The American Board of Medical Specialties this month took a major step toward bringing addiction medicine out of the shadows, announcing on March 14 the recognition of Addiction Medicine as a new subspecialty. The burst of light is a welcome sight at University of Colorado Hospital and the University of Colorado School of Medicine.
The recognition, sponsored by the American Board of Preventive Medicine – a member of ABMS – opens the door to any ABMS board-certified physician to receive certification in Addiction Medicine.
The certification process requires physicians to complete an education and training program based on the latest science and evidence-based medicine and pass a certification exam. Those who earn the certification will be required to maintain it through “a lifelong learning program” aimed at keeping them abreast of standards of practice in the specialty, ABMS officials said.
“This landmark event recognizes addiction as a preventable and treatable disease, helping to shed the stigma of misunderstanding that has long plagued it,” noted Robert J. Sokol, MD, and Patrick G. O’Connor, MD, MPH, president and immediate past president, respectively, of the American Board of Addiction Medicine, in a separate letter to members. “It sends a loud and clear signal that patients can and should seek care from trained and certified physicians and be assured that the care they receive is grounded in research, science and evidence-based practice.”
The ABMS recognition is a critical step in efforts to address the problem of addiction in the United States. The National Institute on Drug Abuse estimates that 22.5 million people age 12 and older need help for drug and alcohol use – a number that reflects a notable increase in those addicted to prescribed narcotic medications. The NIDA estimates that only about 4.2 million of those received care. Yet until now, the sole ABMS recognized addiction-related certification was available through the American Board of Psychiatry and Neurology – and only psychiatrists could obtain it.
“That was unfortunate, given the number of people with addictions we have,” said Patricia Pade, MD, director of the University of Colorado’s Addiction Medicine Fellowship Program. Pade also practices at UCH’s Center for Dependency, Addiction and Rehabilitation (CeDAR) and heads a consult service at A.F. Williams Family Medicine Clinic for chronic pain patients at moderate to high risk of addiction to prescribed opioid medications. The service is a resource for primary care physicians seeking alternatives to prescribing opioids for their chronic-pain patients. She also leads an addiction medicine consult service at UCH.
The one-year Addiction Medicine Fellowship Program at CU, launched in 2014, is one of 40 in the country training physicians (the Addiction Medicine Foundation wants to triple the number over the next decade). At CU, the program gives fellows experience in residential, outpatient and adolescent treatment; