This article was downloaded by: [Temple University Libraries]On: 15 November 2014, At: 10:22Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Journal of Addictive DiseasesPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wjad20

Medical Student AttitudesToward Drug Addiction PolicyNorman G. Hoffmann PhD a , Albert J. Chang BS b &David C. Lewis MD ca Department of Community Health , BrownUniversity, Senior Associate, ABT Associates, Inc. ,USAb Brown University School of Medicine , USAc Medicine and Community Health , BrownUniversity , USAPublished online: 12 Oct 2008.

To cite this article: Norman G. Hoffmann PhD , Albert J. Chang BS & David C.Lewis MD (2000) Medical Student Attitudes Toward Drug Addiction Policy, Journal ofAddictive Diseases, 19:3, 1-12, DOI: 10.1300/J069v19n03_01

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Medical Student AttitudesToward Drug Addiction Policy

Norman G. Hoffmann, PhDAlbert J. Chang, BSDavid C. Lewis, MD

ABSTRACT. This study explores the attitudes and perceptions of med-ical students concerning patients with addictions and policy issues re-lated to drugs. Over 1,250 students from 15 medical schools respondedto an anonymous survey concerning their experience and training re-garding addictions, and their level of support or opposition for variousdrug policy approaches.

Medical students expressed general support for treatment fundingand related demand reduction strategies, but the strength of their sup-port was influenced more by their political orientation than their per-ception of the effectiveness of the strategy. Students who identifiedthemselves as liberals more strongly favored demand reduction andalternatives strategies such as needle exchange programs and drugcourts. Conservatives more strongly favored supply reduction strategiesincluding harsher sanctions for users. Need for additional training inmedical school was indicated by the fact that 20% reported no trainingin addictions. [Article copies available for a fee from The Haworth DocumentDelivery Service: 1-800-342-9678. E-mail address: <getinfo@haworthpressinc.com> Website: <http://www.HaworthPress.com>]

Norman G. Hoffmann is Clinical Associate Professor, Department of CommunityHealth, Brown University, Senior Associate, ABT Associates, Inc.

Albert J. Chang is a Medical Student, Brown University School of Medicine.David C. Lewis is Professor of Medicine and Community Health, Donald G.

Millar Professor of Alcohol and Addiction Studies, and Director, Center for Alcoholand Addiction Studies, Brown University.

Address correspondence to: David C. Lewis, MD, Brown University Center forAlcohol and Addiction Studies, Box G-BH, Providence, RI 02912.

This research was supported by a grant from The John D. and Catherine T.MacArthur Foundation to Physician Leadership for National Drug Policy.

Journal of Addictive Diseases, Vol. 19(3) 2000E 2000 by The Haworth Press, Inc. All rights reserved. 1

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KEYWORDS. Medical students, addiction, medical training, sub-stance abuse, drug policy

INTRODUCTION

Concern about physician attitudes regarding alcohol and drug abus-ing individuals goes beyond patient care. Some physicians have beenactively and vocally involved in community alcohol and drug abuseissues. Others participate more passively, in that their opinions aresolicited by policy makers because they are physicians. Their medicalexpertise and opinions are deemed to be of relevance to alcohol anddrug abuse issues. Since physicians have been--and will continue tobe--involved in this area, the current study was undertaken to deter-mine which experiences and perceptions are related to policy views bymedical students. These individuals may be in positions to influencepolicies in the future, so it is important to know what factors arerelated to forming their policy opinions. Although several studies haveinvestigated the prevalence of substance use among medical stu-dents,1-3 relatively little attention has been given to medical students’perceptions about treatment and questions concerning policies relatedto drug problems. Further, surveys that have polled various segmentsof the professional communities and the general public typically havenot included medical students.4

While knowledge of the policy views of medical students has notheretofore been reported, there is a substantial body of knowledgeabout medical student attitudes toward their substance abusing pa-tients. This is important because their beliefs and attitudes in the earlyyears of training can affect the manner in which they treat their futurepatients. Negative attitudes can lead to delayed diagnosis, inappropri-ate treatment, and decreased willingness to spend the necessary timewith these patients.5,6

