Educational Activities

UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE
UNDERGRADUATE ADDICTIONS SEMINARS
FOR FIRST YEAR MEDICAL STUDENTS

Learning Goals:

At the conclusion of this module, learners will be able to: 

• Demonstrate strategies and skills for assessing alcohol use.
• Describe differences between alcohol dependence, alcohol abuse, at-risk drinking, and moderate drinking (below the NIAAA safe limits).
• Demonstrate strategies and skills for asking questions, advising and negotiating plans that minimize patients’ defensiveness.
• Demonstrate strategies and skills for Brief Interventions that are appropriate both to the severity of the alcohol use disorder and the patient’s interactive style.

Key Learning Principles:

1. Alcohol use problems exist on a continuum. Alcohol dependence is on the severe end and at-risk alcohol use at the mild end, with alcohol abuse in between.
2. Effective physicians know the NIAAA safe (moderate) drinking limits and talk with patients about them
3. Persons with alcohol use disorders consistently minimize and cover up alcohol problems (both consciously and unconsciously).
4. Many serious alcohol problems are obvious to physicians; but action is delayed because intervention may be unsettling and painful.
5. Target brief interventions to patients’ readiness for change.
6. Improve the effectiveness of brief interventions, give clear and direct advice in a relationship centered, empathic and compassionate way that avoids a confrontational style.
7. Learn and use specific skills to help hostile, denying and ashamed patients who feel helpless and hopeless.

Content

1. Two hour seminar (Week 1) Focus on epidemiology for Physician and Patient communication in primary care settings.  (In-class video excerpts from patients and families with alcohol problems are presented.)

2. Two hour seminar (Week 2) Focus on the context of drug dependence as a chronic illness, treatment options, societal issues, AA. (In-class video excerpts from drug dependence videos are presented.)

3. Two hour seminar with a Standardized Patient on talking with and treating patients with alcohol issues – which includes one hour on-line module with four sample videos of Doctor/patient interactions.

4. Optional selective experiences with Alcoholics Anonymous for experiential credit.

Readings for Week 1

1. Epidemiology of alcohol dependence and current and evolving diagnostic criteria. This presentation is available on Medscape at the following link:  http://www.medscape.com/viewarticle/552195  Dr. Willenbring reviews the epidemiology of drinking and binge drinking and discusses using quantity, frequency, and frequency of binge drinking as an approach to defining a risk continuum of alcohol problems.

2. “How primary care providers talk to patients about alcohol”.  This article from the Journal of General Internal Medicine, 2006, 21, uses tapes of actual conversations between physicians and patients to present problems in how physicians communicate with patients about alcohol and alcohol problems. 

3. “Helping Patients who drink too much:  A clinician’s guide”.   This publication by the NIH National Institute on Alcoholism and Alcohol Abuse provides clinicians with materials and approaches to assess and counsel patients with alcohol problems.  Patient education materials, support materials for physicians, screening decision trees and questionnaires, and advice about the use of medications are presented. 

Discussion Topic One:  “Hijacking the Brain Circuits with a Nickel Slot Machine.”  This New York Times article presents psychological and social aspects of the dopamine reward system, with implications for a variety of “dopamine rush activities” ranging from gambling to sporting events to the stock market.

Discussion Topic Two:   “Compulsive Gambling Reported in Patients on Popular Parkinson’s Drug.”   This newspaper article talks about a drug side effect that seems to produce addictions in the form of impulse control disorders, such as compulsive gambling in patients taking certain dopamine drugs.

Discussion Questions for the Addictions Seminar (week one)

To obtain credit for seminar preparation, complete responses to the following discussion questions and turn them in to your preceptor by the time of the small group meeting:

Discussion Question 1:   In one or two paragraphs, describe the three most important things you learned about addictions from the readings for this week.

Discussion Question 2: Write a response to one of the following discussion questions:

• Put yourself in a primary care setting -- Discuss the pros and cons of using the quantity/frequency approach in for alcohol problems  or the more typical approach which focuses on the consequences of drinking.  (Reading 1)

• The advice to clinicians about helping patients with alcohol problems uses branching decision tree approaches to working through alcohol problems with patients.   Respond to either 1 or 2 below:
  • How do these approaches compare to what you have observed in clinic?
  • How well do these approaches fit the patient-centered model of care?

