addison D. “Tad” 

Davis IV, ONDCP’s Assistant Deputy Director for Demand 

Reduction, pledged that his office would work to sustain the 

energy and commitment evidenced by the conferees, saying 

“I met with the Surgeon General within the last two weeks. 

He’s fully on board with what we’re trying to accomplish here, 

and he’s committed to staying with us, as are Dr. Runge and 

Director Walters and others in the community. I think that 

your presence here as a group has reinforced the importance 

of the efforts that are underway.” 

Mr. Davis added that “We will continue to work with other 

agencies, organizations, health care professionals, and leaders in the medical community to develop strategies to integrate new knowledge about alcohol and drug abuse and 

addiction into medical education.” 

WASHINGTON, DC • DECEMBER 1-2, 2004 43

REPORTS FROM THE WORKING GROUPS


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American Medical Association (1998). Report of the Council 

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Bien TH, Miller WR & Tonigan JS (1993). Brief interventions 

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Bradley KA (1994). The primary care practitioner’s role in 

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Bradley KA, Bush KR, McDonell MB, Malone T & Fihn SD 

(1998). Screening for problem drinking. Comparison of CAGE 

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Carroll KM & Schottenfeld R (1997). Nonpharmacologic 

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Dube CE, Lewis DC, Cyr MG & Zwick WR (1989). Project 

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Fiellin DA, Butler R, D’Onofrio G, Brown RL & O’Connor PG 

(2002). The physician’s role in caring for patients with 

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Fiellin DA, Reid MC & O’Connor PG (2000). Screening for 

alcohol problems in primary care: A systematic review. 

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Fleming MF (2002). Screening, assessment, and intervention 

for substance use disorders in general health care settings. In 

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Stauffacher EA (1999). Who teaches residents about the prevention and treatment of substance use disorders? Journal 

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Fleming MF, Mundt MP, French MT et al. (2000). Benefitcost analysis of brief physician advice with problem drinkers 

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Gentilello LM, Rivara FP, Donovan DM et al. (1999). Alcohol 

interventions in a trauma center as a means of reducing the 

risk of injury recurrence. Annals of Surgery 230(4):473-480. 

Gordis E (2003). Conceptual advances in understanding 

alcoholism. In AW Graham, TK Schultz, MF Mayo-Smith, RK 

Ries & BB Wilford (eds.) Principles of Addiction Medicine, Third 

Edition. Chevy Chase, MD: American Society of Addiction 

Medicine. 

Harvard School of Public Health and The Robert Wood 

Johnson Foundation (2000). Report on public attitudes toward 

illegal drug use and drug treatment (telephone survey of 1,012 

adults conducted by International Communications 

Research), unpublished slide presentation. 

44 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


REFERENCES continued 

Institute of Medicine (1990). Treating Drug Problems. Washington, DC: National Academy Press. 

Isaacson JH, Hopper JA, Alford DP & Parran T (in press 2005). 

Prescription drug abuse: What primary care physicians need 

to know. Journal of Family Practice. 

Isaacson JH, Fleming MF, Kraus M, Kahn R & Mundt M 

(2000). A national survey of training programs in SUD in 

residency programs. Journal of Studies on Alcohol 61:912-915. 

Kessler RC, McGonale KZ, Shanyang Z et al. (1994). Lifetime 

and 12-month prevalence of DSM-III-R psychiatric disorders 

in the United States: Results from the National Comorbidity 

Survey. Archives of General Psychiatry 51:8-18. 

Koob GF, Roberts AJ, Schulteis G et al. (1998). Neurocircuitry 

targets in ethanol reward and dependence. Alcoholism: Clinical 

& Experimental Research 22(1):3-9. 

Kraus ML, Isaacson JH, Kahn R, Mundt MP & Manwell LB 

(2001). Medical education about the care of addicted incarcerated persons: A national survey of residency programs. 

Substance Abuse 22:97-104. 

Leshner AI (2003). Understanding drug addiction: Insights 

from the research. In AW Graham, TK Schultz, MF MayoSmith, RK Ries & BB Wilford (eds.) Principles of Addiction 

Medicine, Third Edition. Chevy Chase, MD: American Society 

of Addiction Medicine. 

Lewis DC (1994). Training about alcohol and substance abuse 

for all primary care physicians. Paper presented at: Training 

about Alcohol and Substance Abuse for All Primary Care 

Physicians (conference). New York, NY: Josiah Macy 

Foundation. 

Lewis DC, Niven RG, Czechowicz D & Trumble JG (1987). A 

review of medical education in alcohol and other drug abuse. 

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McLellan AT, Lewis DC, O’Brien CP & Kleber HD (2000). 

Drug dependence, a chronic medical illness: Implications for 

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the American Medical Association 284:1689-1695. 

National Institute on Alcohol Abuse and Alcoholism (NIAAA) 

(1997). Training Physicians in Techniques for Alcohol Screening 

and Brief Intervention. Training manual for The Physicians’ 

Guide to Helping Patients with Alcohol Problems. Rockville, MD: 

NIAAA, National Institutes of Health. 

National Institute on Drug Abuse (1999). Principles of Drug 

Addiction Treatment: A Research-Based Guide. Rockville, MD: 

NIDA/National Institutes of Health (NIH Publication No. 99­

4180), 14. 

National Institute on Drug Abuse (1998). The Economic Costs of 

Alcohol and Drug Abuse in the United States — 1992. Rockville, MD: 

National Institute on Drug Abuse, National Institutes of Health. 

Nestler EJ & Aghajanian GK (1997). Molecular and cellular 

basis of addiction. Science 278:58-63. 

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Regier DA, Farmer ME, Rae DS et al. (1990). Comorbidity of 

mental disorders with alcohol and other drug abuse. Results 

from the Epidemiologic Catchment Area (ECA) Study. Journal 

of the American Medical Association 264(19):2511-2518. 

Saitz R, Mulvey KP, Plough A & Samet JH (1997). Physician 

unawareness of serious substance abuse. American Journal 

of Drug and Alcohol Abuse 23:343-354. 

Saitz R, Sullivan LM & Samet JH (2000). Training community-based clinicians in screening and brief intervention for 

substance abuse problems: Translating evidence into practice. 

Substance Abuse 21:21-31. 

U.S. Preventive Services Task Force (2004). Screening and 

Behavioral Counseling Interventions in Primary Care to 

Reduce Alcohol Misuse: Recommendation Statement. American Family Physician www.aafp.org/afp/20040715/us.html 

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Archives of Internal Medicine 159(9):913-924. 

WASHINGTON, DC • DECEMBER 1-2, 2004 45

REPORTS FROM THE WORKING GROUPS


ACKNOWLEDGEMENTS:


Sections of this report were adapted with permission from David A. Fiellin, M.D., Richard Butler, D.O., Gail 

D’Onofrio, M.D., Richard L. Brown, M.D., M.P.H., and Patrick G. O’Connor, M.D., M.P.H., The Physician’s Role 

in Caring for Patients with Substance Use Disorders: Implications for Medical Education and Training, a Report of 

Project Mainstream, Discipline — Specific Recommendations for Faculty Development, 2002. Appreciation 

is expressed to the officers of Project Mainstream and of the Association for Medical Education and Research 

in Substance Abuse, as well as to the original authors, for their generous assistance in the preparation of this 

document. 

The conference organizers also express their gratitude to David C. Lewis, M.D., and the other organizers of 

the 1994 Macy Conference on Training About Alcohol and Substance Abuse for All Primary Care Physicians, 

for their many contributions to the current effort. 

46 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


RESOURCE DOCUMENTS


AMERICAN MEDICAL ASSOCIATION (1979): 

GUIDELINES FOR PHYSICIAN INVOLVEMENT IN THE CARE OF SUBSTANCE-ABUSING PATIENTS 

I

n 1979, the American Medical Association adopted a policy statement entitled “Guidelines for Physician 

Involvement in the Care of Substance-Abusing Patients.” The Guidelines articulate the principle that every 

physician must assume clinical responsibility for the diagnosis and referral of patients with substance use 

disorders, and broadly define the competencies required to meet that responsibility. The Guidelines thus represent one of the first efforts by a major medical organization to highlight the need for all physicians to have 

competence to address substance use disorders. The Guidelines are published here in their entirety. 

“Alcoholism and other drug dependencies are among the most difficult to treat of medicine’s challenges. 

As physicians, we all have a role in the prevention and treatment of alcohol — and drug-related problems, 

and this role must be addressed now. The future of too many of our current and future patients demands 

that we no longer accept such losses silently.” 

– Otis R. Bowen, M.D., Secretary of Health and Human Services, and


James H. Sammons, M.D., Executive Vice President, American Medical Association


LEVEL I 

For all physicians with clinical responsibility: Diagnosis and Referral: 

•	 Recognize as early as possible alcohol- or drug-caused dysfunction. 

•	 Be aware of the medical complications, symptoms, and syndromes by which alcoholism (or drug 

abuse) is commonly presented. 

•	 Ensure that any complete health examination includes an in-depth history of alcohol and other


drug use.


•	 Evaluate patient requirements and community resources so that an adequate level of care can be 

prescribed, with patients’ needs matched to appropriate resources. 

•	 Make a referral to a resource that provides appropriate medical care. 

LEVEL II 

For physicians accepting limited treatment responsibility (to restore the individual patient to the point 

of being capable of participating in a long-term treatment program): 

•	 Assist the patient in achieving a state free of alcohol and other drugs, including management of 

acute withdrawal syndrome. 

•	 Recognize and treat, or refer, all associated or complicating illnesses. 

•	 Apprise the patient of the nature of his disease and the requirements for recovery. 

•	 Evaluate resources — physical health, economic, interpersonal, and social — to the degree


necessary to formulate an initial recovery plan.


WASHINGTON, DC • DECEMBER 1-2, 2004 47

RESOURCE DOCUMENTS


•	 Determine the need for involving significant other persons in the initial recovery plan. 

•	 Develop a long-term recovery plan in consideration of the above standards and with the patient’s 

participation. 

LEVEL III 

For physicians accepting responsibility for long-term treatment: 

•	 Acquire knowledge, by training and/or experience, in the treatment of alcoholism (and other 

drug dependence). 

•	 The following responsibilities should be conducted or supervised by the physician: 

–	 Establish a supportive, therapeutic, and nonjudgmental relationship with the patient. 

–	 Periodically evaluate and update the recovery plan with the patient’s participation. 

–	 Involve the patient with an abstinent peer group when appropriate. 