One study found that medical students had a greater pessimismregarding the ability to help alcoholics than students in other health-care fields.7 Unfortunately, this perception does not improve with timeand experience. As medical students progress through their trainingand are exposed to more substance abusers, their attitudes towardthese patients have been found to become more negative.8-10 Self-la-beled alcoholics have been found to be less likable to physicians;consequently, areas such as the interview interaction and treatment

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recommendations are adversely affected.11 Given such prejudices,medical students are less likely to view alcoholism as a treatableillness and, consequently, perceive less responsibility for screeningand referral. Stimmel cites several reasons for the fixed pessimisticattitudes of residents and physicians concerning substance abusers.These include inadequate early training, negative perceptions of thepatients, similar attitudes in their superiors, and poor compensation forthe time and effort required to treat these patients.12

Attempts have been made to alter this pessimism by further educat-ing medical students with specific classes and clinical activities,13,14

but often modification of their beliefs has been difficult.15 A five-month training program in chemical dependency failed to improveattitudes of medical interns.5 A course emphasizing the success ofmany treatment programs resulted in minimal positive change in theoptimism of its students.6 Empirical evidence of treatment efficacyand patient exposure do not necessarily change the prejudices of medi-cal students.

Given the aforementioned background about medical students’ atti-tudes toward their patients and disease, this study explores medicalstudent attitudes toward drug addiction policies.

METHODS

A random sample of 18 medical schools was drawn from the listingof schools in the United States. This number was selected to provide asample of approximately 4,000 first- and second-year medical stu-dents. Deans of the selected medical schools were contacted by letterand a follow-up phone call to explain the project and to solicit partici-pation. Of the eighteen schools, fifteen schools in fourteen statesagreed to participate. Reasons for refusing participation included hav-ing completed a recent internal survey and policies against participa-tion in outside surveys.

Faculty contacts and, in some cases, class presidents were identifiedby the participating schools for liaison in implementing the survey.The surveys were shipped to the schools in bulk for distribution byeither the faculty representatives or the designated class officials. Eachsurvey came with a self-addressed, postage paid envelope. Uponcompletion of the survey, each form was to be placed in the accompa-

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nying envelope. A small stipend was offered to the classes at eachschool as a token of appreciation for participating in the project.

The participating schools had a total of 3,307 first- and second-yearstudents enrolled in the spring of 1998, of whom 1,256 (38.0%) re-turned completed questionnaires. While this response rate is not suffi-cient to provide an irrefutable estimate of overall attitudes, it doesprovide a means of studying the relationships between attitudes andthe students’ experiences and perceptions relating to policy issues.

The gender distribution of the survey respondents is 45% femaleand 55% male. Almost 75% are Caucasian, with Asians (16%) repre-senting the largest minority group. Hispanics and African-Americansconstitute about 4% and 3%, respectively. Native Americans, otherminorities, and persons who chose not to answer this question consti-tute the remainder of the sample. Politically, the sample appears bal-anced in that approximately 30% rank themselves as conservative,about the same consider themselves liberal, and 40% label themselvesas moderates.

The objectives of the study were to identify relationships betweenstudents’ experiences, including training, and perceptions of addictsand addictions treatments with opinions related to policy decisions.The survey specifically queried the medical students about the amountof training they had received; their perceptions of the effectiveness ofaddictions treatments; the extent to which they felt physicians shouldbe involved in drug policy; and the extent to which they favored oropposed 14 policy related alternatives. The policy items provided afive point ranking from ‘‘strongly favor’’ to ‘‘strongly oppose.’’

The policy items consisted of a range of options such as ‘‘demandreduction,’’ ‘‘supply reduction,’’ and ‘‘other approaches to reducingdrug use.’’ In order to reduce the policy items to more global andgeneral themes, the items were subjected to a principle componentsfactor analysis with Equamax rotation.16 This resulted in a three factorsolution discussed in greater detail in the next section. Scales werederived from the four to five items loading on their respective factorsand checked for internal consistency. These scales represented policyoptions associated primarily with demand reduction, supply reduction,and other legal options such as drug courts and needle exchange.

To determine what influenced these policy opinions, the three em-pirically derived policy opinion scales served as dependent variablesfor multiple regression analyses, with other variables used as the inde-

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pendent predictors. The independent variables included sex, ethnicity,political orientation, extent of training, and opinions about efficacy oftreatment and physicians’ involvement in both treatment and policy.The results of this analyses are discussed in detail in the next section.