• Primary care providers seemed to have difficulty with talking to patients about alcohol, not following up questions, being tentative, and being uncomfortable.   What do you think accounts for this difficulty? 

• Considering the article on “unexpected reward” and dopamine systems, discuss two dopamine engaging activities (e.g. gambling, internet, video games, sex, chocolate,) and the conditions that might lead to increased rates of “abuse”.    

• Can there be "positive" addictions?

• What are the implications for how we think about addiction if a behavior like compulsive gambling can be a side-effect of a prescription medicine?

Readings and discussion questions for the PCM/PPS alcohol and addictions seminars for week two.

Reading #1:  "Drug Dependence, a Chronic Medical Illness:"  This JAMA article highlights the importance of considering drug dependence as a chronic condition, with comparisons of genetic heritability, social factors, multiple etiology, and health policy implications like other chronic conditions such as diabetes and hypertension.

Reading #2:  "Identifying and Assisting the Impaired Physician".  This article presents issues surrounding the problem of physicians with substance abuse problems.

Discussion Reading #1:  "A Brief Guide to Alcoholics Anonymous".  This pamphlet outlines basic information about one of the most common "12-step" support programs.

Discussion Reading #2:  New York Times Article:  "Homeless alcoholics receive a permanent place to live and drink".  This two page article describes a Seattle program to house alcoholics in a safe place where they can live and continue to drink.

Discussion Reading #3:   Three short medical vignettes about physicians caring for patients with alcohol abuse related disorders.  "Retrieval", "The Disability Blues", and "Saving Sylvia Cleary". 

Discussion Questions for the Addictions Seminar Week Two

To obtain credit for seminar preparation, complete responses to the following discussion questions and turn them in to your preceptor before the small group meeting:

Discussion Question 1:   In one or two paragraphs, describe the three most important things you learned about addictions from the readings.

Discussion Question 2: Write a response to one of the following discussion questions:

• Compare and contrast alcoholism with one of the following chronic medical conditions:  asthma, hypertension, diabetes, or hyperlipidemia.

• The article on impaired physicians suggests that physicians may have increased risk for substance abuse disorders.   What do you think are the most important risk areas for physicians and how could a physician minimize those risks for current physicians in training.

• Treatment for alcohol abuse that has social stigma often raise ethical and political issues.   Discuss the social and political issues that might arise from programs like the Seattle program that attempts to provide a safe place for homeless alcoholics to live and drink.     How do you think such a program would fare in Lexington?

• The three brief medical vignettes highlight the difficulties involved in the doctor patient relationship for substance abuse disorders.  Assume you are a first year resident orienting a new third year medical student to a service that had a significant percentage of patients with alcohol problems. -- What would you tell them about the doctor/patient relationship?

• Read the three case studies and comment on how your own attitudes toward individuals with substance abuse problems might influence your role as a physician.

• Think about programs like Alcoholics Anonymous as if it were a pharmacological treatment regimen.   What would be the "active ingredients" and how would you describe "side-effects".

"Twelve-step, mutual-help groups have proved effective in spurring and sustaining recovery for many individuals formerly addicted to alcohol and/or other substances. But what are the therapeutic dynamics? Researcher William Weathers, in 'Systemically Transformed Self-Efficacy in Narratives of Recovery from Alcoholism,' provides an integrative theoretical approach to understanding these dynamics. Twenty-nine narratives were analyzed and a survey of AA members conducted. Spanning expectancy, systems, and narrative theory, Weathers offers a theory of transformed self-efficacy to show how individuals in recovery have undergone a radical change in their perception of 'self' through participation in a system of shared narrative."

-A snippet from Systemically Transformed Self-Efficacy in Narratives of Recovery from Alcoholism, an Abstract of Dissertation. By William M. Weathers, Jr.

Click here to Download the complete Dissertation.