–	 Become knowledgeable about and be able to utilize various health, social, vocational,


and spiritual support systems.


–	 Evaluate directly or indirectly significant other persons and, unless clearly contraindicated, 

involve them in treatment. 

•	 Continually monitor the patient’s medication needs. After treatment of acute withdrawal, use 

psychoactive drugs only if there is a clear-cut and specific psychiatric indication. 

•	 Be knowledgeable about the proper use of pharmacotherapy. 

•	 Throughout the course of treatment, continually monitor and treat, or refer for care, any complicating 

illness or relapse. 

•	 Be available to the patient as needed for an indefinite period of recovery. 

–	 Within the confines of this relationship, establish specific conditions and limits under which 

the therapy will be conducted, and carefully explain them to the patient. 

48 OFFICE OF NATIONAL DRUG CONTROL POLICY

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THE MACY CONFERENCE (1994):


RECOMMENDATIONS FOR TRAINING ABOUT ALCOHOL AND


SUBSTANCE ABUSE FOR ALL PRIMARY CARE PHYSICIANS


I

n 1994, the Macy Conference on Training About Alcohol and Substance Abuse for All Primary Care 

Physicians moved the conversation forward by elaborating on the competencies articulated in the American 

Medical Association’s policy statement. The report of the conference also contained a number of thoughtful 

essays on the subject by conference chair David Lewis, M.D., and other leaders in medical education. 

The essay excerpted here, by David C. Lewis, M.D., of the Mt. Sinai Medical School, offers insights into why this 

body of knowledge has been so difficult to integrate into medical education, as well as recommendations for 

addressing the problem. 

Chairman’s Summary and Conclusions 

David C. Lewis, M.D. 

According to studies cited during this Macy Conference, our 

nation is paying almost $240 billion a year for undiagnosed 

and untreated substance abuse in the form of medical complications and social problems. It seems obvious that, to save 

time and money, physicians need to be better trained to make 

diagnoses and perform interventions in the course of their 

practice, so that we are not just dealing later with the much 

more expensive complications of substance abuse. 

How to make the case for more adequately training physicians to routinely attend to the substance abuse problems 

they encounter was the challenge presented to the conference planning committee. The committee responded by 

deciding to focus on the residency review committees and 

specialty boards in the primary care disciplines in an effort 

to convince them to strengthen their requirements for training in substance abuse. . . . 

It became clear . . . that the conference participants were 

well aware of the new demands of our emerging health care 

system. . . . There was a discouraging recitation of reasons 

why medical students and residents are not now receiving 

more training in substance abuse, [including] physicians’ negative attitudes toward substance-abusing patients, social and 

professional stigmas associated with physicians who treat 

these patients, and a shortage of trained faculty. But the 

arguments for enhanced training were convincing, especially 

since the competencies needed by physicians are clearly 

defined and training programs already know how to teach 

and develop these competencies. As a result, the discussions 

centered on the issue of timing — a shift from whether more 

training in substance abuse should be required to how soon 

this requirement could be implemented [see the Concluding 

Statement of the Conference Participants]. 

. . . Because the conference planning committee knew that 

the key decisions about how to implement the goals of the 

conference would be made by the boards and residency 

review committees, the conference had not been organized 

to arrive at conclusive decisions. As I reviewed the proceedings of the conference, however, I found a number of strong, 

action-oriented recommendations that had been made during 

the course of the discussions [which follow]. 

I.	 Action Steps for Certifying Boards of Primary 

Care Medical Specialties and the American 

Board of Medical Specialties 

1. Convene primary care boards to determine a set of 

enhanced requirements that board-certified physicians 

must meet with respect to demonstrated expertise and 

training regarding substance abuse. 

2. Consider pilot projects in which the boards use standardized patients to evaluate professional skills related 

to managing substance abuse patients. Coordinate 

with certifying examiners to ensure that questions 

gleaned from encounters with standardized patients 

are reflected on certifying examinations. 

II.	 Action Steps for the Accreditation Council for 

Graduate Medical Education (ACGME) 

1.	 Define substance abuse training standards in ACGME 

general requirements and for the residency review 

committees in all the medical specialties. 

2. “Fast track” all new general and special requirements 

regarding substance abuse training in graduate medical education. 

III. Action Steps for Residency Review Committees 

in Primary Care Specialties (Family Practice, 

Internal Medicine, Pediatrics, and Obstetrics 

and Gynecology) 

1.	 Require more residents’ training to involve experience 

with substance-abusing patients. 

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2.	 Work collaboratively with the Residency Review Committee in Psychiatry to develop common language for 

all special requirements involving training in the 

management of substance abuse. 

3. Require training programs to have faculty members 

who have been trained specifically to manage substance abuse. 

4.	 Require training programs to include substance abuse 

treatment centers as training sites, and assign residents for a one-month rotation in these centers. 

5. Require residents to maintain a case registry of substance abuse patients, and routinely survey residents 

about their experiences. 

6. Require program directors to have residents directly 

observed while managing substance abuse patients 

to ensure their competence. This requirement should 

be part of the annual RRC program audit. 

7. Require training programs to provide residents with 

special training and experience with physicians who 

are impaired due to substance abuse problems. 

IV.	 Action Steps for the Liaison Committee on 

Medical Education and the National Board of 

Medical Examiners 

1. Specify the requirements for medical school educational programs related to substance abuse. 

2. Reinforce and emphasize these requirements in the 

United States Medical Licensing Examination and subject tests of the National Board of Medical Examiners. 

V.	 Action Steps for Medical School Leaders 

1. Reject applicants to medical school whose attitudes 

toward [patients with substance use disorders] . . . 

would make them incapable of treating [such patients] 

. . . in a professional manner. 

2.	 When recruiting new clinical faculty, seek individuals with 

training in the management of substance-abusing patients. 

(The Association for Medical Education and Research in 

Substance Abuse and the American Society of Addiction 

Medicine can assist in identifying potential faculty 

members with this expertise and experience.) 

VI. Action Steps for Leaders of the Medical 

Professions 

1. Educate professionals to understand that substance 

abuse is an intermittent, relapsing chronic disease that 

is preventable, can be treated effectively, and is not 

usually a manifestation of mental disease. 

2. Educate professionals that, in addition to mastering 

problems with drinking or a drug, functional improvements in family, work, and social adjustment are also 

important in achieving gains in quality of life. 

3. Fight professional stigmas attached to physicians and 

other providers who care for substance- abusing patients. 

4. Develop treatment protocols and performance standards for physicians and other providers who care for 

substance-abusing patients. 

VII. Action Steps for Public Policy Makers 

1. Recognize that substance abuse is a disease and reimburse for its treatment comparably to any other disease. 

2. Eliminate managed care restrictions on referrals to 

substance abuse specialists — especially restrictions 

that hinder access to substance abuse treatment. 

3.	 Establish national standards for accrediting substance 

abuse treatment centers. 

4. Support the establishment of fellowship programs to 

train medical school faculty in the management of 

substance abuse. 

5.	 Support basic research and treatment outcomes 

research related to substance abuse. 

Dr. Richard DeVaul’s survey eight months after the conference revealed that the boards and residency review committees had taken significant steps toward implementing the goals 

of the conference. 

CONCLUDING STATEMENT OF THE PARTICIPANTS 

We recommend that the specialties of Family Practice, Internal Medicine, Pediatrics, and ObstetricsGynecology promptly respond to the need to improve the quality of care provided by physicians trained in 

these specialties to patients with alcohol and other drug problems. 

These primary care specialties should require all residents to be trained to develop and to demonstrate those 

skills necessary to prevent, screen for and diagnose alcohol and other drug problems; to provide initial 

therapeutic interventions for patients with these problems; to refer these patients for additional care when 

necessary; and to deliver follow-up care for these patients and their families. 

The certifying boards and residency review committees of these specialties should expeditiously take specific 

actions to strengthen their requirements so that the performance of residents in managing substance abuse 

patients is measurably improved. 

50 OFFICE OF NATIONAL DRUG CONTROL POLICY

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PROJECT MAINSTREAM (2002):


RECOMMENDED PHYSICIAN COMPETENCIES


Project Mainstream, organized by the Association for Medical Education and Research in Substance Abuse 

(AMERSA) with assistance from the Health Resources and Services Administration and the Center for 

Substance Abuse Treatment, represents a multi-year effort to describe in detail the areas of knowledge 

and skills required by practitioners of many health professions. 

The competencies and recommendations offered in the Project Mainstream report have been endorsed by many 

health professions organizations, including the American Medical Association, the American Osteopathic Academy 

of Addiction Medicine, and the Society of Teachers of Family Medicine. 

Brief excerpts from the report are presented here. The full report and accompanying documents can be accessed 

at the AMERSA Web site at www.amersa.org. 

Recommendations 

CORE COMPETENCIES IN SUBSTANCE ABUSE EDUCATION FOR PHYSICIANS 

The following competencies are presented as three levels of 

involvement in the care of patients with SUD. All physicians 

with clinical contact should strive to provide Level I competence. (e.g., primary care and generalist physicians). Level III 

competence should be sought by all physicians providing 

specialty services to patients with SUD. Table 1 lists the 

competencies for each level. 

Table 1. Critical Core Competencies in Substance 

Abuse Education for Physicians 

Level I: All physicians with clinical contact should: 

1. Be able to perform age, gender, and culturally appropriate 

substance abuse screening. 

2.	 Be able to provide brief interventions to patients with SUD. 

3. Be able to use effective methods of counseling patients to 

help prevent SUD 

4.	 Be able to refer patients with SUD to treatment settings that 

provide pharmacotherapy for relapse prevention. 

5.	Recognize and treat or refer comorbid medical and 

psychiatric conditions in patients with SUD. 

6. Be able to refer patients with SUD to appropriate treatment and supportive services. 

7. Be aware of the ethical and legal issues around physician 

impairment from SUD and of resources for referring 

potential impaired colleagues, including employee 

assistance programs, hospital-based committees, State 

physician health programs, and licensure boards. 

8. Identify the legal and ethical issues involved in the care of 

patients with SUD. 

Level II: All physicians coordinating care for patients 

with SUD in addition should: 

1. Use effective methods to assess patients with SUD. 

2. Provide pharmacologic withdrawal to patients with SUD. 

Level III: All physicians providing specialty services 

to patients with SUD in addition should: 

1.	 Provide pharmacotherapy for relapse prevention in 

patients with SUD. 

2. Provide, or refer for psychosocial counseling for relapse 

prevention in patients with SUD. 

