Appendix 1.

Description of 31 Studies of Undergraduate Medical Education Interventions for Substance Abuse Disorders (SAD) Intervention Training, From Highest to Lowest Medical Education Research Study Quality Instrument (MERSQI) Score^*

Source	Participants	Interventions	Evaluations	Results	Competencies addressed^†	MERSQI Score
Kahan et al, 2003¹⁸	Third- and fourth-year medical students from the five medical schools in Ontario, Canada	In a randomized controlled trial, 76 students received a 3-hour workshop either on either problem drinking and alcohol dependence or on depression (control condition). The alcohol workshop consisted of a 1-hour presentation, role plays, and a demonstration of a clinical interview. It covered assessment and management of problem drinking and alcohol dependence.	Postworkshop OSCE (8 stations); all students completed a baseline questionnaire on their beliefs and self-reported clinical behavior as well as a postworkshop questionnaire on beliefs. Four months later, they were mailed a follow-up questionnaire on their knowledge, beliefs, and self-reported behavior.	The alcohol group received significantly higher assessment and management checklist scores and global rating scores and performed better on almost all aspects of clinical management of both problem drinking and alcohol dependence than did the depression group. At 4 months postintervention, the alcohol group also showed a significant increase in beliefs about self-efficacy in managing alcohol problems (from baseline) and had greater knowledge of reduced drinking strategies than did the depression group, but the two groups did not differ on other measures.	N/A	14.83
Walsh et al, 2001²⁸	Fifth-year medical students at the University of Newcastle and University of Sydney, Australia	In two controlled trials, 154 students received either a didactic alcohol education program or didactics plus skills-based training.	Pre- and postintervention videotaped interviews with SPs were assessed by raters using a written rating scale (the pretest and post-test)	The educational approach used had no effect on posttest scores. Alcohol-related interactional skills scores improved for both groups after training at both universities. (Posttest scores were higher than pretest scores).	BI	14.00
Roche et al, 1997²⁹	Fifth year medical students from a “traditionally oriented medical school” in Australia	In a randomized controlled trial involving 115 students, the experimental group received a 3-hour interactive program involving a short lecture, clinical practice, and small group feedback on clinical performance. The control group received 3 hours of a traditional didactic teaching program on the principles and practice of brief and early intervention.	10-minute videotaped encounter with an SP before and after teaching, evaluating students’ general interactional skills and how well they addressed alcohol-related issues	The educational approach had no effect on pre–post differences. Performance on alcohol-related issues and interactional skills were significantly improved equally in each group.	S, BI	13.83
Taverner et al, 2000³⁰	Senior medical students at University of Adelaide, Australia	Three instructional strategies were used to teach clinical skills in assessing and managing drug-seeking patients: didactic small group tutorial (n = 35), video-based tutorial (n = 136), or computer-aided instruction package using digitized video (n = 43).	Student feedback, performance on a case-based written examination, and a structured evaluation of interviews with SPs	No difference was seen in written examination and SP outcomes among the three groups. Student feedback was most positive for the video-based tutorial. The computer-aided instruction was most cost-effective over a 6-year period.	S, RT	13.17
Walsh et al, 1999³¹	Final-year medical students at the University of Newcastle, Australia	In a controlled trial, two student blocks received a manual, a lecture, and a demonstration about the principles and practice of a brief alcohol intervention. Experimental students (n = 29) made a 20-minute videotape and participated in a 1.5-hour small group feedback session in addition. Control students (n = 26) did not.	Pre and postintervention questionnaires and videotaped interviews with SPs	There was no significant difference in the effectiveness of the two methods. Levels of alcohol-related knowledge, attitudes, and interactional skills were significantly improved after teaching in both groups.	BI	13.17
