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Attitudes towards Substance Use and Substance Use Disorders among Medical Students in Israel

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Title: Attitudes towards Substance Use and Substance Use Disorders among Medical Students in Israel
Language: English
Authors: Lev-Ran, Shaul, Steinmetz, Yo, Weiser, Mark
Source: Drugs: Education, Prevention & Policy. 2016 23(6):484-491.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 9
Publication Date: 2016
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Descriptors: Substance Abuse, Negative Attitudes, Medical Students, Smoking, Alcohol Abuse, Drug Abuse, Medical Education, Experience, Moral Values, Competence, Addictive Behavior, Program Effectiveness, Physicians, Foreign Countries, Narcotics, Marijuana
Geographic Terms: Israel (Tel Aviv)
DOI: 10.3109/09687637.2016.1167167
ISSN: 0968-7637
Abstract: Background: Negative attitudes towards substance use and Substance Use Disorders (SUDs) are among the commonly cited barriers to screening and treating these disorders by physicians. These negative attitudes have also been reported in medical students. The aim of this study was to examine attitudes of medical students in Israel towards nicotine, alcohol and drug use and SUDs based on their stage of training and personal experience. Methods: A sample of 329 medical students responded to the Attitudes Towards Substance Use questionnaire, which includes 50 questions regarding substance use and SUDs, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. Results: Students at the clinical phase of their training had higher rates of moralism and lower rates of self-reported competency in treating SUDs compared to those in the pre-clinical phase of training. Personal experience with nicotine or alcohol use, as well as having a friend who suffers from addiction, were associated with lower rates of moralism. Across substances, the lowest ratings of treatment efficacy and of self-reported competence, were directed towards alcohol dependence. Conclusions: Medical education programs should include training in addiction medicine throughout all phases of medical school. This may have a significant role in future physicians' attitudes towards individuals with substance use and SUDs, and eventually in the treatment these patients receive.
Abstractor: As Provided
Number of References: 63
Entry Date: 2018
Accession Number: EJ1189925
Database: ERIC
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  Value: <anid>AN0119476063;5f101dec.16;2019Feb12.16:05;v2.2.500</anid> <title id="AN0119476063-1">Attitudes towards substance use and substance use disorders among medical students in Israel. </title> <p>Background: Negative attitudes towards substance use and Substance Use Disorders (SUDs) are among the commonly cited barriers to screening and treating these disorders by physicians. These negative attitudes have also been reported in medical students. The aim of this study was to examine attitudes of medical students in Israel towards nicotine, alcohol and drug use and SUDs based on their stage of training and personal experience. Methods: A sample of 329 medical students responded to the Attitudes Towards Substance Use questionnaire, which includes 50 questions regarding substance use and SUDs, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. Results: Students at the clinical phase of their training had higher rates of moralism and lower rates of self-reported competency in treating SUDs compared to those in the pre-clinical phase of training. Personal experience with nicotine or alcohol use, as well as having a friend who suffers from addiction, were associated with lower rates of moralism. Across substances, the lowest ratings of treatment efficacy and of self-reported competence, were directed towards alcohol dependence. Conclusions: Medical education programs should include training in addiction medicine throughout all phases of medical school. This may have a significant role in future physicians' attitudes towards individuals with substance use and SUDs, and eventually in the treatment these patients receive.</p> <p>Keywords: Attitudes; medical students; addiction; alcohol; drug; Israel</p> <hd id="AN0119476063-2">Introduction</hd> <p>Nicotine, alcohol and drug use have an enormous impact on our society (Degenhardt & Hall, [<reflink idref="bib16" id="ref1">16</reflink>]). Substance use and Substance Use Disorders (SUDs) have been shown to contribute substantially to the global burden of disease, both directly and indirectly (Vos et al., [<reflink idref="bib59" id="ref2">59</reflink>]). Despite the high prevalence and the associated morbidity and mortality of these disorders, only a fraction of individuals suffering from these disorders receives treatment. For example, it was estimated that among individuals needing treatment for SUDs (not including nicotine), <10% actually receive treatment for their disorder (Substance Abuse and Mental Health Services Administration (SAMHSA), [<reflink idref="bib55" id="ref3">55</reflink>]). Though there are numerous factors affecting this treatment gap, it may partially be related to inadequate screening efforts by physicians and other health care professionals and may reflect negative attitudes towards patients with SUDs (Livingston, Milne, Fang, & Amari, [<reflink idref="bib32" id="ref4">32</reflink>]).</p> <p>Negative attitudes towards specific patient population and the negative effect on healthcare delivery has been reported in several areas including those suffering from addiction, psychiatric patients, HIV-infected individuals and more (Livingston et al., [<reflink idref="bib32" id="ref5">32</reflink>]). Several studies have reported a distressing relationship between physicians' attitudes towards patients and clinical decision-making and willingness to care for the patients (Pottick, Kirk, Hsieh, & Tian, [<reflink idref="bib45" id="ref6">45</reflink>]; Tyer-Viola, [<reflink idref="bib57" id="ref7">57</reflink>]).</p> <p>Stigma towards substance use and SUDs is common and may play a significant role in how individuals develop attitudes towards patients suffering from these disorders (Livingston et al., [<reflink idref="bib32" id="ref8">32</reflink>]). Previous research has shown that physicians hold negative attitudes towards individuals suffering from SUDs, as well as feelings of incompetence in treating these patients (Lev-Ran, Adler, Nitzan, & Fennig, [<reflink idref="bib30" id="ref9">30</reflink>]), not finding working with them rewarding (Ewan & Whaite, [<reflink idref="bib19" id="ref10">19</reflink>]), and holding views that treatment of these disorders is not sufficient (Roche, Parle, Stubbs, Hall, & Saunders, [<reflink idref="bib47" id="ref11">47</reflink>]). Moreover, physicians generally found their training in addictions as lacking, and those physicians trained in addictions were more optimistic about positive outcomes of addiction treatment (Ronzani, Higgins-Biddle, & Furtado, [<reflink idref="bib48" id="ref12">48</reflink>]).