RECOMMENDATIONS FOR LEVEL I 

COMPETENCIES 

All physicians with clinical contact should have Level 1 

competencies. 

Level I, Competency 1 

Physicians should be able to perform age, gender, and culturally appropriate substance abuse screening. 

1. Physicians’ training curricula and licensing examinations at all levels should be modified to include 

content on the use of effective methods of screening patients for SUD. A curriculum in screening for 

SUD should be required and integrated into the standard curricula of all medical schools and residency 

training programs. As a requirement for graduation, 

medical students should demonstrate competency 

in screening, intervention, and referral for SUD 

WASHINGTON, DC • DECEMBER 1-2, 2004 51

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(consistent with Competencies I-2 and I-4 below). 

Licensing examinations should include content and 

questions relevant to appropriate screening strategies for patients with SUD. Increased curricular 

content on screening for SUD should be available 

through CME programs. The development, dissemination, and maintenance of these curricula should 

be coordinated by a lead Federal agency with input 

from all appropate Federal agencies and professional societies. 

Rationale. Screening involves identifying patients with 

unrecognized SUD.

12 Screening for diseases is warranted if 

the following conditions are met: the disease has a significant prevalence and consequences; effective and acceptable 

treatments are available; early identification and treatment 

are preferable; and there are effective screening instruments 

available that are easy to administer. There is strong research 

evidence to support the fact that SUD meet all of these criteria; 

therefore, screening for SUD is indicated although not often 

implemented. 

Recommended Actions. Training in screening for SUD 

should include attention to the rationale, utility, operating 

characteristics, and use of various methods including the 

importance of raising the topic and the appropriate role of 

formal screening instruments (e.g., CAGE, AUDIT), quantityfrequency questions, and biological markers (e.g., MCV, AST, 

ALT, carbohydrate-deficient transferrin).12, 48-54 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, United States Medical Licensure Examination (USMLE), 

and American Board of Medical Specialties (ABMS). 

Level I, Competency 2 

Physicians should be able to provide brief interventions to 

patients with SUD. 

2. A required curriculum in brief treatment interventions for individuals with SUD should be integrated 

into the standard curricula of all medical schools 

and residency training programs. This curriculum 

should outline the components of brief interventions that have demonstrated effectiveness. As a 

requirement for graduation, medical students 

should demonstrate competency in brief intervention for patients with SUD. Licensing examinations 

should include content and questions relevant to 

appropriate treatment strategies for individuals 

with SUD. Increased curricular content should be 

available through CME programs. The development, 

dissemination, and maintenance of these curricula 

should be coordinated by a lead Federal agency with 

input from all appropriate Federal agencies and 

professional societies. 

Rationale. There is evidence that brief interventions can 

reduce alcohol consumption to below hazardous levels for 

patients with hazardous and harmful drinking.

31,55 The incorporation of substance abuse services into settings will allow 

for a direct expansion of the capacity of the health care 

system and will help increase access to care for a wide range 

of patients.

56,57 

Recommended Actions. Training in SUD should devote 

attention to the effectiveness of office-based interventions 

for SUD, including the role of brief interventions in patients 

with alcohol problems. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level I, Competency 3 

Physicians should use effective methods of counseling patients to help prevent SUD. 

3. A required curriculum in counseling to help prevent the development and progression of SUD 

should be integrated into the standard curricula of 

all medical schools and residency training programs. This should include information on community prevention of SUD. Licensing examinations 

should include content and questions relevant to 

appropriate prevention of SUD. Increased curricular content should be available through CME. The 

development, dissemination, and maintenance of 

this curriculum should be coordinated by a lead 

Federal agency with input from all appropriate Federal agencies and professional societies. 

Rationale. Prevention of harm from the use of psychoactive substances can help decrease the impact of SUD on the 

individual and society.

58,59 For instance, decreasing alcohol 

consumption among pregnant women can have a significant 

impact on the incidence of the fetal alcohol syndrome.

23 In 

addition, recent efforts at early recognition and treatment from 

hazardous and harmful drinking are aimed at decreasing 

progression to more severe alcohol problems that are traditionally less amenable to treatment.55 While the risk factors 

for SUD, including specific genetic markers, are still being 

elucidated, and the determinants of progression from substance use to abuse and subsequent dependence are under 

evaluation, early recognition and intervention by physicians 

can be effective in decreasing progression from less severe 

to more severe SUD. 

Recommended Actions. Training in SUD should devote 

specific attention to the effectiveness of counseling patients 

to help prevent the development or progression of SUD using 

formal counseling and brief interventions. 

52 OFFICE OF NATIONAL DRUG CONTROL POLICY

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Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level I, Competency 4 

Physicians should be able to refer patients with SUD to treatment settings that provide pharmacotherapy for relapse 

prevention. 

4. A required curriculum in the available pharmacotherapy for SUD should be integrated into the standard curricula of all medical schools and residency 

training programs. Licensing examinations should 

include content and questions relevant to appropriate prevention of SUD. Increased curricular 

content should be available through CME. The 

development, dissemination, and maintenance of 

this curriculum should be coordinated by a lead 

Federal agency with input from all appropriate 

Federal agencies and professional societies. 

Rationale. Recent research has highlighted the role of neurochemistry in the etiology and maintenance of SUD. For 

instance, there is evidence for involvement of the dopamine, 

GABA, serotonin, and opioid systems in alcohol use disorders, and chronic exposure to narcotics is known to create 

fundamental changes in receptors and intracellular messaging in patients with opioid dependence.

7,60-62 These insights 

have created new pharmacologic therapies such as 

naltrexone, acamprosate, and buprenorphine that are aimed 

at preventing relapse.

26,28,31,63 

Recommended Actions. Training in SUD should devote 

attention to the effectiveness of pharmacotherapy to help 

prevent relapse in abstinent patients with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level I, Competency 5 

Physicians should recognize and treat or refer comorbid 

medical and psychiatric conditions in patients with SUD. 

5. A required curriculum in the medical and psychiatric comorbidities of SUD should be integrated into 

the standard curricula of all medical schools and 

residency training programs. Increased curricular 

content should be available through CME. The 

development, dissemination, and maintenance of 

this curriculum should be coordinated by a lead Federal agency with input from all appropriate Federal 

agencies and professional societies. 

Rationale. Population surveys have revealed high rates of 

comorbid medical and psychiatric disorders in patients with 

SUD. For instance, the Epidemiological Catchment Area and 

the National Comorbidity Study surveys have found a 29% 

to 37% prevalence of comorbid psychiatric disorder in 

patients with alcohol problems.

2,64 In addition, abused substances and the route used to administer (e.g., injection) these 

substances are associated with significant comorbid medical 

conditions such as hepatitis B and C, endocarditis, human 

immunodeficiency virus infection and AIDS, tuberculosis, and 

cirrhosis.

65,66 

Recommended Actions. Training in SUD should devote 

attention to the recognition, treatment, or referral of comorbid 

medical and psychiatric conditions in patients with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level I, Competency 6 

Physicians should be able to refer patients with SUD to 

appropriate treatment and supportive services. 

6. A required curriculum in the process of evaluation 

and referral of patients with SUD should be integrated into the standard curricula of all medical 

schools and residency training programs. As a 

requirement for graduation, medical students 

should demonstrate competency in referral for 

patients with SUD. Licensing examinations should 

include content and questions relevant to the 

appropriate referral of patients with SUD. Increased 

curricular content should be available through CME. 

The development, dissemination, and maintenance 

of this curriculum should be coordinated by a lead 

Federal agency with input from all appropriate 

Federal agencies and professional societies. 

Rationale. Multicenter randomized clinical trials such as 

Project MATCH and data from the Drug Abuse Treatment 

Outcome Study have demonstrated the efficacy of a variety 

of treatment services for patients with SUD.67-69 In addition, 

successful referrals to treatment require an accurate assessment of a patient’s diagnosis and an understanding of the 

treatment process. 

Recommended Actions. Training in SUD should devote 

attention to the effectiveness of appropriate referral of 

patients to substance use services, including formal treatment 

programs. Responsible Agents. LCME, RRC of the ACGME, 

AMA, AOA, USMLE, and ABMS. 

Level I, Competency 7 

Physicians should be aware of the ethical and legal issues 

around physician impairment from SUD and of resources for 

referring potential impaired colleagues, including employee 

assistance programs, hospital-based committees, State 

physician health programs, and licensure boards. 

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7. Physicians’ training curricula and licensing examinations at all levels should be modified to include 

content on the recognition and referral for treatment of physicians and health professionals 

impaired by SUD. A required curriculum in the 

recognition and referral of physicians and other 

health professionals impaired by SUD should be 

integrated in the standard curricula of all medical 

schools and residency training programs. Licensing 

examinations should include content and questions 

relevant to the recognition and referral of physicians and other health professionals with SUD. 

Increased curricular content should be available 

through CME programs. The development, dissemination, and maintenance of this curriculum should 

be coordinated by a lead Federal agency with input 

from all appropriate Federal agencies and professional societies. 

Rationale. Unrecognized and untreated physicians and other 

health professionals impaired by substance use can constitute a major threat to patient safety and the integrity of the 

medical profession.70 Successful programs have been developed to assist physicians and other health professionals who 

have been recognized and referred to treatment.38,71 The 

RRC has recognized the importance of these practices and 

specified institutional requirements for policies that cover 

physician impairment, and in one instance (i.e., internal 

medicine), there is a specialty requirement.45 

Recommended Actions. Training in SUD should devote 

attention to the effectiveness of recognition and referral of 

impaired physicians and other health professionals with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level I, Competency 8 

Physicians should identify the legal and ethical issues involved 

in the care of patients with SUD. 

8.	 A required curriculum in the ethical and legal 

complications of SUD should be integrated into the 

standard curricula of all medical schools and 

residency training programs. Licensing examinations should include content and questions 

relevant to the ethical and legal complications 

of SUD. Increased curricular content should be 

available through CME programs. The development, 

dissemination, and maintenance of this curriculum 

should be coordinated by a lead Federal agency with 

input from all appropriate Federal agencies and 

professional societies. 

Rationale. SUD are frequently associated with legal 

complications stemming from use (e.g., driving under the 

influence) or impaired judgment. Ethical considerations, such 

as patient confidentiality, are important aspects of caring for 

patients with SUD. 

Recommended Actions. Training in SUD should devote 

attention to the legal and ethical issues in caring for patients 

with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

RECOMMENDATIONS FOR LEVEL II 

COMPETENCIES 

All physicians coordinating care for patients with SUD (e.g., 

primary care and generalist physicians) should have Level I 

and Level II competencies. 

