Addiction Training Tied to Lower Physician Stigma in National Survey

Physicians who received more addiction training during medical school, residency and continuing education hold measurably less stigma toward patients with substance use disorders, according to a nationally representative survey of 855 primary care and emergency department doctors published October 8 in the journal Addiction Science & Clinical Practice. The finding that matters most to treatment is not the attitude shift itself but the mechanism behind it: the training appears to reduce stigma almost entirely by convincing physicians they are capable of caring for these patients at all.

The study, led by Renae D. Schmidt at the University of Miami Miller School of Medicine with collaborators at Columbia University and the University of Chicago, drew on a survey conducted between October 2020 and October 2022 that achieved a 53.6 percent response rate — a strong figure for physician surveys — and was weighted to represent doctors nationally.

What the researchers measured

The team separated addiction education into three strands: hours of training during medical school, hours during residency, and participation in Continuing Medical Education, the coursework practicing physicians complete throughout their careers. Stigma was assessed with two validated instruments, the Drug and Drug Problems Perceptions Questionnaire and the Medical Condition Regard Scale, which capture how clinicians emotionally and cognitively regard patients with drug-related problems. The researchers also asked each physician to rate their own capability to care for people with substance use disorders, and measured practice by whether doctors reported actually delivering treatments such as medication for opioid use disorder and behavioral counseling.

Because primary care and emergency physicians were surveyed with overlapping instruments, the investigators used generalized estimating equations — a regression method that handles correlated observations — to pool estimates across both groups while adjusting for sex, race and ethnicity, years since degree and physician type.

Training tracked with less stigma — and more treatment

The association between more training and less stigma held across substances. For alcohol use disorders the standardized coefficient was negative 2.42 and statistically significant at the 1 percent level; for stimulant use disorders it was negative 2.78; for opioid use disorders, negative 2.48. Physicians who reported more training expressed less stigmatizing regard no matter which drug was involved — a notable result for stimulant use disorders, which have no FDA-approved medication and are often viewed with particular pessimism in clinical settings.

Training also tracked with what physicians did. Each increment of education was associated with higher odds of providing treatment: a prevalence ratio of 1.19 for treating alcohol use disorders, 1.09 for prescribing medication for opioid use disorder, 1.10 for delivering behavioral counseling for opioid use disorder and 1.14 for treating disorders involving other drugs. The individual ratios look modest, but across a workforce of hundreds of thousands of physicians they compound. Most Americans with a substance use disorder never receive any treatment, and medication-assisted treatment prescriptions have plateaued even as opioid use disorder prevalence has risen.

Confidence, not attitude, looks like the lever

The most conceptually interesting result concerns mediation. Perceived capability was itself strongly associated with lower stigma across alcohol, stimulant and opioid use disorders, with coefficients of negative 0.55, negative 0.51 and negative 0.59. When the researchers added perceived capability to their models, the direct effect of training on stigma disappeared — while the indirect effect running through capability stayed significant for all three disorder types, with coefficients of negative 0.11 for alcohol, negative 0.09 for stimulants and negative 0.11 for opioids. That pattern indicates full mediation: training lowers stigma not by changing moral attitudes directly, but by building doctors' confidence in their own clinical competence.

The distinction matters for how medical education is designed. If stigma were driven mainly by personal bias, the fix would be attitude-focused interventions such as contact-based anti-stigma campaigns. If it is driven by a felt lack of skill, the fix is more supervised clinical exposure to addiction care — and the data point that way.

What the study does not show

The design is cross-sectional and based on self-report, so it cannot prove that adding training causes stigma to fall; physicians who were already less biased, or more interested in addiction medicine, may have sought out more education. The survey also measured reported practice rather than patient records. And the population is limited to primary care and emergency physicians, the two settings where most Americans first encounter the health system but not the only places addiction care happens.

Still, the study adds a concrete mechanism to a familiar complaint: that addiction is treated as an afterthought in medical training and that patients absorb the consequences. For a health system trying to expand access to opioid use disorder and stimulant use disorder care, the implication is that curriculum hours may do more work than awareness campaigns.