Although the focus of this survey is the consideration of interrela-tionships among experience, clinical perspectives, and policy options,the base rates of the opinions of the sample provide a context for theassociations. As noted above, the response rate is not sufficient tomake a judgment about the experiences and opinions of all medicalstudents, but we do know those of the 1,256 students who constitutethis sample.

RESULTS

Demand reduction approaches such as anti-drug education in schoolsand communities, increased treatment resources, increased training forphysicians, needle exchange programs, and treatment alternatives suchas drug courts are much more strongly favored by medical studentsthan are supply reduction strategies such as interdiction strategies andtougher sentences for users. The exception here is their approval forstronger penalties for drug smugglers. Prevention efforts in schoolsand communities appear to have the greatest support, followed byincreased training of physicians and more funding for treatment. It isinteresting to note that despite this support for treatment, a majority ofthe medical students oppose decriminalization and favor some sanc-tions for users. The modal response for the question probing studentawareness of current federal expenditures correctly identifies 30% ofthe budget as being devoted to demand reduction vs. 70% for supplyreduction efforts. The modal response as to their view of the optimaldistribution is for an equal expenditure between supply and demandreduction.

About half the medical students feel that drug addictions can besuccessfully treated in a majority of cases, but almost 30% disagreewith this opinion. The remaining 21% have no opinion as to whethertreatment tends to be successful. Interestingly, the students are aboutevenly divided as to whether physicians are effective in treating pa-tients with substance abuse problems. Likewise, they are similarlydivided on their opinions of whether or not addictions should betreated only by specialists in that field.

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One noteworthy finding is that almost 20% report receiving notraining in substance abuse. A significantly greater proportion ofwomen than men report no training (24% vs. 16%). Fewer than 24% ofthe students report at least a moderate amount of training. The remain-ing students (56%) list their training as constituting ‘‘a small amount.’’It is possible that a proportion of those reporting no training could bethe first-year students scheduled to receive such training subsequent tothe survey. The fact remains that despite efforts to increase the trainingabout addictions, it would appear that sufficient addictions relatededucation is still lacking.

Approximately 90% of the medical students feel that physiciansshould be involved in drug policy decision-making and in dealing withillicit drug use in their communities. Approximately 36% think physi-cians should be involved ‘‘a great deal’’ in policy decisions and 40%endorse this level of involvement in dealing with drug use in thecommunity. If these views are typical, the findings suggest that medi-cal students feel that physicians should be actively involved in thisarea, although most of them report that their own training on the topichas been minimal.

The factor analysis of the opinion items revealed three factorswhich were then used to derive three additive scales: demand reduc-tion, supply reduction, and legal/harm reduction options. The itemsand the frequencies of responses favoring and strongly favoring eachare itemized in Table 1. The intent here is not to suggest that theseendorsements are typical of all medical students, but to show therelative support for the items by the respondents. The Chronbach’salpha statistic of internal consistency for the three scales was .625 forthe four item demand reduction scale, .744 for the five-item supplyreduction scale, and .654 for the scale of other legal initiatives andresearch. These internal consistency coefficients are adequate for suchbrief scales.

Scales were derived for the three factors by summing the rating forthe individual items noted in Table 1. The scales for demand reductionand supply reduction had a very small but positive correlation (r =.116) which is essentially negligible in terms of any mutual accountingof the variance. The demand reduction and legal alternatives scaleshad a significant positive correlation (r = .339; p < .001). A negativecorrelation of almost equal size (r = −.381; p < .001) was observedbetween the supply reduction and legal alternatives scales. These find-

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TABLE 1. Medical Students’ Endorsement Rates for Policy Alternatives

Items Favor Strongly Favor

Demand ReductionMore anti-drug education in public schools 33% 58%Increased funding for community education 44% 43%Increased substance abuse training for physicians 51% 38%Increased funding for drug treatment 49% 35%

Supply ReductionTougher penalties for drug smugglers 24% 62%Tougher sentences for users 24% 27%Increased funding for police at the street level 45% 22%Use of U.S. military abroad 16% 7%Increased foreign anti-drug aid 25% 4%

Legal AlternativesNeedle exchange programs 38% 30%Make marijuana available for medical use 30% 30%Drug courts that place drug offenders in treatment 50% 29%Increased funding for substance abuse research 49% 24%Decriminalization for possession 14% 7%

ings would suggest that attitudes about the need for supply and de-mand reduction are relatively independent. However, those whostrongly favor demand reduction also favor use of other alternativessuch as needle exchanges and drug courts, while those who morestrongly favor supply reduction are opposed to such alternatives and toany relaxation of sanctions.

