Substance abuse disorders are highly prevalent in the Bronx (alcoholism, 9%, narcotic use 4%)5 and account for a high proportion of inpatient hospital stays and outpatient visits, yet medical training for physicians-in-training is limited and often offered only electively.6-8 National estimates suggest that 25-40% of hospital admissions are related to substance abuse and its sequelae, and that 10-20% of outpatients seen in general medical practice are suffering from problems related to addiction.9-11 At Montefiore Medical Center, which has no dedicated inpatient substance abuse treatment units, over 7% of hospital discharges in 2000 had a primary diagnosis of substance abuse. A 1999 survey of 209 patients hospitalized at Montefiore with medical diagnoses commonly associated with substance abuse found that 9% of patients self-identified as having current alcohol or drug abuse or dependence, 17% screened positive for current alcohol or drug abuse or dependence, and 42% self-identified as ever having had alcohol or drug problems.12 Generalist physician trainees (Internal and Family Medicine residents), who provide the bulk of the medical care received by hospitalized drug users and train in ambulatory care sites in which many patients are drug or alcohol users, are often ill-equipped to diagnose or treat patients.8;13-15
In a recent survey of a national sample of practicing general internists, family physicians, obstetrician-gynecologists, and psychiatrists,16 68% of respondents reported that they regularly ask new patients about drug use, but only 55% reported that they offer formal addiction treatment to drug-abusing patients. Both psychiatrists and primary care doctors in this study were more likely to refer drug-abusing patients to a 12-step program than to a formal treatment program. This practice pattern is contrary to the available evidence, which strongly supports structured addiction treatment such as methadone maintenance, but is less clear regarding the effectiveness of 12-step programs for drug abuse.
The Einstein Community in the Bronx, New York City
The Bronx is the 24th largest county in the US, with an estimated population of 1.3 million (17% of New York City’s population).
The Bronx population includes a predominance of minorities:
- Hispanic (48%--the largest Hispanic population in New York City and the second largest outside the Southwest [after Miami/Dade, Florida], including the largest number of Puerto Ricans of any NYC borough)
- African-American (36%)
- Non-Hispanic White (15%)
- Asian (3%)
Bronx residents report the lowest median household income of any New York City borough ($26,611 in 1999). 31% of the population (and 42% of children) live below the poverty level.
The Bronx compares unfavorably to other U.S. counties similar in size, population composition, and density in a wide range of summary health measures, including:
- average life expectancy
- all-cause mortality
- self-rated health status
- breast cancer
- colon cancer
- coronary heart disease
- homicide
- unintentional injury
The New York State Office of Alcoholism and Substance Abuse Services (OASAS) estimates:
- over 82,000 adults in the Bronx have alcohol abuse or dependence
- 21,000 are non-narcotic drug users
- 40,000 use heroin
- 23,795 admissions to licensed substance abuse treatment programs by Bronx residents, representing an admission rate of 139 per 10,000 population, the highest in New York City (1995)
- 15,987 hospital inpatient discharges of Bronx residents with primary diagnoses of alcoholism or substance abuse numbered (13.3 per 1,000 population, higher than the city-wide rate of 8.3 and highest of the five boroughs) (1995)
- 9.8 drug-related hospitalizations per 1,000 compared to 6.2 for Manhattan and 4.7 for Brooklyn (1999-2003)