</p> <p>Of particular concern is the potential presence of negative attitudes towards SUDs among medical students, as this may indicate that these problems may actually arise during medical school. Students' personal experiences such as exposure to patients with SUDs, exposure to negative attitudes by teaching physicians and personal substance use and abuse may affect their attitudes, though research regarding medical students' attitudes towards SUDs is still scarce and conclusions are unclear. For example, research regarding medical students' attitudes towards SUDs in different phases (e.g. clinical versus pre-clinical) of their training shows conflicting results. While there are studies indicating that significant negative attitudes towards SUDs (measured in terms of general attitudes, role legitimacy, motivation and confidence working with these patients) increase with each year in medical training (Silins, Conigrave, Rakvin, Dobbins, & Curry, [<reflink idref="bib51" id="ref13">51</reflink>]), others found these attitudes actually improved throughout medical school (Landy, Hynes, Checinski, & Crome, [<reflink idref="bib28" id="ref14">28</reflink>]). Furthermore, though attitudes of physicians vary substantially across substances, the majority of research on medical students' attitudes does not include exploration of attitudes towards different substances or personal substance-related habits.</p> <p>Substance use in Israel is widespread across all social strata. Though prevalence of alcohol and drug use disorders has been previously reported to be substantially lower than that in several European countries, recent data indicates that the actual prevalence is much higher than previously suspected. Recent data estimate 12-month prevalence of alcohol and dependence to be 1% and 2%, respectively (Lev-Ran, Florentin, Feingold, & Rehm, [<reflink idref="bib31" id="ref15">31</reflink>]). Attitudes towards substance use and SUDs in Israel are therefore relevant and important from a public-health perspective.</p> <p>The aim of this study was to explore attitudes towards substance use and SUDs among medical students in Israel, based on phase of training (clinical versus pre-clinical), personal experience with substance use and differences between substances. In Israel, the medical system relies both on DSM (i.e. American) as well as ICD (i.e. European) definitions. These are used interchangedly depending on context. In medical education, diagnostic criteria are studied according to DSM, whereas in the public health system, diagnostic codes are provided according to ICD. Since this study was conducted in the educational context, we used DSM-based nomenclature ("Substance Use Disorder"). We hypothesized that (<reflink idref="bib1" id="ref16">1</reflink>) medical school students in their clinical years of training would be more judgmental towards patients with SUDs; (<reflink idref="bib2" id="ref17">2</reflink>) students with previous exposure to substances and SUDs (by themselves, friends or family members) would be less judgmental towards patients with SUDs and (<reflink idref="bib3" id="ref18">3</reflink>) students' attitudes towards drug addiction would be more judgmental than alcohol or nicotine addiction.</p> <hd id="AN0119476063-3">Methods</hd> <p>This study employs a cross-sectional study design with medical students at the Tel Aviv University Faculty of Medicine. Survey items capture students' attitudes towards substance use and SUDs. The study was approved by the Ethics committee in the Sheba Medical Center, affiliated with the Faculty of Medicine at Tel Aviv University.</p> <p>The target population was all medical students enrolled in the Tel Aviv University Faculty of Medicine during the 2014–2015 academic year. In order to explore differences in attitudes based on clinical exposure, we compared students in the pre-clinical phase of their training (PCP) to those in the clinical phase (CP) of training.</p> <p>Questionnaires were sent via email to 900 medical students through their class representatives. A link to the questionnaire was included in the email as well as a declaration of informed consent. All replies were automatically and anonymously entered into a pre-constructed computerized database.</p> <p>Two questionnaires were self-administered by each participant: (<reflink idref="bib1" id="ref19">1</reflink>) a personal questionnaire and (<reflink idref="bib2" id="ref20">2</reflink>) the Attitudes Towards Substance Use questionnaire. The first questionnaire included information on age, medical school year and personal information regarding nicotine and alcohol use. The latter included the following questions: (<reflink idref="bib1" id="ref21">1</reflink>) Do you regularly smoke cigarettes? (<reflink idref="bib2" id="ref22">2</reflink>) Have you regularly smoked cigarettes in the past? (<reflink idref="bib3" id="ref23">3</reflink>) Do you occasionally drink alcohol? (<reflink idref="bib4" id="ref24">4</reflink>) Have you ever had more than four standard alcoholic drinks in one sitting (1/3 litre of beer, glass of wine, shot of liquor)? (<reflink idref="bib5" id="ref25">5</reflink>) Do you have any family members that suffer from addiction? And (<reflink idref="bib6" id="ref26">6</reflink>) Do you have any friends that suffer from addiction? Given previous reports on reduced response rates when asked about illicit substance use (Babor, Brown, & Del Boca, [<reflink idref="bib2" id="ref27">2</reflink>]) and particularly among medical professionals (Oreskovich, [<reflink idref="bib42" id="ref28">42</reflink>]), and given the fact that this study was conducted in one medical school in the country, we were particularly concerned about potentially low response rates and low reliability, and accordingly chose to omit questions pertaining to illicit drug use.</p> <p>The Attitudes Towards Substance Use questionnaire is a 50-item questionnaire developed by the authors and used in previous studies. Particular items were derived from prior surveys of attitudes towards alcohol and drug abuse. Specific psychometric properties of the original surveys which served as a base for this questionnaire are provided elsewhere (Chappel, Veach, & Krug, [<reflink idref="bib9" id="ref29">9</reflink>]; Marcus, [<reflink idref="bib34" id="ref30">34</reflink>]; Soverow, Rosenberg, & Ferneau, [<reflink idref="bib53" id="ref31">53</reflink>]). In the first phase, items to be included in the survey were translated into Hebrew by three independent researchers. The resulting translations were compared and composed into a single version. This version was sent to researchers involved in the research of addiction treatment for comments and suggestions on the Hebrew wording. In the second phase, backward translation was conducted by an independent expert, the result was compared with the original, and slight inconsistencies were reconciled.