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Increasing the Addiction Workforce: Fellowship Training in Addiction Medicine

Substance use is one of the most significant public health issues in the United States. Annual costs related to crime, lost work productivity and health care due to use of tobacco, alcohol, and illicit drugs exceeds $700 million annually (http://www.drugabuse.gov/related-topics/trends-statistics). In 2013, an estimated 9.4% of the population (24.6 million Americans aged 12 or older) were current illicit drug users. Slightly more than half (52.2 percent) of Americans aged 12 or older (136.9 million people) were current alcohol users, with nearly one quarter (22.9 percent) reporting binge alcohol use. (Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality. September 4, 2014. The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings. Rockville, MD.)

Despite the prevalence of medical illness in this population, their high utilization of health care services, and the increasing availability of effective treatment options, large numbers of individuals with substance use disorders still do not receive treatment. In most settings, substance abuse treatment is not readily available in coordination with medical treatment, leaving individuals to receive care from specialty treatment centers. These specialized settings however, are not sufficient to meet the need for treatment. The 2013 National Survey on Drug Use & Health estimated that 22.7 million individuals aged 12 or older needed treatment for an illicit drug or alcohol use problem. Of these, only 2.5 million received treatment at a specialty facility for addiction (SAMHSA, 2014).

A number of factors contribute to this discrepancy between individuals in need of treatment and the services available. While addiction is increasingly recognized as a medical illness, ongoing stigma remains about substance use and other behavioral health disorders. Limited insurance coverage for addiction related services also contributes to the treatment gap.

Traditionally, the bulk of addiction services have been provided outside the medical model by non-physician staff. Greater acceptance of the notion of addiction as a disease has shifted that somewhat, with greater physician involvement in treatment, particularly over the last few decades. Most physicians, however, do not receive sufficient education about addiction during medical school and residency, leading to a physician workforce that is inadequately equipped to provide substance abuse treatment services. Addiction specialists, individuals who have received additional training and practice in substance abuse treatment, are a critical component in closing this treatment gap. Specialists can provide direct care as well as support primary care and other providers in the treatment of individuals with substance use disorders. When primary care providers can trust in the availability of expert consultation, they can be more confident in their ability to treat individuals with addiction. Addiction specialists can also serve as educators, helping to ensure evidence-based care models are followed and roviding guidance about resources such as self-help and specialty addiction treatment programs with which primary care providers may not be familiar.

The first physicians to become board-certified as specialists in addiction were psychiatrists. Since 1991, the American Board of Medical Specialties has recognized addiction psychiatry as a subspecialty, requiring fellowship training and a certifying exam. While these specialists have been a welcome addition to the field, the number of addiction psychiatrists is not sufficient to meet the treatment needs of individuals with substance use disorders.

Non-psychiatric physicians specializing in the treatment of substance use disorders are called specialists in Addiction Medicine. Addiction Medicine is distinct from Addiction Psychiatry, and is one of the few multidisciplinary specialties, meaning that addiction medicine physicians come from a wide range of primary specialties such as family medicine, internal medicine, pediatrics, emergency medicine, obstetrics and gynecology, and surgery. A certifying examination has been offered since the 1980s, first by the American Society of Addiction Medicine (ASAM) and since 2007 by the American Board of Addiction Medicine (ABAM), an independent board which oversees the exam, as well as promoting the mission of physician training and certification in addiction.

Historically, physicians have been eligible to take the exam to become certified in addiction medicine if they had an unrestricted medical license, were board certified or board eligible in a primary specialty, documented 1 year of practice with patients with substance use disorders, and completed 50 hours of continuing medical education in the field of addiction. More recently, individuals can also become eligible through the completion of an ABAM accredited addiction medicine fellowship program, and it is likely that fellowship training will become a required qualification for certification in addiction medicine within the next several years.

Formalized fellowship training in addiction medicine is a groundbreaking step towards increasing the number of addiction physicians and closing the treatment gap. The ABAM Foundation defined required competencies for this training in 2010 and the first ten fellowship programs were recognized in 2011. Fellowship programs accept physicians that have trained in a wide range of medical specialties, and training consists of exposure to substance abuse treatment in the inpatient and outpatient settings, consultation-liaison services, and continuity care for individuals with substance use disorders. Today, there are 39 fellowship programs in the US and Canada, and ABAM has set a goal of 65 fellowships by 2020.

In the newly established Fellowship in Addiction Medicine at the Institute for Family Health, fellows will have the opportunity to provide substance abuse treatment in an integrated care model. Integrated treatment, in which substance abuse treatment (and often behavioral health treatment) is provided in collaboration with primary care services at the same location, allow individuals to receive care from a team of treatment providers and increases access to care. Further, integrated treatment models may reduce the stigma that can be associated with seeking substance abuse treatment by providing treatment from clinicians with whom the patient has already developed a therapeutic relationship in a setting that is already familiar to the individual.

Providing comprehensive medical and substance abuse services also enhances recovery. Research has shown that individuals with substance abuse related medical conditions who access primary care services are three times more likely to achieve remission over 5 years and are up to 30% less likely to require hospitalization (Weisner, C, Mertens, J, Parthasarathy, S, Moore, C, and Lu, Y. (2001). Integrating Primary Medical Care with Addiction Treatment. JAMA: The Journal of the American Medical Association, 286(14):1715-1723. doi:10.1001/jama.286.14.1715). Integrated treatment is ideal for meeting the comprehensive needs of individuals with substance use disorders.

The growth of addiction medicine promotes an integrated model of health care and moves towards closing the treatment gap. Addiction medicine training expands the workforce of specialist physicians to include a broad array of medical specialties and allows for treatment of a more diverse population in a greater number of clinical settings.

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