O’Neil et al, 1980⁴²	Third-year medical students rotating through psychiatry at the Medical University of South Carolina	One group (n = 66) received a programmed self-instruction text, called the Alcohol Learning Program (ALP). The control group (n = 60) received the less extensive alcohol teaching usually provided (also a programmed self-instruction text).	Pre- and posttest on alcoholism-related knowledge and attitude	Students receiving the ALP had a greater pre–post improvement in knowledge compared with controls. No attitude change was seen.	RT	12.83
Gopalan et al, 1992²⁴	First-, second-, and fourth-year medical students at the Johns Hopkins University School of Medicine.	The Model Alcohol Curriculum (MAC) emphasized learning state-of-the-art approaches to the diagnosis and management of alcoholism and other drug problems. Content and teaching methods were directed toward building positive attitudes toward patients and toward treatment for these disorders. The MAC included experiential aspects, including interacting with recovering alcoholics and drug addicts and attending self-help groups (e.g., AA).	Surveys recorded students’ knowledge, attitudes, beliefs in role responsibility, and confidence in clinical skills related to the diagnosis and treatment of SAD.	Significant improvements occurred in the students’ attitudes, beliefs in role responsibility, and confidence in skills during their preclinical years. These positive changes were stronger and better sustained during the clinical years in those students who participated in special programs or elective courses focusing on SA; they were not always sustained in other students.	S, BI, RT	12.50
Lee et al, 2008³²	First-year medical students at New York University School of Medicine	This controlled trial, compared the effectiveness of an interactive Web module (n = 82) with that of a traditional lecture (n = 81) to improve medical students’ competence in screening and interventions for hazardous drinking.	SP alcohol case, Pre- and posttest of knowledge, student OSCE evaluations	The Web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score, and they self-reported as better prepared for the SP case. Participation in instruction was higher in the Web module group.	S, BI	12.17
Matthews et al, 2002²⁵	Third-year medical students at the University of Massachusetts Medical School	This study, conducted over four years, involved student participation in a one- or two-day interclerkship about SA.	Pre- and post-interclerkship test about attitudes and knowledge of SAD (attitude questions modified from the SAAS), a final course evaluation, and AAMC graduate questionnaire data. In addition, during one year, each student’s clinical skills in SA assessment and intervention were evaluated at the end of the 6-week psychiatry clerkship using OSCEs with two SPs, one with and one without active SA issues.	Students’ attitudes toward and knowledge about SA disorders and their confidence about SA assessment and intervention all showed significant positive changes immediately after the interclerkship. The OSCE performance data demonstrated a significant sustained improvement in clinical skills in SA assessment and intervention, as measured up to 6 months following the interclerkship.	S, BI, RT	11.83
Chappel et al, 1977⁴³	Second-year medical students at the University of Nevada School of Medical Sciences	Forty-eight students were given a 28-hour course on SA, including history, epidemiology, and a conceptual overview. Topics/activities included the impact of advertising, management of overdose and withdrawal, medical complications, psychological aspects, cultural aspects, treatment methods, field trips to treatment programs, assessment of treatment programs, panel of basic and behavioral scientists, detection technology, legal aspects, role of the physician, physician susceptibility, and prevention.	Pre- and posttest knowledge and attitude measure	Significant positive changes in attitudes: Students reported feeling less upset when they encountered alcoholics, “hard” drug abusers, “soft” drug abusers, compulsive smokers, and obese overeaters, as well as having a more positive view of the physician’s role in the treatment of substance dependence. Students’ personal experience with alcohol and other drugs was shown to have an influence on attitude changes.	RT	11.33