</p> <p>The survey included general questions referring to attitudes towards substance use and SUDs, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin. The first three substances were targeted as they are the most prevalence substances used in Israel (Bar-Hamburger, Ezrahi, Rosiner, & Nirel, [<reflink idref="bib4" id="ref32">4</reflink>]) and worldwide (United Nations Office on Drugs and Crime, [<reflink idref="bib58" id="ref33">58</reflink>]). Specific questions on heroin were included as it has been graded as being among the most harmful drugs to the individual (Nutt, King, & Phillips, [<reflink idref="bib41" id="ref34">41</reflink>]) and we wished to compare students' attitudes towards illicit drugs which are regarded as less harmful (cannabis) compared to the most harmful (heroin) (Nutt et al., [<reflink idref="bib41" id="ref35">41</reflink>]).</p> <p>The questions were divided into five domains: (<reflink idref="bib1" id="ref36">1</reflink>) perception of addiction as a medical disorder (e.g. "alcohol dependence is a medical disorder"); (<reflink idref="bib2" id="ref37">2</reflink>) effective treatment options (e.g. "physicians who diagnose alcoholism early improve the chance of treatment success"); (<reflink idref="bib3" id="ref38">3</reflink>) moralism (e.g. "people dependent on nicotine have a weak will"); (<reflink idref="bib4" id="ref39">4</reflink>) competency (e.g. "the tools I acquired during medical training for diagnosing SUDs are sufficient") and (<reflink idref="bib5" id="ref40">5</reflink>) lack of treatment satisfaction (e.g. "I enjoy treating patient with alcohol dependence less than treating other patients"; i.e. higher scores in this domain indicate lower satisfaction of treatment).</p> <p>The survey addressed the above questions using five Likert-type response options for each question (5 = agree; 1 = disagree). In line with standard Likert-type questionnaire surveys, 10% of items in the questionnaire were reverse-scored.</p> <p>For each category of questions, an arithmetic mean was calculated to produce a mean factors score (MFS). We employed chi-square analysis for categorical variables and <emph>t</emph>-tests and analysis of variance (ANOVA) for continuous variables to compare MFS using the following dependent variables: phase of training (clinical/pre-clinical), personal experience with substances and SUDs. In order to explore differences in students' attitudes towards use and SUDs across a range of different categories of substances, comparisons were conducted on identically framed questions referring to different substances (e.g. "People addicted to [nicotine/alcohol/marijuana/heroin] have weak character") using repeated-measures ANOVA. Tukey's <emph>post hoc</emph> analyses were used to determine significant (<emph>p</emph> < 0.05) differences between subgroups. Greenhouse–Geisser corrections were applied when appropriate.</p> <hd id="AN0119476063-4">Results</hd> <p>Three hundred and twenty nine students responded to the questionnaire (36% response rate). Among the respondents, 193 were in the PCP group and 136 were in the CP group. The majority of respondents were in the 26- to 30-year-old age category (54%), did not smoke cigarettes (93%) and drank alcohol occasionally (80%) (Table 1).</p> <p>Table 1. Personal characteristics of study respondents.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Characteristic</td><td><italic>n</italic> (%)</td></tr></thead><tbody valign="top"><tr><td>Age category</td><td /></tr><tr><td char="–"> 18–20</td><td char="(">3 (1%)</td></tr><tr><td char="–"> 21–25</td><td char="(">96 (29%)</td></tr><tr><td char="–"> 26–30</td><td char="(">179 (54%)</td></tr><tr><td char="–"> 31–35</td><td char="(">39 (12%)</td></tr><tr><td> >35</td><td char="(">12 (4%)</td></tr><tr><td>Smoking status</td><td /></tr><tr><td> Current smoker</td><td char="(">22 (7%)</td></tr><tr><td> Past smoker</td><td char="(">64 (19%)</td></tr><tr><td>Alcohol drinking status</td><td /></tr><tr><td> Occasional drinking</td><td char="(">262 (80%)</td></tr><tr><td> At least one incident drinking >4 standard drinks</td><td char="(">245 (74%)</td></tr><tr><td>Family or friends with addiction</td><td /></tr><tr><td> Family member with drug or alcohol addiction</td><td char="(">33 (10%)</td></tr><tr><td> Friend with drug or alcohol addiction</td><td char="(">50 (15%)</td></tr></tbody></table> </ephtml> </p> <p>Several differences were found when comparing attitudes of students from different phases of training towards substance use and SUDs (Table 2).</p> <p>Table 2. Comparison of attitudes towards substance use disorders among students based on phase of medical training.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Category</td><td>Pre-clinical phase</td><td>Clinical phase</td><td><italic>p</italic> Value</td></tr></thead><tbody valign="top"><tr><td>Perception of addiction as a medical disorder</td><td char="±">3.66 ± 0.58</td><td char="±">3.83 ± 0.55</td><td>*</td></tr><tr><td>Effective treatment options</td><td char="±">3.19 ± 0.32</td><td char="±">3.15 ± 0.37</td><td char=".">0.63</td></tr><tr><td>Moralism</td><td char="±">2.83 ± 0.44</td><td char="±">2.92 ± 0.42</td><td>*</td></tr><tr><td>Physician competency</td><td char="±">2.68 ± 0.63</td><td char="±">2.10 ± 0.68</td><td>***</td></tr><tr><td>Lack of treatment satisfaction</td><td char="±">2.87 ± 0.60</td><td char="±">2.950 ± 0.80</td><td char=".">0.058</td></tr></tbody></table> </ephtml> </p> <p>1 *<emph>p</emph> < 0.05, ***<emph>p</emph> < 0.001.</p> <p>Students in the CP group had significantly higher levels of moralism (i.e. were more judgmental) compared to those in the PCP group and rated their levels of competency in diagnosing and treating addictions as significantly lower than students in the PCP group. Regarding perception of addiction as a medical disease, students in the CP group perceived addiction more as a disease compared to those in the PCP group.</p> <p>When comparing students' attitudes towards alcohol and drugs, individuals in the PCP group students reported that their training in treating patients with drug addiction (2.62 ± 0.77) was better than that in treating alcohol addiction (2.50 ± 0.76) (<emph>p</emph> < 0.05); no differences between students' self-reported levels of training in treating drug (1.75 ± 0.70) versus alcohol (1.72 ± 0.72) (<emph>p</emph> = 0.35) addiction were found in the CP group. Students in the CP group reported higher levels of "lack of satisfaction" (i.e. less satisfaction) in treating patients with drug (3.16 ± 1.00) versus alcohol (3.00 ± 1.06) (<emph>p</emph> < 0.05) addiction; no differences in levels of "lack of satisfaction" were found among students in the PCP group when comparing drug (2.94 ± 0.75) versus alcohol (2.88 ± 0.79) (<emph>p</emph> = 0.34) addiction.