Level II, Competency 1 

Physicians should use effective methods to assess patients 

with SUD. 

1. A curriculum in the assessment of patients with 

SUD should be integrated into the curricula of all 

medical schools and appropriate residency training programs. Licensing examinations in the appropriate disciplines should include content and 

questions relevant to methods to assess patients 

with SUD. Increased curricular content should be 

available through CME programs. The development, 

dissemination, and maintenance of this curriculum 

should be coordinated by a lead Federal agency with 

input from all appropriate Federal agencies and 

professional societies. 

Rationale. Assessment involves identifying the realms of a 

patient’s life affected by SUD. Criteria exist for the diagnosis 

of substance dependence syndromes72 and instruments are 

available to assess the severity of SUD, such as the Addiction 

Severity Index,73 which evaluates the spectrum of areas 

affected by SUD (e.g., medical, psychosocial, legal, and family 

domains). Assessment of these domains is necessary to 

understand the full impact of SUD on the individual. 

Recommended Actions. Training in SUD should include 

attention to the medical, psychological, family, legal, and 

employment complications attributed to SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level II, Competency 2 

Physicians should provide pharmacologic withdrawal to 

patients with SUD. 

54 OFFICE OF NATIONAL DRUG CONTROL POLICY

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2. A curriculum in the pharmacologic withdrawal of 

patients with SUD should be integrated into the 

curricula of all medical schools and appropriate 

residency training programs. Licensing examinations in appropriate disciplines should include 

content and questions relevant to methods to provide withdrawal to patients with SUD. Increased 

curricular content should be available through CME 

programs. The development, dissemination, and 

maintenance of this curriculum should be coordinated by a lead Federal agency with input from all 

appropriate Federal agencies and professional 

societies. 

Rationale. Recent clinical trials have provided empirical 

evidence for efficient and effective care of patients requiring 

detoxification services in office-based settings.13,74 In addition, the use of symptom-triggered, instead of fixed, doses 

of benzodiazepines has been shown to reduce length of stay 

and cost for patients treated for alcohol withdrawal.13,75 In 

opioid-dependent patients, updated regimens and new 

medications have extended the utility of these services in 

inpatient and outpatient settings.

32,63,76,77 

Recommended Actions. Training in SUD should include 

attention to the role and logistics of detoxification for patients 

with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

RECOMMENDATIONS FOR LEVEL III 

COMPETENCIES 

Level III competence should be sought by all physicians 

providing specialty services to patients with SUD. 

Level III, Competency 1 

Physicians should provide pharmacotherapy for relapse 

prevention in patients with SUD. 

1.	 curriculum in pharmacotherapy to help prevent 

relapse in abstinent patients with SUD should be 

integrated into the curricula of all medical schools 

and appropriate residency training programs. 

Licensing examinations in appropriate disciplines 

should include content and questions relevant to 

pharmacotherapy for relapse prevention in abstinent 

patients with SUD. Increased curricular content 

should be available through CME programs. The 

development, dissemination, and maintenance of 

this curriculum should be coordinated by a lead 

Federal agency with input from all appropriate 

Federal agencies and professional societies. 

Rationale. Effective new therapies are available for patients 

with alcohol problems.26,28,31,63 Methadone maintenance 

has demonstrated efficacy in decreasing illicit drug use, HIV 

transmission, and criminal activity.63 In addition, office-based 

pharmacologic treatments have been shown to be effective 

for opioid-dependent patients previously stabilized at narcotic 

treatment programs 78-80 and for those actively using 

drugs.33,76,77 Recommended Actions. Training in SUD 

should include information on the effectiveness of pharmacotherapies to help prevent relapse in abstinent patients with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, and ABMS. 

Level III, Competency 2 

Physicians should provide, or refer for, psychosocial counseling for relapse prevention in patients with SUD. 

2. A curriculum in psychosocial therapies to help prevent relapse in abstinent patients with SUD should 

be integrated into the curricula of all medical schools 

and appropriate residency training programs. Licensing examinations in appropriate disciplines should 

include content and questions relevant to psychosocial therapy for relapse prevention in abstinent 

patients with SUD. Increased curricular content 

should be available through CME programs. The 

development, dissemination, and maintenance of 

this curriculum should be coordinated by a lead 

Federal agency with input from all appropriate 

Federal agencies and professional societies. 

Rationale. Effective new psychosocial therapies are available for patients with SUD.

24,31,55,68,69 

Recommended Actions. Training in SUD should include 

information on the effectiveness of psychosocial therapies 

to help prevent relapse in abstinent patients with SUD. 

Responsible Agents. LCME, RRC of the ACGME, AMA, 

AOA, USMLE, ABMS, and appropriate Federal agencies. 

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PROGRAM MODEL: CONTINUING MEDICAL EDUCATION


CLINICAL, LEGAL AND ETHICAL ISSUES IN PRESCRIBING 

CONTROLLED DRUGS 

Continuing Education Program Offered Annually by The University of 

South Florida College of Medicine; Joseph Krzanowski, Ph.D., Chair 

Since the mid-1980s, the University of South Florida’s College of 

Medicine has offered a CME program on “Clinical, Legal and Ethical Issues in Prescribing Controlled Drugs.” Offered annually, the 

course is the longest-running and best-evaluated CME program on 

prescribing issues and prescription drug abuse in the U.S. 

The course was developed by the university in collaboration with 

the Florida Board of Medicine, the Florida Alcohol and Drug 

Program Office, and the Florida Medical Association in response to 

reports of physicians misprescribing controlled drugs or being 

deceived by patients who wished to obtain such drugs for personal 

use or resale. It is co-directed by Joseph J. Krzanowski, Jr., Ph.D., 

Professor of Pharmacology & Therapeutics and Associate Dean for 

Graduate Affairs at the USF College of Medicine, and addiction 

expert John C. Eustace, M.D., representing the Florida Society of 

Addiction Medicine. The course is taught by faculty from the 

University of South Florida College of Medicine, representatives of 

the Florida Board of Medicine and the U.S. Drug Enforcement 

Administration, and other experts. 

The course focuses on pharmaceutical agents (including analgesics, 

CNS stimulants and depressants, antidepressants, anabolic steroids, 

neuropsychopharmacologic agents) which, because of their effects 

on the central nervous system, have a potential for abuse. Lectures 

encompass basic pharmacology, appropriate clinical use, ethical 

considerations, and legal implications involved in the use of these 

drugs. Presentations also address the currently accepted medical 

uses of controlled drugs, compliance with Federal and state laws 

and regulations, risk/benefit considerations, and problem avoidance 

for both patients and physicians. 

Upon completion of the course, participants are expected to be 

able to: 

•	 Understand the basic pharmacokinetic principles relating to 

prescription drugs with abuse potential; 

•	 Describe the basic pharmacology of drugs subject to abuse, 

including opiates, sedative — hypnotics, psychotropic agents, 

steroids and stimulants; 

•	 Assess the indications for and proper use of these drugs in 

managing acute and/or chronic pain and mood disorders; 

•	 Identify the legal basis of Federal and state drug control policies, 

with special emphasis on compliance with the Florida Medical 

Practice Act; 

•	 Discuss recordkeeping, enforcement agency practices, and risk 

mitigation. 

The course is specifically designed for physicians but is open to all 

health care professionals. Physicians are referred to the course by 

medical boards in many states. It is approved for 23 Category I 

credits toward the AMA Physician’s Recognition Award. For more 

information, contact the CME Office, University of South Florida 

College of Medicine, 12901 Bruce B. Downs Blvd., MDC Box 60, 

Tampa, Florida, 33612 or phone (813) 974-4296. 

SCREENING AND BRIEF OFFICE INTERVENTIONS 

FOR PATIENTS WITH AT-RISK AND HARMFUL 

DRINKING 

Continuing Education Program developed by the Rochester 

(NY) Academy of Medicine, 2003-2005 

Those involved will learn: 

•	 How to screen patients for risky, harmful, and dependent 

drinking; 

•	 How to make connections between medical problems and 

underlying alcohol abuse; 

•	 How to make a brief office intervention around alcohol 

abuse; and 

•	 How to develop office systems that make screening and 

brief interventions flow easily. 

THE PROGRAM 

Step 1:	 Read one to three monographs or articles or attend 

a one hour lecture (2 hours credit for reading all 3, 

one hour credit for reading one monograph or 

attending the lecture) 

Step 2:	 Spend l to 2 hours with a substance abuse trainer 

who will review this material and have you read, 

and help you practice screening and brief interventions. In addition, the trainer will meet with your 

office staff in helping to develop a system for your 

particular practice, which will enable you to actually 

do this screening and the brief interventions. 1-2 

hours credit 

Step 3:	 Screen patients and use your trainer as a resource 

person for questions. After you and others in your 

office have a few positive screens, the trainer will 

return to discuss these patients with you. The trainer 

will return several times, but two follow up visits to 

discuss the process and review patients are the 

norm. Dr. Norman Wetterau, an addiction medicine 

specialist who is also in primary care, will also be 

available to meet with you if you desire. 

Additional credit hours are available for additional directed 

study in this area including in motivational interviewing or 

adolescent interventions. 

Providers who complete the initial training, begin to screen 

patients, and attempt an intervention with an at-risk patient 

will be eligible for CME credit for time spent in this program 

(up to 10 hours). A program evaluation will be required. 

This program is co-sponsored by the Rochester Demand 

Treatment Team and the Rochester Academy of Medicine. 

The Rochester Academy of Medicine designates this continuing medical education activity for a maximum of 10 hours 

of Category I credit toward the Physicians Recognition Award 

of the American Medical Association. Each physician should 

claim only those hours of credit that he/she actually spent 

in the educational activity. 