Brown et al, 1990³³	Third-year medical students, rotating through family medicine rotation at Jefferson Medical College of Thomas Jefferson University	Four groups of self-selected students participated. The experimental group (n = 33) received three computer assisted instruction (CAI) modules, active discussion, role play, opportunities for applying new knowledge and clinical skills, and modeling of clinical interest by a family doctor. The immersion group (n = 12) received one week immersion experience on a SA inpatient unit. The limited formal teaching group (n=35) received 1–4 hours of lecture and the no formal teaching group (n=28) received no intervention.	End of rotation questionnaires assessing knowledge, satisfaction with SA teaching, and motivation for continued learning	The CAI course resulted in higher levels of knowledge on early diagnosis but similar attitudes and satisfaction to those of the other three groups. The CAI and immersion courses produced more favorable outcomes than lecture-based teaching and no formal teaching. Compared with no formal teaching, lecture did not produce a measurable effect.	S, RT	11.17
Bland et al, 2001³⁴	Second-year medical students during 5-week human reproduction block at the University of Ottawa Faculty of Medicine, Ontario, Canada.	All 84 students received lectures (1 hour) on SAD during pregnancy, a 2-hour problem-based small-group tutorial concerning a young pregnant woman with alcohol dependence, and a 2-hour interaction with an SP.	Questionnaire (51 items) given before and after training regarding attitudes toward and counseling for SAD during pregnancy (used shortened, modified version of SAAS in second section of survey)	Students showed statistically significant improvement in their level of comfort in dealing with women with SAD in pregnancy.	N/A	11.00
Stillman et al, 1990⁴⁴	Second year medical students at four medical schools in New England	Students (n = 794) were given a selection of articles about alcoholism and SA prior to SP encounters. Then, each student participated in a 3-hour mandatory session and was randomly assigned to 3 of 34 30-minute SP scenarios.	Feedback after each SP encounter, including a case-specific checklist and rating of the student’s performance on the Arizona Clinical Interview Rating (ACIR) scale	There was a statistically significant difference between checklist scores and ACIR scale scores across encounters. Student performance improved from the first to third SP encounter.	S, BI, RT	11.00
Christison et al, 2003³⁵	Third-year medical students rotating through psychiatry clerkship at the Loma Linda University School of Medicine	As part of the 6-week psychiatry clerkship, 153 students were assigned either to a 1-week addiction treatment experience at either an intensive outpatient VA addiction treatment program (70%) or to an addiction treatment program at a private university-based psychiatric hospital (30%).	Pre and postclerkship Medical Condition Regard Scale (MCRS) assessing attitudes towards patients with alcoholism, major depression, and emphysema; postclerkship psychiatric subject examination score before (historical controls) and after introduction of the one-week addiction treatment experience to the clerkship.	Students’ mean MCRS scores increased significantly for patients with alcoholism and major depression but did not change for patients with emphysema. Psychiatric subject examination scores before and after the curriculum change were not significantly different.	RT	10.83
Ramirez-Cacho et al, 2007⁴⁵	Third-year medical students rotating through the obstetrics–gynecology clerkship at the University of New Mexico School of Medicine	During the first 4 weeks of the clerkship, the experimental group (n = 52) was assigned to a half-day prenatal clinic designed specifically for women with SAD. The control group (n = 52) was assigned to the special prenatal clinic during the second 4 weeks.	Survey measuring comfort level and attitude at beginning and midway point of clerkship (adapted from an instrument designed and described by Bland et al.)³⁴	At baseline, experimental and control groups had similar comfort levels and attitudes. Students in experimental group became more comfortable in talking with patients about their substance use and less judgmental in treating these patients. Compared with before the clerkship, the control group became less comfortable in talking with these patients about their habits, less aware about the prevalence of SA during pregnancy, and less aware of the efficacy of counselors.	S	10.83
Chappel and Veach, 1987³⁶	Second-year medical students at the University of Nevada School of Medical Sciences	Same as Chappel et al, 1977,⁴³ but with 5 years of students (n = 48 for each year).	Pre and post SAAS (50 items). Five stable attitude factors—“Permissiveness” factor, “Treatment Intervention” factor, “Nonstereotypes” factor, “Treatment optimism” factor and “Nonmoralism” factor—were identified during the development of the survey.	Positive attitude change could be achieved during a SA course. When the course was scheduled in competition with demanding basic science courses, however, the students’ attitudes did not become as positive as or became more negative than when the course was part of a less demanding schedule. The study found that “Time pressure inhibits attitude change.”	RT	10.67
