Drama Plays Role in Doctors' Drug Abuse Education

When it comes to drug abuse in America, particularly prescription drug abuse, you get the sense America is on one Long Day's Journey into Night.

In 2006, I was a spectator in a Congressional hearing room in Washington D.C., as a mother pleaded for lawmakers' action regarding prescription drug abuse after her college age son died. It was July 27, 2006 – five years ago, almost to the day -- as I sit in my office typing these words.

During that hearing, the chairman of the subcommittee on criminal justice, drug policy and human resources talked about a problem of "epidemic proportions."

Today, the non-medical use or abuse of prescription drugs is the fastest-growing drug problem in the U.S., according to the White House Office of Drug Control Policy.

Indeed, there is a lot of determined talk in Washington D.C. Still, the prescription drug abuse problem continues, unrelentingly. As for any issue involving medication, physicians are on the front lines. If someone gains weight, they admonish people to cut out the cake. If someone smokes, some doctors order their patients: Stop now. (Not enough, probably).

But in discussions with patients who may be potentially abusing drugs, including prescription drugs, doctors appear reticent, and reluctant to press too hard on the issue. At least that's what top officials of the National Institute of Drug Abuse tell me.

The idea is for physicians to get a handle on the massive prescription abuse problem facing the country by digging deep into which medications patients really need, and which ones they don't. To help physicians, federal officials are tapping into the dramatic arts to get the point across about the problems of substance abuse.

Over the last several months, the National Institute on Drug Abuse (NIDA) has been conducting workshops that include a dramatic reading of Act III of Eugene O'Neill's Long Day's Journey into Night, to prompt discussions how to incorporate screening and interventions in substance abuse treatment, as well as talk about addicted patients in primary care settings.

They are also exploring the role of individual biases and beliefs about people who abuse drugs and how these beliefs affect physicians in screening and treatment of patients.

The project is part of NIDA's educational outreach to practicing physicians, physicians in training or other health professions. The NIH also has handed out toolkits and informed physicians about possible dialogue with patients under its Addiction Performance Project.

The Addiction Performance Project, a free continuing education program, offers providers the opportunity to gain compassion and understanding for patients. The programs, usually linked with other medical meetings, have attracted more than 1,000 people in Boston, Phoenix, and Washington D.C. this year. Shows are scheduled through 2012.

Gaya Dowling, PhD, deputy chief, science policy branch for the NIDA, says the lack of physician questioning about the drug issue with patients is puzzling, but not surprising.

"A major priority for us is engaging the medical community in screening for substance abuse," says Dowling. "We think it's a problem that affects a lot of people. A lot of those people aren't going to seek treatment on their own, but they are going to see their doctor. Physicians are really in a unique position to identify people who have substance abuse problems or may potentially develop them, but physicians don't routinely ask about substance abuse."

There are a number of immediate reasons why physicians aren't engaged in that dialogue, she says. "They don't have time, don't know what to ask, and are not comfortable with the issue. So we are taking a multipronged approach to address those." Showing the piece of Long Day's Journey into Night and subsequent discussions are among the "unique ways of addressing the physician who says: I don't feel comfortable with talking about this issue," Dowling says.

Also, NIDA's Addiction Performance Project "is a creative way for doctors to earn (continuing medical education) credit while raising the stigma issue associated with drug addiction," she says.

As NIDA officials tell it, a fraction of people who need specialty treatment for drug or alcohol addiction receive it each year. In 2009, more than 23 million people aged 12 or older needed such treatment for drug or alcohol problems. An overwhelming number – about 21 million – didn't get the help they needed. .

A lot can be done, though, to promote reduced alcohol and tobacco use. For instance, NIDA reports say that a growing body of literature also cites the benefits of screening and intervention for illicit or non-medical prescription drug use.

"We've been wrestling with physicians handling the prescription drug abuse issue," Dowling says, "and I think physicians have been wrestling with it." Physicians must confront the issues of "overprescribing or being duped into prescribing for someone who is drug seeking," Dowling says.

 "Every physician is going to ask: what medication is the patient on?" Dowling asks. "If the patient is showing signs of drug abuse, there's a way to open the dialogue."

Dowling blames the lack of medical school training for physician failure to penetrate drug abuse. "It's not taught well in medical schools," she says. (Physicians) don't feel comfortable addressing it. Physicians have such a huge burden on them, how much they have to do in a short period of time, and they don't know if they have the tools to address it."

To improve the system, the NIH is working to "get substance abuse questions incorporated into electronic health records to make it easier to address the issue," Dowling says. "This wouldn't be accusatory, [but] something the physicians asks routinely of his patients," she said. In addition, NIH is working with centers of excellence to develop curricula to help train physicians regarding substance abuse.

A Long Day's Journey into Night is a powerful play, with Act III "completely surrounding the matriarch addicted to morphine, the family dynamics with alcohol abuse," says Dowling.

Dramatic readings spur debate and emotion. And real life testimony in the halls of Congress about a woman's loss of her son touches the soul. Both send home the message: physicians need to take action to stop drug abuse, prescription or otherwise.