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    Addiction Medicine on the Road to Subspecialty Status

    By: Naseem S. Miller, Internal Medicine News Digital Network

    Dr. Daniel P. Alford stumbled into addiction medicine after he finished his residency in internal medicine more than a decade ago.He hesitantly took a part-time position as the medical director for a city-run methadone maintenance program and ended up staying for 10 years. "I loved it the minute I got there," he said. "I realized that there’s a whole other world out there in terms of addiction treatment that I wasn’t exposed to. Generalist disciplines ... get exposed to the most severe forms of the problem, but when I got to the methadone maintenance program, I met all these patients who were doing great. Their problem was being treated with medication and counseling," he said.
    Today, he’s the director for the addiction medicine residency program at Boston University, which is 1 of 10 training programs in the country that have recently become accredited by the American Board of Addiction Medicine (ABAM). A key goal of his: Confront and eliminate the stigma that addiction treatment is always a losing proposition.

    There’s a big push to educate non-psychiatrists about the progress of addiction treatment, and one way to do that is by gaining sub-specialty recognition, explained Dr. Richard D. Blondell, ABAM’s chairman of the Residency Accreditation Review Committee. The goal is to get an additional 10-15 addiction medicine programs accredited by July 2012 to reach the target 20-25 programs that are required for sub-specialty recognition by the American Board of Medical Specialties (ABMS). "We’re the largest group of physicians that doesn't have a home," he said. Sub-specialty accreditation is a "very important step. The goal is to bring the specialty of addiction medicine under the tent of organized medicine."
    Although non-psychiatrists have practiced addiction medicine for decades and thousands have been certified by ABAM and by the American Society of Addiction Medicine, none of the post-residency training programs has been accredited or recognized by the national bodies, ABMS, or the Accreditation Council for Graduate Medical Education (ACGME).

    Dr. Blondell said that part of the reason that addiction medicine hasn’t become a recognized sub-specialty is the fact that the field isn't highly compensated. "So, there aren’t many resources to do all the paperwork. It’s taken us a bit longer, but we’ll get there."
    Advocates say that having addiction medicine as a recognized sub-specialty will open the door to physicians from various backgrounds to train in the field and will help increase patient access to addiction treatment. In addition, they say having more experts in the field will help educate the physician workforce, reduce the stigma among physicians, and help with existing reimbursement issues.
    "In a sense no specialty wanted to claim addiction medicine," said Dr. Peter Friedmann, professor of medicine and community health at Brown University in Providence, R.I., and an ABAM-certified addiction medicine specialist. It really is a field that crosses disciplines, and "the establishment of residency really sets the wheels in motion to have specialists in medical centers and in communities recognized for this particular expertise. It also brings a level of legitimacy, and a certain body of knowledge that is important for all physicians to know and to integrate into their practices.

    "The American Academy of Addiction Psychiatry (AAAP) in concert with the American Psychiatric Association and other organizations succeeded in getting addiction psychiatry recognized as a sub-specialty by the American Board of Psychiatry and Neurology (an ABMS member), and Addiction Psychiatry fellowships by the ACGME in the early 1990s. The majority of addiction psychiatry programs, however, accept psychiatry residents only.
    "We've been supporting the ability of non-psychiatrists to get post-residency training in addiction for a long time," said Dr. Richard Rosenthal, past president of AAAP and the current head of public policy at the association. "We’re glad that there’s finally a mechanism to get extra training for primary care doctors and others.

    "Dr. Rosenthal said he expects that there will be growing pains and tension between the two sub-specialties, which overlap in many areas. "But my attitude is that given the patient density, there’s more than enough pie to go around. More and more we have to look at building care teams that address the broad array of medical problems," said Dr. Rosenthal. In a 2009 report, the American Board of Addiction Medicine Foundation, which accredited the addiction medicine programs this year, estimated that 5,000 new physicians need to be certified by 2020 to meet demand. Yet, the addiction psychiatry programs currently produce only 20-40 sub-specialists annually, and the addiction medicine fellowship adds another 20-30 per year, leading to a shortfall of 30-60 physicians, according to a 2011 analysis of addiction medicine programs by Dr. Blondell and his colleagues. (Substance Abuse 2011;32:84-92).


    "There’s an enormous population and not enough doctors," said Dr. Stuart Gitlow, acting president of the American Society of Addiction Medicine, the professional organization for addiction medicine specialists, which established ABAM in 2007.
    Applicants to addiction medicine programs come from a wide range of backgrounds. Some are fresh out of a residency; others are mid-career. Dr. Blondell estimated that roughly 40% of fellows come from psychiatry, 25% from family practice, 25% from internal medicine, and the rest from a wide range of backgrounds, including ob.gyn., pediatrics, and surgery. Some of the addiction medicine programs run in close collaboration with the addiction psychiatry residencies, and some say that there are benefits to having the two groups of residents side by side. Boston University’s addiction medicine residency modeled itself after the existing addiction psychiatry residency. "We have a good relationship with the university’s addiction psychiatry residency," said Dr. Alford. "It was really critical for us to sit down with addiction psychiatry and figure out how to put it all together."


    There’s overlap, but there are also significant differences between addiction medicine and addiction psychiatry. While addiction medicine specialists focus more on the medical treatment of patients with medical and/or surgical comorbidities, addiction psychiatrists tend to focus on the treatment of coexisting mental illnesses."The whole subspecialty is so young that we don’t have much experience on how this will play out," said Dr. Petros Levounis, chief of the division of addiction psychiatry at Mount Sinai St. Luke’s and Mount Sinai West hospitals. "Eventually, it will be clear who the patient needs to go to," he said, adding that for starters having medical vs. psychiatric comorbidity could serve as a designating role.

    Under the ABAM accreditation, the addiction medicine training should have four components: training in inpatient settings; training in outpatient settings such as residential programs; program-specific training depending on the region and nearby facilities; and electives, which are based on the physicians’ backgrounds. "So, at the end of the year, they all will have similar knowledge, although they come from all sorts of backgrounds," Dr. Blondell said.Despite the obvious need for an addiction medicine sub-specialty, Dr. Friedmann added a note of caution."I think we have to be mindful that creating a sub-specialty is not a substitute for physicians and other providers developing greater knowledge and skill in the addiction field," he said. "There are too many patients. We’re not going to be able to train enough specialists to treat all those folks. The general medicine field needs to accept that these are legitimate medical conditions for which they should take responsibility."

    Accredited Addiction Medicine Residency Training Programs
    Addiction Institute of New York Fellowship in Addiction Medicine, NY.
    Boston University Medical Center Addiction Medicine Residency.
    Cincinnati Addiction Medicine Fellowship.
    Geisinger Addiction Medicine Residency at Marworth, Waverly, Pa.
    Minnesota Addiction Medicine Residency Program, Minneapolis.
    University at Buffalo (N.Y.) Addiction Medicine Fellowship.
    University of Florida Addiction Medicine Program, Gainesville.
    University of Hawaii Addiction Medicine Training Program Honolulu.
    University of Maryland-Sheppard Pratt Training Program, Baltimore.
    University of Wisconsin Program, Madison.

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