Weinberg and Morse, 1975⁴⁶	First-year medical students at the Mayo Medical School	Forty students received 4 hours of lecture and case material, took part in small-group discussions in which recovering alcoholics related their histories, and served as group leaders. Later during the year, students interviewed patients who were being treated for alcoholism and heard lectures on the pharmacology of alcohol and other psychotropic drugs.	“Understanding Alcoholism” pre- and posttest, consisting of 42 true-false items	On the pretest, students’ mean number correct was 31.0/42; the immediate posttest mean was 39.9/42, and the one-year follow-up mean score was 38.1/42.	N/A	10.33
Silins et al, 2007⁴⁷	First- and fourth-year medical students at an Australian university	Students took part in a structured education and clinical experience about SA. First-year students (n = 223) completed a 3-week addiction medicine learning module. Each week included 3 PBL tutorials, 6 lectures, 6 web-based learning resources, 3 interactive large-group teaching sessions, and 2 clinical skills sessions related to the “case of the week” (alcohol, benzo, or opiate). Guests with past alcohol dependence or current opioid dependence acted as speakers or interviewees. For fourth-year students (n = 222), there was a 9-week psychological and addiction medicine block. The block included 6 weeks of structured teaching sessions, with 2 PBL tutorials and 3 related seminars each week. Students also attended 3 clinical placements of 3 weeks’ duration. Students were required to interview and present the history of one patient with alcohol use disorder and one with another SAD.	Pre- and postsurvey consisting of 39 items on attitudes toward users of alcohol, tobacco and illicit drugs; confidence in managing patients with SAD; motivation toward intervening with substance users; and perception of the legitimacy of the medical practitioner’s role in dealing with patients with drug and alcohol problems. Twenty-one questions were derived from the Alcohol and Alcohol Problems Perception Questionnaire.	Men, older students and those with prior clinical experience tended to have more negative attitudes at baseline. Attitudes improved significantly after exposure to interactive learning modules. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility toward providing intervention and less anticipation of discomfort working with these patients. By the end of drug and alcohol education, less than half (42%) of students reported they could imagine working with substance misusers as a career.	S	10.00
Hunter et al, 1989³⁷	Third-year medical students rotating through psychiatry clerkship at Texas A&M University College of Medicine	During a two-week clinical rotation at the Alcohol and Drug Dependence Treatment Program (ADDTP), medical student functioned as subinterns, followed patients, attended AA meetings, watched films on chemical dependency, and attended didactic sessions with attending physicians.	NBME SA exam and student feedback via questionnaire	Students who rotated on the ADDTP performed as well as the students who had not rotated at the ADDTP in previous years. Students scored significantly higher on the NBME SA exam than the national mean. Pre-/posttest results indicated an increase in knowledge by at least one SD. Students reported ADDTP as “educationally valuable.”	N/A	9.50
Klein et al, 1991⁴⁸	Third-year medical students rotating through psychiatry clerkship at the University of Rochester Medical Center	Recovering alcoholics served as patient instructors (PIs) to teach 62 students interviewing and counseling skills.	PI rating of students’ performance (using University of Rochester Risk Factor Interview Scale [URRFIS]) but questionable as to whether that was part of intervention. Intervention included a questionnaire and student evaluation of exercise.	Students’ overall performance was rated by PIs as a 5 (highest possible rating) or a 4 in 58% of the exercises. In terms of specific skills on the URRFFIS, students did best in the “relationship” and “general interview technique” and less well in “positive focus” and “instigating behavior change.” Students gave positive evaluations of the exercise.	S, BI, RT	9.50