</p> <p>Significant associations were found between students' personal habits and attitudes towards addiction (Table 3). Students who were current smokers were less judgmental towards substance use and SUDs compared to those who never smoked. Similarly, past smokers were less judgmental (2.64 ± 0.38) compared to those who never smoked (2.92 ± 0.42) (<emph>p</emph> < 0.001). No differences were found between current and past smokers compared to non-smokers in all other domains. Students who reported casual use of alcohol were less judgmental than those who reported no use, and students reporting at least one incident of heavy drinking in the past were also less judgmental towards substance use and SUDs (2.79 ± 0.41) compared to those with no incident of heavy drinking in their past (3.08 ± 0.42) (<emph>p</emph> < 0.001). Students who reported having a friend who suffered from addiction were less judgmental towards substance use and SUDs compared to this without friends with addiction. No difference were found in levels of moralism between students with (2.86 ± 0.43) and without (2.87 ± 0.45) family members suffering from addiction (<emph>p</emph> = 0.89).</p> <p>Table 3. Comparison of attitudes towards substance use disorders (SUDs) among students based on personal experience with substance use and SUDs.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Category</td><td>Exposed</td><td>Not exposed</td><td><italic>p</italic> Value</td></tr></thead><tbody valign="top"><tr><td /><td><bold>Current Smoker</bold></td><td><bold>Non-smoker</bold></td><td /></tr><tr><td>Perception of addiction as a medical disorder</td><td char="–">3.53–0.43</td><td char="±">3.7 ± 0.57</td><td char=".">0.09</td></tr><tr><td>Effective treatment options</td><td char="±">3.12 ± 0.41</td><td char="±">3.18 ± 0.33</td><td char=".">0.47</td></tr><tr><td>Moralism</td><td char="±">2.52 ± 0.18</td><td char="±">2.89 ± 0.43</td><td>***</td></tr><tr><td>Physician competency</td><td char="±">2.7 ± 0.53</td><td char="±">2.42 ± 0.71</td><td char=".">0.78</td></tr><tr><td>Treatment satisfaction</td><td char="±">2.76 ± 0.70</td><td char="±">2.91 ± 0.68</td><td char=".">0.32</td></tr><tr><td /><td><bold>Occasional alcohol drinker</bold></td><td><bold>Non-drinker</bold></td><td /></tr><tr><td>Perception of addiction as a medical disorder</td><td char="±">3.77 ± 0.55</td><td char="±">3.72 ± 0.57</td><td char=".">0.45</td></tr><tr><td>Effective treatment options</td><td char="±">3.18 ± 0.35</td><td char="±">3.16 ± 0.28</td><td char=".">0.62</td></tr><tr><td>Moralism</td><td char="±">2.81 ± 0.40</td><td char="±">3.07 ± 0.46</td><td>***</td></tr><tr><td>Physician competency</td><td char="±">2.45 ± 0.69</td><td char="±">2.4 ± 0.75</td><td char=".">0.65</td></tr><tr><td>Lack of treatment satisfaction</td><td char="±">2.90 ± 0.71</td><td char="±">2.89 ± 0.60</td><td char=".">0.94</td></tr><tr><td /><td><bold>Friend with addiction</bold></td><td><bold>No friend with addiction</bold></td><td /></tr><tr><td>Perception of addiction as a medical disorder</td><td char="±">3.81 ± 0.62</td><td char="±">3.71 ± 0.55</td><td char=".">0.27</td></tr><tr><td>Effective treatment options</td><td char="±">3.09 ± 0.28</td><td char="±">3.19 ± 0.34</td><td>*</td></tr><tr><td>Moralism</td><td char="±">2.72 ± 0.40</td><td char="±">2.89 ± 0.43</td><td>*</td></tr><tr><td>Physician competency</td><td char="±">2.40 ± 0.72</td><td char="±">2.44 ± 0.70</td><td char=".">0.68</td></tr><tr><td>Lack of treatment satisfaction</td><td char="±">2.9 ± 0.76</td><td char="±">2.9 ± 0.67</td><td char=".">0.99</td></tr></tbody></table> </ephtml> </p> <p>2 *<emph>p</emph> < 0.05, ***<emph>p</emph> < 0.001.</p> <p>Students rated individuals with alcohol dependence as having "weak character" significantly more than individuals with nicotine dependence, and individuals with heroin dependence as having "weak character" significantly more than those with nicotine and alcohol dependence (Table 4).</p> <p>Table 4. Comparison of medical students' response to the question/s: "people addicted to nicotine/alcohol/marijuana/heroin have a weak character".</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Comparison between substances</td><td><italic>p</italic> Value</td></tr></thead><tbody valign="top"><tr><td char="±">Nicotine (2.53 ± 1.09)</td><td /></tr><tr><td> Alcohol</td><td>**</td></tr><tr><td> Marijuana</td><td char=".">0.12</td></tr><tr><td> Heroin</td><td>***</td></tr><tr><td>Alcohol (2.70 ± 1.0)</td><td /></tr><tr><td> Marijuana</td><td char=".">0.10</td></tr><tr><td> Heroin</td><td char=".">0.19</td></tr><tr><td>Marijuana (2.61 ± 1.10)</td><td /></tr><tr><td> Heroin</td><td>*</td></tr><tr><td>Heroin (2.76 ± 1.97)</td><td /></tr></tbody></table> </ephtml> </p> <p>3 *<emph>p</emph> < 0.05, **<emph>p</emph> < 0.01, ***<emph>p</emph> < 0.001.</p> <p>When asked if medical (i.e. pharmacological) treatment was effective in the treatment of nicotine, alcohol and heroin dependence, students perceived medical treatment of nicotine dependence as more effective than that of alcohol and heroin dependence, and treatment of heroin dependence as more effective than that of alcohol dependence (Table 5).</p> <p>Table 5. Comparison of medical students' response to the question/s: "medical treatment of nicotine/alcohol/heroin is effective".</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Comparison between substances</td><td><italic>p</italic> Value</td></tr></thead><tbody valign="top"><tr><td char="±">Nicotine (3.42 ± 0.84)</td><td /></tr><tr><td> Alcohol</td><td>***</td></tr><tr><td> Heroin</td><td>***</td></tr><tr><td>Alcohol (2.99 ± 0.78)</td><td /></tr><tr><td> Heroin</td><td>**</td></tr><tr><td>Heroin (3.19 ± 0.86)</td><td /></tr></tbody></table> </ephtml> </p> <p>4 **<emph>p</emph> < 0.01, ***<emph>p</emph> < 0.001.</p> <p>Students rated lower levels of confidence in treating individuals with alcohol compared to drug dependence, and reported receiving less tools during their training to diagnose and treat alcohol dependence compared to drug dependence. When asked whether "confrontation is a necessary part of enrolling a patient in treatment", students agreed with this statement significantly more when asked about individuals with drug addiction compared to alcohol addiction (Table 6).</p> <p>Table 6. Comparison of medical students' responses to questions regarding attitude towards alcohol versus drug dependence.