56 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


APPENDIX A: 

CONFERENCE AGENDA 

OFFICE OF NATIONAL DRUG CONTROL POLICY 

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE 

Washington, DC, December 1-2, 2004 

WEDNESDAY, DECEMBER 1, 2004 

6:00 - 9:00 PM 

5:00 pm Registration opens (Hotel Mezzanine) 

6:00 pm Dinner Meeting (Consulate Room, 

Mezzanine Level) 

6:00 - 6:10 pm Welcome and Acknowledgments 

Addison D. “Tad” Davis IV 

Acting Deputy Director for Demand 

Reduction Office of National Drug 

Control Policy 

6:10 - 7:00 pm Dinner (generously sponsored by The Robert

Wood Johnson Foundation) 

7:00 - 7:10 pm Introduction of the Panelists (Mr. Davis) 

7:10 - 8:00 pm Panel Discussion 

Dr. Bertha K. Madras, 

Dr. Sheldon Miller, Dr. Mark L. Kraus 

8:00 - 8:30 pm Questions and Discussion 

8:30 - 9:00 pm Overview of Thursday’s Activities and 

Adjourn for the Evening 

Mr. Davis & 

Bonnie B. Wilford, 

Conference Facilitator 

THURSDAY, DECEMBER 2, 2004 

8:00 AM - 5:00 PM 

8:00 - 8:30 am	 Registration and Continental Breakfast 

8:30 - 9:00 am	 Introduction of Director Walters 

Mr. Davis 

Address and Charge to the Conferees 

John P. Walters 

Director, Office of National Drug 

Control Policy 

9:00 - 9:20 am	 Health Professions Education: The View 

from NIDA 

Nora D. Volkow, M.D. 

Director, National Institute 

on Drug Abuse 

THURSDAY, DECEMBER 2, 2004 continued 

9:20 - 9:40 am	 Health Professions Education: 

The View from NIAAA 

Ting-Kai Li, M.D. 

Director, National Institute on 

Alcohol Abuse and Alcoholism 

9:40 - 10:00 am	 Questions and Discussion 

(Dr. Volkow & Dr. Li) 

10:00 - 10:10 am	 Overview of the Day and Introduction 

of the Small Group Chairs 

Mr. Davis & Mrs. Wilford 

10:15 - 10:30 am	 Break 

10:30 - 12:00 pm Small Groups Meet — Session 1 

Group 1 (Undergraduate Medical Education) 

Group 2 (Graduate Medical Education) 

Group 3 (Continuing Medical Education) 

12:00 - 12:50 pm Working Lunch 

12:50 - 1:10 pm	 Health Professions Education: 

The View from NHTSA 

Jeffrey Runge, M.D. 

Administrator, National Highway 

Traffic Safety Administration 

1:10 - 1:15 pm	 Overview of the Afternoon 

Mr. Davis & Mrs. Wilford 

1:15 - 1:30 pm	 Break 

1:30 - 3:00 pm	 Small Groups Meet — Session 2 

3:00 - 3:15 pm	 Break 

3:15 - 3:35 pm	 Health Professions Education: 

The View from the Surgeon General 

Vice Admiral Richard H. Carmona,


M.D., M.P.H.


Surgeon General of the United States


3:35 - 4:30 pm	 Small Group Discussion Summaries 

4:30 - 5:00 pm	 Planning for the Future 

Mr. Davis & Mrs. Wilford 

5:00 pm	 Conference Adjourns 

WASHINGTON, DC • DECEMBER 1-2, 2004 57

APPENDICES


APPENDIX B: 

ACKNOWLEDGEMENTS 

The contributions of the following individuals and agencies 

are acknowledged with gratitude: 

Office of National Drug Control Policy 

John P. Walters, Director


Addison D. “Tad” Davis IV


Martha M. Gagné


Substance Abuse and Mental Health Services Administration


Charles G. Curie, M.A., A.C.S.W., Administrator


Stephenie Colston


Center for Substance Abuse Treatment 

H. Westley Clark, M.D., J.D., M.P.H., Director


Anton C. Bizzell, M.D.


Center for Substance Abuse Prevention 

Beverly Watts Davis, Director 

Robert C. Stephenson, Ph.D. 

National Institute on Alcohol Abuse and Alcoholism 

Ting-Kai Li, M.D., Director


Peggy Murray, M.S.W.


National Institute on Drug Abuse 

Nora D. Volkow, M.D., Director


Cindy Miner, Ph.D.


The Robert Wood Johnson Foundation 

Riza Lavizzo-Mourey, M.D., President 

Johnson, Bassin & Shaw, Inc. 

Bonnie B. Wilford, M.S., Conference Facilitator 

58 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


APPENDIX C: 

CONFERENCE PARTICIPANTS 

AND SMALL GROUP ASSIGNMENTS 

REPRESENTATIVES OF PRIVATE SECTOR ORGANIZATIONS 

Audrey Rhodes Boyd,


M.S., M.D., FAAFP


American Academy of Family Physicians

Clinical Assistant Professor


University of South Carolina


Family and Preventive Medicine


Residency Program, and


South Carolina Department


of Mental Health


2200 Harden Street


Columbia, SC 29203


Phone: 803-737-5300


E-mail: arb83@cmt.dmh.state.sc.us


Doris Brooker, M.D. 

Federation of State Medical Boards


of the United States


University of Minnesota


Department of Obstetrics


and Gynecology


515 Delaware St., SE


Minneapolis, MN 55455


Phone: 612-845-4480


E-mail: brook001@umn.edu


Lawrence S. Brown, Jr., M.D., M.P.H.

President, American Society of


Addiction Medicine and


Senior Vice President


Addiction Research and


Treatment Corporation


22 Chapel Street


Brooklyn, NY 11201


Phone: 718-260-2917


E-mail: lbrown@artcny.org


Stephen Cantrill, M.D. 

American College of


Emergency Physicians


Associate Director


Emergency Medicine


Denver Health Medical Center, EMS


777 Bannock Street, Mailcode 0108


Denver, CO 80204-4507


Phone: 303-436-7144


E-mail: stephen.cantrill@dhha.org


Mary Cesare-Murphy, Ph.D. 

Senior Executive Director


Behavioral Healthcare Accreditation


Joint Commission on Accreditation


of Healthcare Organizations, Inc.


One Renaissance Blvd.


Oakbrook Terrace, IL 60181


Phone: 630-792-5790


E-mail: mcesaremurphy@jcaho.org


Michael Dekker 

Health Professional Students


for Substance Abuse Training


2620 S. University Drive, Apt. 201


Davie, FL 33328


Phone: 954-309-6493


E-mail: dekker@nova.edu


Barbara Hatcher, Ph.D., M.P.H., R.N.

Director


Scientific and Professional Affairs


American Public Health Association


800 I Street, N.W.


Washington, DC 20001-3710


Phone: 202-777-2490


E-mail: barbara.hatcher@apha.org


Victor Hesselbrock, Ph.D. 

President


Research Society on Alcoholism


University of CT Health Center


Department of Psychiatry – MC2103


263 Farmington Avenue


Farmington, CT 06030-2103


Phone: 860-679-3266


E-mail: hesselb@psychiatry.uchc.edu


Brian Hurley 

Director for Curriculum


American Medical Student Association


150 S. Detroit Street


Los Angeles, CA 90036


Phone: 323-937-5783


E-mail: bhurley@usc.edu


Samuel M. Jones, M.D. 

Association of Family Medicine


Residency Directors and Program Director,


VCU – Fairfax Family Practice Center


3650 Joseph Siewick Dr., Suite 400


Fairfax, VA 22033


Phone: 703-391-2020


E-mail: sjones@ffpcs.com


Murray Kopelow, M.D., MSC, FRCPC 

Chief Executive Officer


Accreditation Council for


Continuing Medical Education


55 N. State Street, Suite 2150


Chicago, IL 60610


Phone: 312-755-7401


E-mail: mkopelow@accme.org


David C. Lewis, M.D. 

Physicians and Lawyers for


National Drug Policy


Distinguished Professor of Alcohol


and Addiction Studies


Center for Alcohol and Addiction Studies


Brown University, Box G-BH


Providence, RI 02912


Phone: 401-444-1818


E-mail: david_lewis@brown.edu


Jeanne Mahoney 

American College of


Obstetricians and Gynecologists


Providers Partnership Project


409 – 12th Street, S.W.


Washington, DC 20024


Phone: 202-314-2352


E-mail: j.mahoney@acog.org


James Manlandro, D.O., FAOAAM 

President, American Osteopathic


Academy of Addiction Medicine


Family Addiction Treatment Services


1076 Route 47 S


Rio Grande, NJ 08242


Phone: 609-889-3611


E-mail: drydoc80@aol.com


WASHINGTON, DC • DECEMBER 1-2, 2004 59

APPENDICES


REPRESENTATIVES OF PRIVATE SECTOR ORGANIZATIONS continued 

Marianne T. Marcus,


Ed.D., R.N., FAAN


Executive Director


Project Mainstream


John P. McGovern Professor


in Addiction Nursing


University of Texas Health


Science Center


6901 Bertner, Room 711


Houston, TX 77030


Phone: 713-500-2120


E-mail: marianne.t.marcus@uth.tmc.edu


Laura McNicholas, M.D., Ph.D. 

Assistant Professor of Psychiatry


University of Pennsylvania


School of Medicine


Center for Addiction Studies


Treatment Research Center


3900 Chestnut Street


Philadelphia, PA 19104


Phone: 215-222-3200


E-mail: mcnicholas_l@mail.trc.upenn.edu


Donald E. Melnick, M.D., FACP 

President


National Board of Medical Examiners


3750 Market Street


Philadelphia, PA 19104


Phone: 215-590-9546


E-mail: dmelnick@nbme.org


Sheldon I. Miller, M.D. 

Accreditation Council for


Graduate Medical Education


Lizzie Gilman Professor of


Psychiatry and Behavioral Science


Feinberg School of Medicine


Northwestern University


NMH/Onterie Building


446 E. Ontario St., Suite 7-100


Chicago, IL 60611


Phone: 312-926-2323


E-mail: sim065@northwestern.edu


Patrick O’Connor, M.D., M.P.H. 

Society of General Internal Medicine


Professor of Medicine and Chief


Section of General Internal Medicine


Yale University School of Medicine


333 Cedar Street, DC013K


New Haven, CT 06520-8025


Phone: 203-688-6532


E-mail: patrick.oconnor@yale.edu


Winston Price, M.D., M.P.H. 

President


National Medical Association


1012 Tenth Street, N.W.


Washington DC 20001


Phone: 202-347-1895


E-mail: president@nmanet.org


John Renner, M.D. 

Chair, Committee on Addiction


Psychiatry Training (PGY I-IV Years)


American Academy of


Addiction Psychiatry


Addiction Psychiatry Residency Program


VA Outpatient Clinic


251 Causeway Street


Boston, MA 02114


Phone: 617-248-1022


E-mail: john.renner@med.va.gov


Elena Rios, M.D., M.S.P.H. 

President & CEO


National Hispanic Medical Association


1411 K Street, NW, Suite 1100


Washington, DC 20005


Phone: 202-628-5895


E-mail: nhma@earthlink.net


Jeffrey Samet, M.D., M.A., M.P.H. 