To get a better perspective of the factors that influence the policyrelated attitudes, multiple regression was employed using studentcharacteristics such as sex and minority status, reported political ori-entation along a liberal-conservative dimension, level of training re-ceived, and other perceptions such as whether treatment worked andwhether physicians should be involved in drug related issues (eitherfrom a policy or community perspective). The three-factor scale scoresderived from summing the five-point ratings of the items in Table 1and the rating of whether treatment funding should be increased wereused as the dependent variables in the analyses. Table 2 presents theorder in which the various items entered into the regression equationsfor each of the four analyses. To be included into the regressionequation a variable had to have a significance threshold of p = .01 orless.

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TABLE 2. Items Predicting Policy Attitudes

Variables are listed in the order in which they entered into regression analyses.

Characteristics favoring demand reduction strategies:1. Think physicians should be involved in addressing drug use in their communities.2. Politically liberal.3. Female.4. Think physician leaders should be involved in drug policy decision making.5. Perception of risk in using drugs is high.

Characteristics favoring supply reduction strategies:1. Think marijuana use should be a crime--do NOT think it should be legal for

adults.2. Politically conservative.3. Perception of risk in using drugs is high.4. Think physicians are effective in treating patients with substance abuse.5. Caucasian--not a minority person.6. Think that physician leaders should NOT be involved in policy decision making.7. Do think that physicians should be involved in addressing drug use in their

communities.

Characteristics favoring legal alternatives/harm reduction:1. Think that marijuana should be legal for adults--think use should NOT be a crime.2. Politically liberal.3. Think physician leaders should be involved in drug policy decision making.4. Female.

Characteristics favoring increased funding for treatment:1. Politically liberal.2. Think physician leaders should be involved in drug policy decision making.3. Think that drug abuse should be treated by specialists.4. Think that physicians should be involved in addressing drug use in their commu-

nities.

The most striking finding from the regression analyses is that politi-cal orientation--in terms of being either liberal or conservative--ap-pears to be more important in the students’ policy orientations thaneither the amount of their educational exposure to substance abuse ortheir perceptions of whether treatment for drug abuse is effective.Neither the amount of training in medical school or the perception oftreatment effectiveness entered into any of the regression equations. Incontrast, their political orientation was either the most discriminatingitem or was the second item to enter into the regression equations.Ironically, effectiveness entered into the regression equations only forsupply reduction, where the persons more likely to feel that physicians

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are effective in treating persons with drug problems are also morelikely to favor sanctions and police efforts in dealing with drugs.

Bivariate relationships between variable pairs resulted in both antic-ipated and unexpected findings. Other than gender, no associationswere seen between these variables and the level of training. In otherwords, the students’ level of training regarding addictions was notsignificantly correlated with their perceptions of whether treatmenttended to work or whether physicians were successful in dealing withaddictions. As might be expected, those who think treatment is mostlikely to be successful are also more optimistic about the ability ofphysicians to successfully address drug problems in patients. Interest-ingly, neither the amount of training nor the degree to which thestudents thought treatment worked were related to their opinions ofwhether funding should be increased for treatment or whether physi-cians should receive more training in addictions. One of the largercorrelation coefficients (r = .313) was between political conservatismand the determination that marijuana use should be considered a crimerather than a legal activity. No significant correlation was noted be-tween ethnicity and political orientation or gender.