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Question</td><td>Alcohol</td><td>Drugs</td><td><italic>p</italic> Value</td></tr></thead><tbody valign="top"><tr><td>Alcohol/drug dependence are treatable disorders</td><td char="±">3.95 ± 0.69</td><td char="±">3.93 ± 0.85</td><td char=".">0.67</td></tr><tr><td>I know how to refer patients with alcohol/drug dependence to appropriate treatment</td><td char="±">2.24 ± 1.01</td><td char="±">2.39 ± 0.99</td><td>**</td></tr><tr><td>Confronting patients with alcohol/drug dependence is an essential part of treatment</td><td char="±">3.03 ± 1.04</td><td char="±">3.22 ± 1.06</td><td>***</td></tr><tr><td>I enjoy treating patients with alcohol/drug dependence less than other patients</td><td char="±">2.93 ± 0.92</td><td char="±">3.03 ± 0.87</td><td>*</td></tr><tr><td>I feel more aggressive when interacting with patients with alcohol/drug dependence than with other patients</td><td char="±">2.79 ± 0.92</td><td char="±">2.87 ± 0.92</td><td char=".">0.80</td></tr><tr><td>The tools I acquired during medical training and residency for diagnosing alcohol/drug use disorders are sufficient</td><td char="±">2.29 ± 0.86</td><td char="±">2.37 ± 0.877</td><td>*</td></tr><tr><td>The tools I acquired during medical training and residency for treating alcohol/drug use disorders are sufficient</td><td char="±">2.18 ± 0.84</td><td char="±">2.26 ± 0.856</td><td>**</td></tr></tbody></table> </ephtml> </p> <p>5 *<emph>p</emph> < 0.05, **<emph>p</emph> < 0.01, ***<emph>p</emph> < 0.001.</p> <p>When directly comparing attitudes towards alcohol and heroin, students agreed more with the statement that "individuals with heroin dependence seek treatment only when they hit rock bottom" (3.35 ± 1.04) compared to the same question regarding individuals with alcohol dependence (2.95 ± 1.07) (<emph>p</emph> < 0.001), as well as with the statement "an individual with heroin dependence who relapsed a number of times is refractory to treatment" (2.43 ± 0.89) compared to the same question regarding alcohol dependence (2.2 ± 0.83) (<emph>p</emph> < 0.001).</p> <hd id="AN0119476063-5">Discussion</hd> <p>This study sought to examine medical students' attitudes towards substance use and SUDs across different phases of their training, different personal experience and across different substances. This is the first study of its kind conducted in Israel, and as the subjects included in the study are to-be physicians, its importance lies in the repeated association shown between physicians' attitudes and knowledge in the field of addiction and the quality of care provided to their patients.</p> <p>In line with our first hypothesis, students from CPs of their training were more judgmental towards addiction than their pre-clinical peers. In addition, individuals in the CP group reported lower levels of competency in diagnosing and treating addiction compared to those in the PCP group. Though the opposite may be expected to be the case (given that those in the CP group are more advanced in their medical training), these findings are in line with previous findings from other places in the world showing that students attitudes towards alcohol and drug use problems become increasingly negative as they progress through their training (Ritson, [<reflink idref="bib46" id="ref41">46</reflink>]), and that interest in treating addiction declines as medical education progresses (Cape, Hannah, & Sellman, [<reflink idref="bib6" id="ref42">6</reflink>]; Ritson, [<reflink idref="bib46" id="ref43">46</reflink>]). This echoes findings on physicians' attitudes towards addiction which are generally high in terms of moralism and low in self-reported feelings of competence (Lev-Ran et al., [<reflink idref="bib30" id="ref44">30</reflink>]). Various factors may partially explain these findings. It is possible that medical students in the CP of treatment are more exposed to practicing physicians and that attitudes towards individuals suffering from addiction are acquired through repeated exposure. This hypothesis is in line with findings from this study indicating that medical students' attitudes in the clinical (but not in the pre-clinical) phase of their training are similar to previously reported attitudes of physicians in Israel (Lev-Ran et al., [<reflink idref="bib30" id="ref45">30</reflink>]). In addition, it is possible that medical students' distress, including stress, depression and burnout (Dyrbye, Thomas, & Shanafelt, [<reflink idref="bib17" id="ref46">17</reflink>]) which increases gradually throughout training, may contribute to negative attitudes (Griffith & Wilson, [<reflink idref="bib22" id="ref47">22</reflink>]).</p> <p>Comparing attitudes towards different substances within each group, we found that individuals in the CP group perceived treating patients with drug dependence as less satisfying ("higher levels of 'lack of satisfaction'") compared to treating patients with alcohol dependence. This is in line with previous reports on physicians' attitudes towards drug versus alcohol dependence which show greater stigma towards drug use (Lev-Ran et al., [<reflink idref="bib30" id="ref48">30</reflink>]), and less negative attitudes and stigma towards legal substances such as nicotine (Cunningham, Sobell, & Chow, [<reflink idref="bib13" id="ref49">13</reflink>]). Clearly, though lowering stigma should no doubt stand as a societal goal, as social acceptability of a specific substance is not associated with less negative effects of the substance (nicotine and alcohol use disorders are among the major contributors to the global burden of disease, despite being legal), this should be emphasized in medical training.</p> <p>Students who had personal experience with substance use were generally less judgmental towards substance use and SUDs compared to those with no personal exposure. This was true for both cigarette smoking (both current and past) as well as alcohol consumption.</p> <p>Among medical students included in the study, 80% reported occasional alcohol consumption. This is somewhat lower than studies conducted elsewhere in the world. For example, Croen et al. found the prevalence of alcohol consumption among medical students in USA to be 97.8% of first year students and 95.0% of third year students (Croen, Woesner, Herman, & Reichgott, [<reflink idref="bib11" id="ref50">11</reflink>]); Pickard reported 86% of first year medical students in UK consumed alcohol (Pickard, Bates, Dorian, Greig, & Saint, [<reflink idref="bib44" id="ref51">44</reflink>]). The lifetime prevalence of a heavy drinking incident in our study was found to be 74% (i.e. 94% of all drinkers). Previous research indicates that medical students and physicians are not immune to their own problems of substance use (Berry, Crome, & Plant, [<reflink idref="bib5" id="ref52">5</reflink>]; Newbury-Birch, Walshaw, & Kamali, [<reflink idref="bib39" id="ref53">39</reflink>]; Pickard et al., [<reflink idref="bib44" id="ref54">44</reflink>]; Stecker, [<reflink idref="bib54" id="ref55">54</reflink>]), and that both medical students and physicians are at increased risk for alcohol-related problems (Baldwin, Hughes, Conard, Storr, & Sheehan, [<reflink idref="bib3" id="ref56">3</reflink>]; Granville-Chapman, Yu, & White, [<reflink idref="bib21" id="ref57">21</reflink>]), hence appropriate education in addiction medicine is relevant not only for treating patients with SUDs but for medical students as well.