Association for Medical Education


and Research in Substance Abuse


Boston University School of Medicine


91 East Concord Street, Suite 200


Boston, MA 02118


Phone: 617-414-7288


E-mail: jsamet@bu.edu


Eric Strain, M.D. 

American Psychiatric Association


Professor


Johns Hopkins Bayview Medical Center


5510 Nathan Shock Drive


Baltimore, MD 21224


Phone: 410-550-1191


E-mail: ecsgss@aol.com


James Thompson, M.D. 

President and CEO


Federation of State Medical Boards


of the United States, Inc.


P.O. Box 619850


Dallas, TX 75261-9850


Phone: 817-868-4060


E-mail: jthompson@fsmb.org


William Vilensky, D.O., R.Ph.,


FASAM


American Osteopathic Association


110 S. Nassau Avenue


Margate, NJ 08402


Phone: 609-822-3317


E-mail: wvilensky@hotmail.com


Leslie R. Walker, M.D. 

Society for Adolescent Medicine


Associate Professor


Department of Pediatrics


Director


Section of Adolescent Medicine


Georgetown University


Hospital/MedStar


3800 Reservoir Road, NW, 2-PHC


Washington, DC 20007


Phone: 202-444-8839


E-mail: walkerl1@georgetown.edu


Richard Yoast, Ph.D. 

Director


Office of Alcohol Programs


American Medical Association


515 North State Street, 8th Floor


Chicago, IL 60610


Phone: 312-464-4202


E-mail: richard_yoast@ama-assn.org


60 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


REPRESENTATIVES OF FEDERAL AGENCIES


Eric Akers, Counsel 

United States Senate


Caucus on International


Narcotics Control


Hart Senate Office Building, Room 818C


Washington, DC 20510


Phone: 202-224-9032


E-mail: eric_akers@drugcaucus.senate.gov


Anton Che’ Bizzell, M.D. 

Medical Officer


Division of Pharmacologic Therapies


Center for Substance Abuse Treatment


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 2-1067


Rockville, MD 20857


Phone: 240-276-2702


E-mail: abizzell@samhsa.hhs.gov


Margaret Calloway, M.D. 

Uniformed Services University


of the Health Sciences


4301 Jones Bridge Road


Bethesda, MD 20814


Phone: 800-515-5257


E-mail: mcalloway@usuhs.mil


Vice Admiral Richard Carmona,


M.D., M.P.H.


Surgeon General of the United States


U.S. Public Health Service


5600 Fishers Lane, Room 18-66


Rockville, MD 20857


Phone: 202-401-8073


E-mail: ggonzalez@osophs.dhhs.gov


H. Westley Clark, M.D., J.D., M.P.H.


Director, Center for


Substance Abuse Treatment


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 5-1015


Rockville, MD 20857


Phone: 240-276-1660


E-mail: wclark@samhsa.hhs.gov


Beverly Watts Davis 

Director, Center for


Substance Abuse Prevention


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 4-1057


Rockville, MD 20857


E-mail: bdavis@samhsa.hhs.gov


Addison D. “Tad” Davis IV 

Assistant Deputy Director


Office of Demand Reduction


Office of National Drug Control Policy


Executive Office of the President


The White House


Washington, DC 20500


Phone: 202-395-4992


E-mail: adavis@ondcp.eop.gov


Robert E. DeMartino, M.D. 

Associate Director for Medical Affairs


Center for Mental Health Services


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 2-1007


Rockville, MD 20857


Phone: 240-276-1963


E-mail: robert.demartino@samhsa.hhs.gov


Anita R. Everett, M.D. 

Senior Medical Advisor


Office of the Administrator


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 8-1053


Rockville, MD 20857


Phone: 240-276-2016


E-mail: aeverett@samhsa.hhs.gov


Martha M. Gagné 

Senior Policy Analyst


Office of Demand Reduction


Office of National Drug Control Policy


Executive Office of the President


The White House


Washington, DC 20500


Phone: 202-395-4622


E-mail: mgagne@ondcp.eop.gov


Patricia Good 

Director, Professional Liaison


Office of Diversion Control


Drug Enforcement Administration


600 Army-Navy Drive


Arlington, VA 22202


Phone: 202-307-7165


Ting-Kai Li, M.D. 

Director, National Institute


on Alcohol Abuse and Alcoholism


National Institutes of Health


5635 Fishers Lane, Rm. 2000, MSC 9304


Bethesda, MD 20892-9304


Phone: 301-443-3885


E-mail: tli@niaa.nih.gov


Robert Lubran, M.S., M.P.A. 

Director, Division of


Pharmacologic Therapies


Center for Substance Abuse Treatment


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 2-1075


Rockville, MD 20857


Phone: 240-276-2714


E-mail: rlubran@samhsa.hhs.gov


Jeffery Michael 

National Highway Traffic


Safety Administration


400 7th Street, S.W.


Washington, DC 20590


Phone: 202-366-4299


E-mail: jeff.michael@nhtsa.dot.gov


Lucinda Miner, Ph.D. 

Deputy Director, OSPC


National Institute on Drug Abuse


National Institutes of Health


6001 Executive Boulevard, Room 5230


Bethesda, MD 20892


Phone: 301-443-6036


E-mail: cminer@nida.nih.gov


Howard Moss, M.D. 

Associate Director for Education


National Institute on


Alcohol Abuse


and Alcoholism


National Institutes of Health


5635 Fishers Lane, Room 3097


Bethesda, MD 20892-1705


Phone: 301-402-0944


E-mail: mossh@mail.nih.gov


Peggy Murray, M.S.W. 

Chief, Health Sciences Education


National Institute on


Alcohol Abuse


and Alcoholism


National Institutes of Health


5635 Fishers Lane, Room 3105


Bethesda, MD 20892-1705


Phone: 301-443-2594


E-mail: pmurray@mail.nih.gov


WASHINGTON, DC • DECEMBER 1-2, 2004 61

APPENDICES


REPRESENTATIVES OF FEDERAL AGENCIES continued 

Jeffrey Runge, M.D. 

Administrator


National Highway Traffic


Safety Administration


400 7th Street, SW


Washington, DC 20590


Phone: 202-366-0123


E-mail: webmaster@nhtsa.dot.gov


Phillip Smith, M.D. 

Indian Health Service


Reyes Building


801 Thompson Avenue, Suite 400


Rockville, MD 20852


Phone: 301-443-6528


E-mail: psmith@hge.ihs.gov


Marcia Starbecker, M.D. 

Bureau of Health Professions


Health Resources and


Services Administration


5600 Fishers Lane


Parklawn Bldg., Room 8A-09


Rockville, MD 20857


Phone: 301-443-6867


E-mail: mstarbecker@hrsa.gov


Robert Stephenson, M.P.H. 

Deputy Director


Center for Substance Abuse Prevention


Substance Abuse and Mental Health


Services Administration


1 Choke Cherry Road, Room 4-1051


Rockville, MD 20857


Phone: 240-276-2420


E-mail: bstephenson@samhsa.hhs.gov


Richard T. Suchinsky, M.D. 

Associate Chief for


Addictive Disorders


Department of Veterans Affairs


810 Vermont Avenue, NW


Washington, DC 20420


Phone: 202-273-8437


E-mail: richard.suchinsky@hq.med.va.gov


Nora D. Volkow, M.D. 

Director


National Institute on Drug Abuse


National Institutes of Health


6001 Executive Blvd., Room 4133


Bethesda, MD 20892


E-mail: nvolkow@nida.nih.gov


William J. Walker 

Deputy Assistant Administrator


Office of Diversion Control


Drug Enforcement Administration


600 Army-Navy Drive


Arlington, VA 22202


Phone: 202-307-7165


E-mail: william.j.walker@usdoj.gov


John P. Walters 

Director, Office of National


Drug Control Policy


Executive Office of the President


The White House


Washington, DC 20500


Mark Willenbring, M.D. 

Director, Division of Treatment


& Recovery Research


National Institute on Alcohol Abuse


and Alcoholism


National Institutes of Health


5635 Fishers Lane


Bethesda, MD 20892-1705


Phone: 301-443-1208


E-mail: mwillenbring@niaaa.nih.gov


62 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


MEMBERS OF THE EXPERT PANEL


Hoover Adger, M.D., FAAP 

Professor of Pediatrics


The Johns Hopkins Medical Institutions


600 N. Wolfe Street


Baltimore, MD 21287


Phone: 410-955-2910


E-mail: hadger@jhmi.edu


Andrea G. Barthwell, M.D., FASAM 

1010 Lake Street, Suite 422


Oak Park, IL 60305


Phone: 708-383-2700


E-mail: agbmd@aol.com


David A. Fiellin, M.D. 

Associate Professor of Medicine


Yale University School of Medicine


333 Cedar Street


New Haven, CT 06520-8025


Phone: 203-688-2984


E-mail: david.fiellin@yale.edu


Michael F. Fleming, M.D., M.P.H. 

Professor of Family Medicine


University of Wisconsin


Medical School


777 South Mills Street


Madison, WI 53715


Phone: 608-263-9953


E-mail: mfleming@fammed.wisc.edu


J. Harry Isaacson, M.D. 

Associate Professor of Medicine and


Director of Clinical Education


Department of General


Internal Medicine


Cleveland Clinic Foundation


9500 Euclid Avenue, NA24


Cleveland, OH 44195


Phone: 216-444-0730


E-mail: isaacsj@ccf.org


Mark L. Kraus, M.D., FASAM 

Assistant Clinical Professor


of Medicine


Yale University School of Medicine


714 Chase Parkway, Arcade Suite 101


Waterbury, CT 06708


Phone: 203-755-4577


E-mail: marklk@cox.net


Petros Levounis, M.D. 

Assistant Professor


of Clinical Psychiatry


Columbia University College


of Physicians and Surgeons, and


Director, The Addiction Institute


of New York


St. Luke’s & Roosevelt Hospitals


1000 Tenth Avenue


New York, NY 10019


Phone: 212-523-6876


E-mail: plevounis@AddictionInstituteNY.org


Bertha K. Madras, Ph.D. 

Associate Director for Medical Education


Division on Addictions, and


Professor of Psychobiology


Department of Psychiatry


Harvard Medical School


The Landmark Center


401 Park Drive, 2nd Floor East


Boston, MA 02115


Phone: 617-384-9030


E-mail: bertha_madras@hms.harvard.edu


Jonathan Ritvo, M.D. 