The policy scales were trichotomized into categorical scales forhigh, moderate, and low support for the dimension in question todevelop additional perspectives on the relationships between the policyissues and political orientation, as contrasted to the respondents’ per-ception of whether treatment works. Approximately 55% of conserva-tives, compared to 74% of liberals, score in the moderate to highsupport range for the demand reduction scale, while 20% and 38%,respectively, fell into the high support category. Neither the opinionabout marijuana use as a crime or perception of treatment effective-ness shows a statistically significant relationship to the support fordemand reduction strategies. Of those who feel that marijuana useshould be a crime, 26% feel into the high support range for demandreduction compared to 30% for those who feel that it should be legalfor all adults. Approximately 29% of those who think treatment worksmost of the time fell into the high range on the demand reduction scaleas compared to 24% who do not think that treatment works. In short,the demand reduction scale, while significantly correlated with politi-cal orientation (X2 = 41.09; df = 4; p < .00001), is generally favoredby all subgroups of the medical student sample.

When considering funding for treatment specifically, the vast ma-

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jority of all medical students in this sample favor more funding irre-spective of political persuasion or perception of efficacy. The differen-tials based on political orientation appear more in the strength of thesupport. More than 75% of the conservatives favor more treatmentfunding, but only about 20% strongly favor more funding. In contrastalmost 50% the liberals strongly favor more treatment funding. Mod-erates fall between these two, with about 36% strongly favoring moretreatment funding.

The supply reduction construct consisting of support of increasedsanctions and greater reliance on police and foreign efforts at supplyreduction seems even more politically and philosophically grounded.Over 45% of those who think that marijuana use should be a crime fallinto the highest two-thirds of this scale while 60% of those who feelmarijuana should be legal for adults are in the lowest third. Over 40%of conservatives are in the high support range, as compared to 20% ofthose who classify themselves as liberal. As with demand and treat-ment funding, the perception of whether treatment works is not relatedat a statistically significant level.

As one might expect, the legal alternatives scale negatively corre-lates with supply reduction. About 55% of liberals are highly support-ive of these legal alternatives as compared to slightly over 10% ofconservatives.

Looking at needle exchange and drug courts in order to reduce anyconfounding of issues such as decriminalization and medical use ofmarijuana, the same general trends emerge. While 52% of liberalsstrongly favor needle exchanges, only 11% of conservatives stronglysupport this. Drug courts show a similar, though not as pronounced,pattern. About 50% of liberals strongly favor the use of drug courts ascompared with just under 20% of conservatives. Although the percep-tion of treatment effectiveness did not associate significantly withneedle exchange, it does reach modest statistical significance for asample of this size (X2 = 25.98; df = 6; p < .005). About one-third ofthose who believe treatment works strongly support drug courts, ascompared to 27% who do not think treatment is effective in mostcases. Interestingly, in this case, the people who are of no opinion onwhether treatment works are least likely (23%) to strongly favor drugcourts.

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DISCUSSION

While this study does not provide a basis for judging the generallevel of support or opposition to a given policy or attitude among allmedical students at all medical schools, it does provide compellingindications about the relationships between ingrained attitudes andviews for this sample of over 1,200 students. Political orientation andsimilar ingrained attitudes seem to have more of a bearing on students’views on policy issues than even their own perceptions of whethertreatment tended to be successful. Although support for more fundsfor treatment and emphasis on physician education was foundthroughout the political spectrum, substantial differences were foundaccording to political orientation. In particular, students who considerthemselves to be politically conservative express much more supportfor supply reduction efforts and greater sanctions for users as well asdealers. The more conservative students also are much less likely tofavor alternative policies such as needle exchange programs and drugcourts.

Demographics appeared to play a role only with regard to gender.Women were more supportive of demand reduction and legal andpublic health strategies for harm reduction. Women were also morelikely to indicate a lack of education regarding substance abuse thanmen. Minority students were only slightly more likely to favor de-mand reduction, but no other associations of even marginal signifi-cance were noted.

Although the adequacy of medical education in addictions mayhave increased over the past 20 years,17 it would appear from thissurvey that more progress is yet to be made. Because one in five of themedical students in the survey reported no training in substance abuseand less than one in four reports at least a moderate amount of trainingin this area, more time must be devoted to training in this area.

The fact that perception of whether or not treatment works did notenter into the equation for favoring greater treatment funding is puz-zling. For such a straightforward question, one would hope for moreconsistency. One would expect that those who felt treatment tended tobe successful would support more resources for treatment. Instead, itwould appear that political persuasions and attitudes about physicianroles are more significant than perception of treatment efficacy.

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