Siegal et al, 1986²⁶; Siegal and Rudisill. 1983⁴⁹	First- and second-year medical students at Wright State University School of Medicine	Students acted as participant-observers in the Weekend Intervention Program (WIP) through which they learned about alcoholism, diagnosis and assessment, and opportunities for treatment and referral. Students observed individual and group counseling sessions, attended AA meetings, and interacted with clients/patients. (WIP had more than 10,500 clients; the number of medical students was not provided.)	Multiple-choice tests assessing knowledge, history-taking, counseling, and attitudes (65 items) of students who had participated in WIP compared with those who had not	Significantly higher overall scores were found on knowledge, skills, and attitudes among those who had participated in WIP than those who had not. No difference was found between the group tested immediately following completion of the WIP and the group tested 12 months later.	S, BI, RT	9.50
Fazzio et al, 2003⁵⁰	Third-year medical students rotating through psychiatry clerkship at New York University School of Medicine	The 36 students were rotating through a required 5-week psychiatry rotation on 4 general psychiatry units at a major public urban teaching hospital. Most patients were dually diagnosed with SA and mental illness. The study describes a 1-hour lecture on spirituality and AA, but that was in addition to other lectures that are part of the clerkship.	Pre- and postclerkship evaluation of attitudes toward AA (spiritually based treatments) via 17-item questionnaire	At the beginning of the clerkship, students rated a spiritually oriented approach as important in addiction treatment as a biological approach, whereas at the end of the clerkship, they rated the biological approach as more important.	N/A	8.83
Ungerleider et al, 1992³⁸	First- and second-year medical students at the UCLA School of Medicine	More than 180 students participated in 16 hours of elective, small-group, interactive teaching seminars (IATs), which covered 12-step programs and prevention/education, and included law enforcement and treatment site visits. Students taught one another other. Seminars used audiovisuals, role-plays, and SPs in a report/debate format.	Pre and post SAAS administration (50 items)	IATs changed students’ attitudes on about one-third of SAAS items and decreased students’ uncertainty about SA issues on several other items. However, some items that dealt directly with key issues did not show a change in mean score or response distribution following the IATs.	S, BI, RT	8.83
Toraker and Rydberg, 1989⁵¹	Fifth-year medical students at The Karolinska Institute in Stockholm, Sweden	Students (n=140) took a 2-week course (80 hours) in alcoholism and drug dependence, including 1 week of lecture and 1 week of clinical training. Lecture topics included basic science, clinical science, prevention, early diagnosis, and legal and philosophical aspects of SA. Clinical training was in an inpatient ward with an outpatient clinic, and included seminars and community site visits.	Questionnaire, both after the week of lectures and after the clinical training, asked students to rate their attitudes toward alcoholism and drug dependence problems before and after the course (retrospective pre–post)	Students liked the course. Students’ interest in alcohol and drug dependence problems increased significantly after the course compared with their interest before it. The students were also more inclined to work in this field after the course.	S, RT	8.17
Coggan et al, 1981⁵²	Third-year medical students rotating through the family medicine clerkship at the University of Washington School of Medicine	Students (n = 19) participated in an alcoholism module, which included a 3-hour seminar, 2 site visits to a treatment center, and a visit to an AA meeting.	Students’ ratings of the alcoholism module (5-point scale); course final examination, including SP encounter	The alcoholism module received a rating of 4.3, the seminar 4.5, and the treatment center visits 4.1. Students did well in the course final examination; when a simulated alcoholic patient was included in the videotaped part of the examination, all students made the diagnosis correctly.	S, BI, RT	8.00
Oldham and Sipe 1990⁵³	Medical students enrolled in the Medical Student Professional in Residence (PIR) Summer School at the Betty Ford Center, Rancho Mirage, California	Students (n = 24) participated in the “Experiential Training Program” within a chemical dependency unit: 16 participated as mock chemically dependent inpatients and 8 as mock family member outpatients.	Pre- and postprogram administration of SAAS	There were significant score increases after the PIR training on the two discriminating factors “treatment intervention” and “treatment optimism.”	RT	7.83