Associate Clinical Professor of


Psychiatry and Training Director


Addiction Psychiatry Residency Program


University of Colorado


School of Medicine


501 South Cherry Street, #650


Denver, CO 80246


Phone: 303-333-3163


E-mail: jritvo@dhha.org


Richard N. Rosenthal, M.D. 

Chairman of Psychiatry


St. Luke’s & Roosevelt Hospitals


1090 Amsterdam Avenue, Floor 16


New York, NY 10025-1737


Phone: 212-523-5366


E-mail: rrosenthal@chpnet.org


Richard Saitz, M.D., M.P.H.,


FASAM, FACP


Associate Professor


of Medicine and Epidemiology


Section of General Internal Medicine


Boston University School of Medicine


91 East Concord Street, Suite 200


Boston, MA 02118


Phone: 617-414-7399


E-mail: rsaitz@bu.edu


Christopher Welsh, M.D. 

Assistant Professor


Department of Psychiatry


Division of Alcohol & Drug Abuse


University of Maryland


School of Medicine


22 South Greene Street


Room P-1-H-10, Box 349


Baltimore, MD 21201


Phone: 410-328-6106


E-mail: cwelsh@psych.umaryland.edu


Norman Wetterau, M.D.,


FAAFP, FASAM


Chair, AAFP Committee


on Substance Abuse


Tricounty Family Medicine


6 Clinton Street


Dansville, NY 14437


Phone: 585-468-2581


E-mail: normwetterau@aol.com


Bonnie B. Wilford, M.S. 

Conference Facilitator


Director, Center for Health Services


& Outcomes Research


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 240-645-4136


E-mail: bwilford@jbs.biz


Stephen A. Wyatt, D.O. 

Medical Director


Stonington Institute


75 Swantown Hill Road


North Stonington, CT 06359


Phone: 860-535-1010


E-mail: swyatt@adelphia.net


WASHINGTON, DC • DECEMBER 1-2, 2004 63

APPENDICES


CONFERENCE STAFF


Dennis Burke, M.A., M.S. 

Recorder, Group 3


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: dburke@jbs.biz


Ellen Dreyer, R.N., M.S. 

Recorder, Group 2


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: edreyer@jbs.biz


Janeane L. Gibbs 

Conference Secretary


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: jgibbs@jbs.biz


Darrell L. Harvey 

Facilitator, Group 4


12217 Shadetree Lane


Laurel, MD 20708


Phone: 301-502-2953


E-mail: dharvey.imsinc@erols.com


Loretta Hobbs 

Facilitator, Group 3 

O’Neal-Hobbs Associates 

73 P Street, NW 

Washington, DC 20001 

Phone: 202-667-2777 

E-mail: lhobbs7@aol.com 

Mary Kelly, M.S.L.S. 

Recorder, Group 1


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: mkelly@jbs.biz


Nina Kern, M.A., M.S.O.D. 

Conference Development


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: nkern@jbs.biz


Debbie Levi 

Conference Logistics


Capital Meeting Planning, Inc.


6521 Arlington Blvd., Suite 505


Falls Church, VA 22042


Phone: 703-536-4991


E-mail: Debbie@cmpinc.net


Samara Mendoza, CMP 

Meeting Planner


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: smendoza@jbs.biz


Marcia Meth, M.A. 

Recorder, Group 4


Johnson, Bassin & Shaw, Inc.


8630 Fenton Street, Suite 1200


Silver Spring, MD 20910


Phone: 301-495-1080


E-mail: mmeth@jbs.biz


Pearl Seidman 

Facilitator, Group 2


7635 Moon Portrait Way


Columbia, MD 21046


Phone: 410-493-8820


E-mail: aplrseid@comcast.net


Stephen Shearer 

Facilitator, Group 1


Stephen Shearer, Inc.


446 Upland Road


Redwood City, CA 94062


Phone: 650-599-9007


E-mail: qqquality@aol.com


64 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


SMALL GROUP ASSIGNMENTS


GROUP 1:


UNDERGRADUATE MEDICAL EDUCATION


Chair:	 Laura McNicholas, M.D., Ph.D., 

University of Pennsylvania Medical School 

Co-Chair:	 J. Harry (Bud) Isaacson, M.D., 

Cleveland Clinic 

Lerner College of Medicine 

Reporter:	 Christopher Welsh, M.D., 

University of Maryland Hospitals & Clinics 

Members of the Expert Panel: 

Hoover Adger, M.D., FAAP,


Johns Hopkins Medical Institutions, Baltimore


Bertha K. Madras, Ph.D., Harvard Medical School


Representatives of Federal Agencies: 

Margaret Calloway, M.D., Uniformed Services


University of the Health Sciences (USUHS)


Anita Everett, M.D.,


Substance Abuse and Mental Health Services


Administration (SAMHSA)


Representatives of Private Sector Organizations: 

Doris Brooker, M.D.,


Federation of State Medical Boards (FSMB)


Michael Dekker, Health Professional Students


for Substance Abuse Training (HPS-SAT)


Barbara Hatcher, Ph.D., M.P.H., R.N.,


American Public Health Association (APHA)


Brian Hurley,


American Medical Student Association (AMSA)


Donald E. Melnick, M.D.,


National Board of Medical Examiners (NBME)


Winston Price, M.D., M.P.H.,


National Medical Association (NMA)


Jeffrey Samet, M.D., M.A., M.P.H., Association for Medical


Education and Research in Substance Abuse (AMERSA)


William Vilensky, D.O., R.Ph., FASAM,


American Osteopathic Association (AOA)


GROUP 2:


GRADUATE MEDICAL EDUCATION


Chair:	 Sheldon Miller, M.D., 

Northwestern University School of Medicine 

(ACGME) 

Co-Chair:	 Jonathan Ritvo, M.D., 

University of Colorado School of Medicine 

Reporter:	 Richard N. Rosenthal, M.D., 

St. Luke’s & Roosevelt Hospitals, New York City 

Members of the Expert Panel: 

Richard Saitz, M.D., M.P.H., FACP, 

Boston University School of Medicine 

Stephen A. Wyatt, D.O., 

Stonington Institute, Connecticut 

Representatives of Federal Agencies: 

Phillip Smith, M.D., Indian Health Service (IHS)


Marcia Starbecker, M.D.,


Health Resources and Services Administration (HRSA)


Richard T. Suchinsky, M.D.,


Department of Veterans Affairs (VA)


Mark Willenbring, M.D., National Institute on


Alcohol Abuse and Alcoholism (NIAAA/NIH)


Representatives of Private Sector Organizations: 

Stephen Cantrill, M.D.,


American College of Emergency Physicians (ACEP)


Samuel M. Jones, M.D., Association of


Family Medicine Residency Directors (AFMRP)


Marianne T. Marcus, R.N., Ed.D., FAAN,


Project Mainstream


Patrick O’Connor, M.D., M.P.H.,


Society for General Internal Medicine (SGIM)


John Renner, M.D.,


American Academy of Addiction Psychiatry (AAAP)


Richard Yoast, Ph.D., American Medical Association (AMA)


Robert Wood Johnson Foundation


Leslie R. Walker, M.D.,


Society for Adolescent Medicine (SAM)


WASHINGTON, DC • DECEMBER 1-2, 2004 65

APPENDICES


GROUP 3:


CONTINUING MEDICAL EDUCATION


Chair:	 Murray Kopelow, M.D., MSC, FRCP, 

Accreditation Council for 

Continuing Medical Education (ACCME) 

Co-Chair: Mark L. Kraus, M.D., FASAM, 

Private Practice of Medicine, Connecticut 

Reporter: Murray Kopelow, M.D., MSC, FRCP 

Members of the Expert Panel: 

Andrea G. Barthwell, M.D., FASAM, 

Private Practice of Medicine 

David A. Fiellin, M.D., Yale University School of Medicine 

Norman Wetterau, M.D., FAAP, Chair, 

AAFP Committee on Substance Abuse 

Representatives of Federal Agencies: 

Eric Akers, United States Senate,


Caucus on International Narcotics Control


Anton C. Bizzell, M.D.,


Center for Substance Abuse Treatment (CSAT/SAMHSA)


Jeffery Michael, National Highway


Transportation Safety Administration (NHTSA)


Cindy Miner, Ph.D.,


National Institute on Drug Abuse (NIDA/NIH)


Howard Moss, M.D., National Institute on


Alcohol Abuse and Alcoholism (NIAAA/NIH)


Peggy Murray, M.S.W., National Institute on


Alcohol Abuse and Alcoholism (NIAAA/NIH)


William J. Walker, Drug Enforcement Administration (DEA)


Representatives of Private Sector Organizations: 

Audrey Rhodes Boyd, M.D., M.S., FAAFP,


American Academy of Family Physicians (AAFP)


Lawrence S. Brown, Jr., M.D., M.P.H., FASAM,


American Society of Addiction Medicine (ASAM)


Mary Cesare-Murphy, Ph.D., Joint Commission on


Accreditation of Healthcare Organizations (JCAHO)


Victor Hesselbrock, Ph.D.,


Research Society on Alcoholism (RSA)


Jeanne Mahoney, American College of


Obstetricians and Gynecologists (ACOG)


James J. Manlandro, D.O., American Osteopathic


Academy of Addiction Medicine (AOAAM)


Eric Strain, M.D., American Psychiatric Association (APA)


James Thompson, M.D.,


Federation of State Medical Boards (FSMB)


GROUP 4:


FEDERAL AGENCIES


Chair:	 David C. Lewis, M.D., 

Brown University School of Medicine (PLNDP) 

Co-Chair:	 Petros Levounis, M.D., 

Addiction Institute of New York 

Reporter:	 Mark Willenbring, M.D., National Institute on 

Alcohol Abuse and Alcoholism (NIAAA/NIH) 

Representatives of Federal Agencies: 

Eric Akers, United States Senate,


Caucus on International Narcotics Control


Anton C. Bizzell, M.D.,


Center for Substance Abuse Treatment (CSAT/SAMHSA)


Margaret Calloway, M.D., Uniformed Services


University of the Health Sciences (USUHS)


Robert E. DeMartino, M.D.,


Center for Mental Health Services (CMHS/SAMHSA)


Anita Everett, M.D., Substance Abuse and


Mental Health Services Administration (SAMHSA)


Robert Lubran, M.S., M.P.A.,


Center for Substance Abuse Treatment (CSAT/SAMHSA)


Jeffery Michael, National Highway


Transportation Safety Administration (NHTSA)


Cindy Miner, Ph.D.,


National Institute on Drug Abuse (NIDA/NIH)


Howard Moss, M.D., National Institute on


Alcohol Abuse and Alcoholism (NIAAA/NIH)


Peggy Murray, M.S.W., National Institute on


Alcohol Abuse and Alcoholism (NIAAA/NIH)


Phillip Smith, M.D.,


Indian Health Service (IHS)


Marcia Starbecker, M.D.,


Health Resources and Services Administration (HRSA)


Richard T. Suchinsky, M.D.,


Department of Veterans Affairs (VA)


William J. Walker,


Drug Enforcement Administration (DEA)


GROUP 5: 

PUBLIC INPUT 

Reporter:	 Sidney H. Schnoll, M.D., Ph.D., 

Purdue Pharma LLP; former Chair, Examination 

Committee, American Society of Addiction 

Medicine; former Chair, Division of Addiction 

Medicine, Medical College of Virginia 

66 OFFICE OF NATIONAL DRUG CONTROL POLICY

APPENDIX D: 

FOLLOW-UP SURVEY OF THE CONFEREES 

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


QUESTIONS ASKED IN THE 

DEBRIEFING INTERVIEWS 

1.	 Was the Leadership Conference relevant to the mission and 

goals of your organization? 

2.	 Were the goals of the Leadership Conference clear 

to you? 

3.	 What do you think were the most significant outcomes of 

the Leadership Conference? 

4.	 If there was one thing you or your organization could do to 

advance the effort re-kindled by the Leadership Conference, 

what would that be? 

5.	 If there was one thing ONDCP or other conference 

participants could do to assist you or your organization in 

engaging in such an effort, what would that be? 

6.	 If there is an individual or organization not yet involved in 

this effort that should be, who would that be? Would you be 

willing/able to help us make contact and help involve that 

individual/organization? 

7.	 What would be a good way to measure the results of the 

conference and follow-up effort (that is, outcome measures)? 

How do you think we could best measure the impact of the 

conference over the next year? 

8.	 What is the one “breakthrough” or sign of progress 

you would most like to see accomplished over the 

next year? 

9.	 If there is a follow-up Leadership Conference in 2005, 

would you be interested in attending? 

10. Do you have any other comments or suggestions concerning 

the Leadership Conference and the follow-up effort? 

CONFEREES’ RESPONSES TO THE 

DEBRIEFING QUESTIONS 

The following brief summary reflects feedback from 

participants in the Leadership Conference on Medical 

Education in Substance Abuse. 

1.	 Interviewers report that the follow-up interviews have 

been beneficial in helping participants reflect and focus 

on the conference and what is needed to move forward. 

REPRESENTATIVE COMMENT: “This follow up 

debrief with individual participants is terrific; this is an 

excellent way to keep the ball rolling. Ask participants 

for something concrete that they will do and then 

follow up with them to see if it was done (several 

people already made promises or suggestions).” 

2.	 Interviewers report that to sustain the momentum 

created by the conference, it is essential to issue 

some sort of interim report in the near future. 

REPRESENTATIVE COMMENT: “A number of 

interviewees have requested a summarization of 

the conference so they can use it to underpin their 

discussions. For example, Dr. Samuel Jones requested 

a summarization because he has an opportunity to 

influence the Board of Family Medicine in a meeting 

he will attend the third week of February. He is 

one of the newest members of this network and 

his enthusiasm blew me away.” 

3.	 Conferees viewed the Federal agency representatives 

as helping the small group discussions by making 

specific commitments to assist in the areas of 

education, licensing boards and exams. 

REPRESENTATIVE COMMENT: “Actions were 

discussed on a higher level than I originally would have 

thought. Ideas of bringing business into this discussion 

were significant. There was a broad strategy to tackle 

difficult problems and they pledged money.” 

WASHINGTON, DC • DECEMBER 1-2, 2004 67

APPENDICES


4.	 Many interviewees view progress toward a second 

(e.g., Surgeon General) meeting as an indicator of 

success. Other conferees saw a task force or highlevel planning committee as the way to go. The 

facilitators agreed that some mechanism for continued 

communication, at a frequency the conferees find 

appropriate, is important. 

REPRESENTATIVE COMMENT: “Instead of a 

conference next year, create a Task Force whose 

mission it is to address the goals of the conference 

and assess the extent to which they are addressed 

throughout the year. The Task Force would then make 

strategic recommendations to major stakeholders, 

such as funding agencies, HRSA, AAMC, RRC, Deans 

of medical schools, etc.” 

5.	 GENERAL COMMENTS: 

“I went with low expectations, but ended with great 

enthusiasm and was extremely impressed.” 

“The networking was wonderful. I have and will 

continue to utilize those I met to come together on 

some issues. The conference gave great opportunity 

to do that.” 

“The opportunity to really talk through topics in a 

group of people that had the same interest was 

extremely helpful. It opened areas that I had not 

considered before.” 

“It is clear that each of the participants has bits of 

information that others need to know. For example, 

Jon Ritvo has information directly beneficial to 

Rich Saitz and Patrick O’Connor and to all the others 

indirectly. Sheldon Miller has information about the 

high level conference that should be jointly discussed. 

Sam Jones has excitement about influencing Family 

Medicine that would be a boost to all the participants.” 

68 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE


APPENDIX E: 

GLOSSARY 

Addiction. 

A primary, chronic, neurobiological disease, with genetic, 

psychosocial, and environmental factors influencing its 

development and manifestations. Addiction is characterized by three or more of the following behaviors occurring 

at any time in the same 12-month period: tolerance; 

withdrawal; use in larger amounts or over a longer period 

of time than intended; persistent desire or unsuccessful 

efforts to cut down; spending a great deal of time in 

activities necessary to obtain alcohol or drugs (including 

prescription drugs); giving up or reducing important social, 

occupational, or recreational activities; continued use 

despite knowledge of having a persistent or recurrent 

physical or psychological problem. 

Co-occurring/co-morbid disorders. 

The simultaneous presence of two or more disorders, 

such as the co-existence of a substance use disorder with 

a psychiatric or medical disorder. Use of the term carries 

no implication as to which disorder is primary and which 

secondary, which disorder occurred first, or whether one 

disorder caused the other. 

Dependence. 

Used in three different ways: (1) physical dependence, a 

physiological state of adaptation to a specific psychoactive 

substance characterized by the emergence of a withdrawal 

syndrome during abstinence, which may be relieved in 

total or in part by read ministration of the substance; 

(2) psychological dependence, a subjective sense of need 

for a specific psychoactive substance, either for its positive 

effects or to avoid negative effects associated with its 

abstinence; and (3) one category of psychoactive substance use disorder. 

Prevention. 

Social, economic, legal, medical, and/or psychological 

measures aimed at minimizing the use of potentially 

addictive substances, lowering the dependence risk in 

susceptible individuals, or minimizing other adverse 

consequences of psychoactive substance use. Targeted 

preventive interventions constitute a system that targets 

prevention activities to specific levels of risk. For example, 

universal interventions are targeted to the public or a 

whole population group that has not been identified on 

the basis of individual risk. The intervention is desirable 

for everyone in that group. Universal interventions have 

advantages in terms of cost and overall effectiveness for 

large populations. Selective interventions are targeted to 

individuals or a subgroup of the population whose risk of 

developing substance use disorders (SUDs) is significantly 

higher than average. The risk may be imminent, or it may 

be a lifetime risk. The basis may be biological, psychological, 

or environmental. Indicated interventions are targeted 

to reach high-risk individuals who are identified as having 

minimal but detectable signs or symptoms foreshadowing 

SUDs or biological or familial markers indicating a predisposition for SUDs, even though they do not meet DSM-IV 

diagnostic levels at the current time. 

Substance abuse. 

The problematic consumption or illicit use of alcoholic 

beverages, tobacco products, or drugs, including misuse 

of prescription drugs. Abuse typically leads to clinically 

significant impairment or distress, as manifested by one or 

more of the following occurring within a 12-month period: 

recurrent use resulting in a failure to fulfill major role 

obligations at work, school, or home; recurrent use in 

physically hazardous situations; recurrent legal problems 

associated with use; continued use despite persistent or 

recurrent social or interpersonal problems caused or 

exacerbated by the effects of alcohol or other drugs, 

including prescription drugs. In the literature on economic 

costs, substance abuse means any cost-generating aspect 

of alcohol or other drug consumption; this definition differs 

from the clinical use of the term, which involves specific 

diagnostic outcomes. 

Substance use disorder. 

The spectrum of disorders encompassed in alcohol 

and/or drug abuse and dependence that is attributed to 

problematic consumption or illicit use of alcoholic beverages, tobacco products, and drugs, including misuse of 

prescription drugs. 

Modified from the U.S. Department of Health and Human 

Services, National Center for Health Statistics (2000). Healthy 

People 2010. Hyattsville, MD: NCHS. 

WASHINGTON, DC • DECEMBER 1-2, 2004 69

APPENDICES


APPENDIX F: 

ACRONYMS 

AAAP American Academy of Addiction Psychiatry 

AACOM American Association of Colleges of Osteopathic Medicine 

AAFP American Academy of Family Physicians 

AAP American Academy of Pediatrics 

ABMS American Board of Medical Specialties 

ACGME Accreditation Council for Graduate Medical Education 

ACOG American College of Obstetricians and Gynecologists 

AMA American Medical Association 

AMERSA Association for Medical Education and Research in Substance Abuse 

AOAAM American Osteopathic Academy of Addiction Medicine 

ASAM American Society of Addiction Medicine 

CME continuing medical education


CSAP Center for Substance Abuse Prevention


CSAT Center for Substance Abuse Treatment


DEA Drug Enforcement Administration


FSMB Federation of State Medical Boards of the United States


HRSA Health Resources and Services Administration


LCME Liaison Committee for Medical Education


NHTSA National Highway Traffic Safety Administration 

NIAAA National Institute on Alcohol Abuse and Alcoholism 

NIDA National Institute on Drug Abuse 

ONDCP Office of National Drug Control Policy 

RRC Residency Review Committee 

SAMHSA Substance Abuse and Mental Health Services Administration 

SUDs substance use disorders 

VA Department of Veterans Affairs 

70 OFFICE OF NATIONAL DRUG CONTROL POLICY

LEADERSHIP CONFERENCE ON MEDICAL EDUCATION IN SUBSTANCE ABUSE 

APPENDIX G:


SUPPORTING LITERATURE


MEDICAL EDUCATION AND TRAINING 

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PRESCRIBING DRUGS WITH 

ABUSE POTENTIAL 

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