</p> <p>Seven percent of all students reported current smoking, which is substantially lower than the prevalence of young adults in the general population and among students. This is similar to findings reported on the rates of smoking among medical students in USA (7%), Australia (6%), India (7%) and China (6%) and lower than several European countries such as Spain (42%) and Greece (32%) (Lam, Tse, Yu, & Griffiths, [<reflink idref="bib27" id="ref58">27</reflink>]; Smith & Leggat, [<reflink idref="bib52" id="ref59">52</reflink>]; Warren, Sinha, Lee, Lea, & Jones, [<reflink idref="bib61" id="ref60">61</reflink>]). Since it has been shown that doctors who smoke are less likely to counsel their patients to quit smoking, and that feeling ill-equipped to help others in this domain while they have failed to quit smoking themselves (Meshefedjian, Gervais, Tremblay, Villeneuve, & O'Loughlin, [<reflink idref="bib36" id="ref61">36</reflink>]; Tong, Strouse, Hall, Kovac, & Schroeder, [<reflink idref="bib56" id="ref62">56</reflink>]), personal habits such may not only form attitudes but affect the treatment provided by physicians. Hence, repeated efforts towards adequate training of medical students about smoking and smoking cessation, as well as drinking and reducing heavy alcohol consumption are required. Since the vast majority of medical students recognize their crucial role as sources of advice and information on health issues and role models (Pantsidis, Papageorgiou, & Bouros, [<reflink idref="bib43" id="ref63">43</reflink>]), medical schools need to take appropriate action by including approaches to smoking and drinking in their curriculum (Chatkin & Chatkin, [<reflink idref="bib10" id="ref64">10</reflink>]). Sadly, this does not seem to be the case today – e.g. only about one-quarter of 561 medical schools from 109 countries have a separate course covering the issues of smoking, and this is usually limited to the theoretical level alone (Pantsidis et al., [<reflink idref="bib43" id="ref65">43</reflink>]).</p> <p>In order to understand the reported rates of nicotine and alcohol consumption among Israeli adults in the international context, it should be noted that rates of Drug Use Disorders in Israel generally seem to be comparable to the lower range in several European countries, while prevalence of Alcohol Use Disorders seems to be lower than rates reported in USA and several European countries (Lev-Ran et al., [<reflink idref="bib31" id="ref66">31</reflink>]). Due to a lack of epidemiological studies on SUDs across various age groups in Israel, it is not possible to fully compare these prevalence rates among university-age students in Israel versus other countries. Specific available data include prevalence of regular cigarette smoking, which affects 19% of the adult (over 21 years old) population. In comparison to other OECD countries, Israeli men and women are rated 27 and 32 out of 40 OECD countries, respectively (Israel Ministry of Health Publication, [<reflink idref="bib24" id="ref67">24</reflink>]). Regarding alcohol use – (Neumark, Rahav, & Jaffe, [<reflink idref="bib38" id="ref68">38</reflink>]) data indicate that ∼9% of the Israeli population in the 18- to 40-year-old age group report binge-drinking (five or more standard drinks) in the past month. In comparison, past-month prevalence of binge-drinking in USA is estimated at ∼17% (Centers for Disease Control and Prevention (CDC), [<reflink idref="bib8" id="ref69">8</reflink>]). Various explanations have been suggested for the relatively lower rates of alcohol dependence, including social and cultural influences and a potentially genetic heightened sensitivity to the effects of ethanol (related to alcohol dehydrogenase polymorphisms) (Shea, Wall, Carr, & Li, [<reflink idref="bib50" id="ref70">50</reflink>]). Despite this, alcohol use in Israel is becoming more prevalent, with a significant increase in the use of high-alcohol-content beverages ("liquors") and a gradual reduction of age-of-onset of alcohol use (Bar-Hamburger et al., [<reflink idref="bib4" id="ref71">4</reflink>]). Therefore, despite the apparent lower rates of alcohol dependence compared with North America and Europe, this is gradually becoming a significant public health concern.</p> <p>Students who had a friend suffering from addiction were less judgmental towards addiction compared to those who did not have such friends. This was not found among those with family members suffering from addiction. It has been shown that families of individual with addiction may actually suffer from increased stigma towards addiction, as well as self-stigma (Mak & Cheung, [<reflink idref="bib33" id="ref72">33</reflink>]) and associated stigma (stigma which befalls individuals by virtue of their association with discredited others) (Mehta & Farina, [<reflink idref="bib35" id="ref73">35</reflink>]), all which may partially explain the difference in levels of moralism towards addiction among those with friends versus family members suffering from addiction. This warrants future research which should focus on level of proximity to the family member, as well as specific substances (alcohol and drugs) used.</p> <p>Across substances, the highest rates of moralism were directed towards individuals with heroin addiction, followed by alcohol, cannabis and nicotine. Interestingly, ratings of treatment efficacy for alcohol dependence were lowest among substances. This is particularly concerning given existing, as well as emerging, pharmacotherapies (Garbutt, [<reflink idref="bib20" id="ref74">20</reflink>]) and brief interventions(Kaner et al., [<reflink idref="bib25" id="ref75">25</reflink>]) for the treatment of alcohol dependence. One possible explanation for these findings is the fact that to-date, no medication for the treatment of alcohol dependence is included in the medication formulary in Israel (Lev-Ran, [<reflink idref="bib29" id="ref76">29</reflink>]). Accordingly, though rates of prescription for medications targeted at alcohol dependence is generally low, it can be expected to be even more so when these medications must be imported privately and patients are not reimbursed for them. Most medical students in Israel would therefore be expected to have close to no exposure to the prescription of medications for the treatment of alcohol dependence, and this may contribute to the combination of low perceived levels of effective treatment and high rates of moralism.</p> <p>Consistently, attitudes towards heroin dependence were the most judgmental across substances. The perception that treating heroin dependence requires confrontation may play a part in maintaining a vicious cycle, in which applying ineffective confrontations labels patients as "difficult to treat", which may in turn increase confrontation (Miller, Benefield, & Tonigan, [<reflink idref="bib37" id="ref77">37</reflink>]). This is particularly unfortunate given the significant detrimental health and mental health effects of heroin dependence (Degenhardt et al., [<reflink idref="bib15" id="ref78">15</reflink>]) and the association between stigma against SUDs and the lower standard of treatment patients suffering from these disorders receive (Livingston et al., [<reflink idref="bib32" id="ref79">32</reflink>]).</p> <p>The results presented in this study should be understood in the context of the structure of the medical system in Israel and the (lack of) exposure the average medical student in Israel has to specialized addiction treatment. The medical system in Israel is a two-tier system, including both public and private medical services. Each citizen in the country benefits from a comprehensive public-health plan, provided by four Health Maintenance Organizations (HMOs). Currently, almost one-third of the medical services in the country are provided through the private system and two-thirds through the public system. Addiction treatment is unique in that it is provided through designated Ministry of Health centres, and not part of the general medical system. Accordingly, these centres, which focus largely on either inpatient detoxification or long-term out-patient maintenance treatment for opioid dependence (using Methadone or Buprenorphine), are not academically affiliated and medical students are not exposed to them. Otherwise, long-term psychosocial treatment is provided ambulatory centres and Therapeutic Communities run by the Ministry of Welfare, to which medical students are not exposed either. Thus, the average medical student is not exposed to specialized treatment of addiction and encounters patients with addiction only within the general medical system, which lacks the specialized personnel which can provide the appropriate education. This may partially explain medical students' perceptions regarding lack of efficient medical treatment for addiction. Since these treatments are not offered in academic-affiliated hospitals (where the vast majority of medical training takes place) nor in Primary Care Services (where an additional part of medical education in Israel takes place), medical students are not practically exposed to medication-prescribing for SUDs at all.</p> <p>All this leads to dire need of integrating a proper Addiction Medicine curriculum into medical schools in Israel. Medical schools in Israel use a 6-year European model of undergraduate education. Their programs include three and a half years of preclinical studies (equivalent to pre-med and years one and two in North American medical schools) and two and a half years of clerkship rotations in various clinical departments (equivalent to years three and four in North America). Upon completion of medical school, all students pass a standardized national examination (administered by the medical schools), after which they are required to complete a 1-year internship before being given a medical license by the Ministry of Health. Consequently, though medical schools generally have academic independence regarding curriculums throughout medical school, all students must attain a high standard level of knowledge. Therefore, medical schools may serve as an ideal platform for integrating Addiction Medicine education which should be represented in the curriculum for the standardized national examination.</p> <p>Internationally, different solutions have been provided for the dire need for Addiction Medicine education. In addition to postgraduate studies such as ABAM and ISAM accreditations in North America and internationally, Master's studies in Addiction Medicine as well as Addiction Medicine specialties, there are several attempts to integrate Addiction Medicine education in the undergraduate level (such as the UK St George's project which has promoted standardized Addiction Medicine education in 19 medical schools) (Klimas, [<reflink idref="bib26" id="ref80">26</reflink>]). Looking at the near future in Israel and given the non-academic set-up of Addiction Medicine services, we believe stratifying requirements regarding Addiction Medicine in a nationally accepted curriculum, which should be inter-disciplinary in nature and emphasize the bio-psycho-social approach underlying clinical practice (Carroll et al., [<reflink idref="bib7" id="ref81">7</reflink>]) will help medical students understand the disorder and decrease moral attitudes as well as utilize the many effective tools in treating addictions today. This may in turn increase self-perception of competence and satisfaction among future physicians when treating clients with addictions. Research focusing on medical students' attitudes towards substance use and SUDs before and after integration of such a standardized curriculum as well as analysis of scores on questions pertaining to SUDs in standardized national examinations should be conducted in order to validate its efficacy both in terms knowledge as well as attitudes towards substance use and SUDs among medical students.</p> <p>Limitations of this study should be recognized. First, the low response rate: while response rates <40% are particularly common in surveys conducted among medical personnel in Israel (Abu-Hammad, Dreiher, Vardy, & Cohen, [<reflink idref="bib1" id="ref82">1</reflink>]; Endevelt, Werner, Karpati, & Ami, [<reflink idref="bib18" id="ref83">18</reflink>]; Werner & Vered, [<reflink idref="bib63" id="ref84">63</reflink>]), this is lower than response rates reported in some studies conducted among medical students in Israel regarding cancer, cardiovascular disease and perception of medical specialties (Notzer & Abramovitz, [<reflink idref="bib40" id="ref85">40</reflink>]; Weissman et al., [<reflink idref="bib62" id="ref86">62</reflink>]). This may reflect a low level of importance medical students relate to the problem or express a potential selection bias due to the expected accordance between agreement to participate in the survey and importance physicians relate to the treatment of SUDs. In addition, though we intentionally did not include questions regarding students' drug use, it is possible that inclusion of personal question such as those regarding alcohol use, friends and family members suffering from addiction physicians' further reduced the response rate, as has been reported in physicians' surveys on use of other substances (Oreskovich, [<reflink idref="bib42" id="ref87">42</reflink>]). Finally, caution should be exercised in generalization of results. Attitudes towards substance use and SUDs are affected by social constructs (Room, [<reflink idref="bib49" id="ref88">49</reflink>]) which may differ substantially between countries and regions.</p> <p>Medical school is a critical and essential stage in the development of physicians who should be competent in diagnosing and treating SUDs. Evidence shows that improving emotional preparedness to work with substance users based on improved role adequacy (the belief that the physician has sufficient knowledge); role legitimacy (the belief that substance use issues are a legitimate health area for the physician to examine) and role support (the belief that appropriate advise is available when needed) (Deehan, Marshall, & Strang, [<reflink idref="bib14" id="ref89">14</reflink>]) is associated with increased preparedness of physicians to be involved with the treatment of individuals with SUDs. As it has been repeatedly suggested that both training as well as clinical experience in the addiction field within medical training is inadequate and often non-existent (Crome, [<reflink idref="bib12" id="ref90">12</reflink>]; Isaacson, Fleming, Kraus, Kahn, & Mundt, [<reflink idref="bib23" id="ref91">23</reflink>]; Walsh, [<reflink idref="bib60" id="ref92">60</reflink>]) improving educational programs targeted at theoretical and practical aspects of diagnosing and treating SUDs is an important step in changing future physicians' attitudes towards addiction.</p> <hd id="AN0119476063-6">Declaration of interest</hd> <p>The authors report no conflicts of interest.</p> <ref id="AN0119476063-7"> <title> References </title> <blist> <bibl id="bib1" idref="ref16" type="bt">1</bibl> <bibtext> Abu-Hammad, T., Dreiher, J., Vardy, D.A., & Cohen, A.D. (2008). Physicians' knowledge and attitudes regarding periconceptional folic acid supplementation: A survey in Southern Israel. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Attitudes towards Substance Use and Substance Use Disorders among Medical Students in Israel
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Lev-Ran%2C+Shaul%22">Lev-Ran, Shaul</searchLink><br /><searchLink fieldCode="AR" term="%22Steinmetz%2C+Yo%22">Steinmetz, Yo</searchLink><br /><searchLink fieldCode="AR" term="%22Weiser%2C+Mark%22">Weiser, Mark</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Drugs%3A+Education%2C+Prevention+%26+Policy%22"><i>Drugs: Education, Prevention & Policy</i></searchLink>. 2016 23(6):484-491.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 9
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2016
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Substance+Abuse%22">Substance Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Negative+Attitudes%22">Negative Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Smoking%22">Smoking</searchLink><br /><searchLink fieldCode="DE" term="%22Alcohol+Abuse%22">Alcohol Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Abuse%22">Drug Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Education%22">Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Experience%22">Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Moral+Values%22">Moral Values</searchLink><br /><searchLink fieldCode="DE" term="%22Competence%22">Competence</searchLink><br /><searchLink fieldCode="DE" term="%22Addictive+Behavior%22">Addictive Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Physicians%22">Physicians</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Narcotics%22">Narcotics</searchLink><br /><searchLink fieldCode="DE" term="%22Marijuana%22">Marijuana</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Israel+%28Tel+Aviv%29%22">Israel (Tel Aviv)</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.3109/09687637.2016.1167167
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0968-7637
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Negative attitudes towards substance use and Substance Use Disorders (SUDs) are among the commonly cited barriers to screening and treating these disorders by physicians. These negative attitudes have also been reported in medical students. The aim of this study was to examine attitudes of medical students in Israel towards nicotine, alcohol and drug use and SUDs based on their stage of training and personal experience. Methods: A sample of 329 medical students responded to the Attitudes Towards Substance Use questionnaire, which includes 50 questions regarding substance use and SUDs, as well as specific questions focusing on nicotine, alcohol, cannabis and heroin use. Results: Students at the clinical phase of their training had higher rates of moralism and lower rates of self-reported competency in treating SUDs compared to those in the pre-clinical phase of training. Personal experience with nicotine or alcohol use, as well as having a friend who suffers from addiction, were associated with lower rates of moralism. Across substances, the lowest ratings of treatment efficacy and of self-reported competence, were directed towards alcohol dependence. Conclusions: Medical education programs should include training in addiction medicine throughout all phases of medical school. This may have a significant role in future physicians' attitudes towards individuals with substance use and SUDs, and eventually in the treatment these patients receive.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 63
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2018
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1189925
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1189925
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.3109/09687637.2016.1167167
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 9
        StartPage: 484
    Subjects:
      – SubjectFull: Substance Abuse
        Type: general
      – SubjectFull: Negative Attitudes
        Type: general
      – SubjectFull: Medical Students
        Type: general
      – SubjectFull: Smoking
        Type: general
      – SubjectFull: Alcohol Abuse
        Type: general
      – SubjectFull: Drug Abuse
        Type: general
      – SubjectFull: Medical Education
        Type: general
      – SubjectFull: Experience
        Type: general
      – SubjectFull: Moral Values
        Type: general
      – SubjectFull: Competence
        Type: general
      – SubjectFull: Addictive Behavior
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Physicians
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Narcotics
        Type: general
      – SubjectFull: Marijuana
        Type: general
      – SubjectFull: Israel (Tel Aviv)
        Type: general
    Titles:
      – TitleFull: Attitudes towards Substance Use and Substance Use Disorders among Medical Students in Israel
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Lev-Ran, Shaul
      – PersonEntity:
          Name:
            NameFull: Steinmetz, Yo
      – PersonEntity:
          Name:
            NameFull: Weiser, Mark
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2016
          Identifiers:
            – Type: issn-print
              Value: 0968-7637
          Numbering:
            – Type: volume
              Value: 23
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Drugs: Education, Prevention & Policy
              Type: main
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