Bishop et al, 1990²⁷	Second-year medical students at the Medical College of Pennsylvania	“Alcoholism Day” included small-group discussions with faculty and a person in recovery, demo interview with SP (or videotape), lecture on pharmacology and pathophysiology of alcoholism, public health aspects of alcoholism (case discussion), treatment modalities lecture and case discussion. The study reported the number of students from a “representative year” as 79.	Attendance, student evaluation of “Alcoholism Day” as a whole (excellent, good, fair), student performance on written examinations at the end of the second year	Student response to both the presentation and content of the day was positive. Attendance averaged 75% of the class, above average for lectures in the second year. Course evaluations from a representative year showed 80% of students who completed evaluations rated the day as excellent or good, 17% as fair, and 2% as poor. Fourth-year students in a required ambulatory care clerkship demonstrated knowledge of the CAGE on a written examination. Student performance on written examination at the end of the second year showed excellent retention of material presented (80% answered questions on alcoholism correctly). However, in most discriminating questions relating to screening and early diagnosis, students chose wrong answers reflecting common misbeliefs about alcoholism 40% of the time.	S, RT	7.17
Brown and Byrne, 1990⁵⁴	Third-year medical students rotating through the family medicine clerkship at Jefferson Medical College of Thomas Jefferson University	A group of 33 students received 3 CAI modules on early diagnosis, attitudes and screening questionnaires, as well as 2 conferences. CAI 1 included content about early diagnosis of substance abuse, CAI 2 included the SAAS, and CAI 3 had CAGE/MAST. The 3 modules and 2 conferences were followed by a clinical experience in which the students interviewed a patient at risk for SA in ambulatory or ER settings, and performed a physical exam, lab evaluation, and a chart review. They also submitted a write-up.	Evaluation forms on CAI modules and conferences immediately upon completion; on each form, students rated attributes of each experience and provided comments on positive features and suggestions for improvement. On the last day of the clerkship, students completed a questionnaire on SA teaching.	All students gave high ratings to all of the learning activities and the entire curriculum. Almost all were satisfied with the emphasis on SA in their clerkship and expressed motivation to learn more.	S, RT	7.00
Harris and Westermeyer, 1978⁵⁵	Second-year medical students at the University of Minnesota Medical School	Students (n = 240) participated in supervised clinical tutorials at chemical dependency treatment centers.	Evaluation forms with ratings and subjective comments	Students had both positive and negative feedback about the tutorials. Positive ratings included the educational value of the experiences at the centers. Negative feedback centered on unguided exposure at the centers and issues with the chemical dependency counselors.	RT	7.00
Welsh, 2003⁵⁶	Second-year medical students at University of Maryland School of Medicine	Students (n = 122) attended a 100-minute lecture on intoxication and withdrawal syndromes of 11 substances, which included a videotape incorporating clips from various commercially available films, several television news shows, and a training film displaying intoxication and withdrawal syndromes.	Eight-question, anonymous written questionnaire	More than 90% of the 89 respondents believed that the clips helped them recognize these syndromes and appreciate their potential severity. All students believed that the movie clips would help them remember the syndromes, with more than 90% reporting that it would help very much.	N/A	6.50
Confusione et al, 1982¹⁹	Third-year medical students rotating through family medicine clerkship at SUNY Stony Brook	Students (n = 61) spent one day at local methadone maintenance clinic. They attended a series of seminars and interviewed two patients.	Questionnaire at end of program, evaluating students on their knowledge, attitudes, and level of participation in the drug abuse treatment program	The students on the whole showed an increase in knowledge and an improved attitude toward drug abusers’ health care needs.	S, BI, RT	6.33

CAGE is a common acronym for four questions that are used as a screening test for alcoholism. CAI indicates computer-assisted instruction; MAST, Michigan Alcoholism Screening Test; OSCE, objective structured clinical examination; RCT randomized control trial; SP, standardized or simulated patient; SA, substance abuse; SAAS, Substance Abuse Attitude Survey (developed by Chappel and Veach)³⁹; SAD, substance abuse disorders.

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S= Screening, BI= Brief intervention, RT=Referral for treatment, N/A= not enough information to assess objectives.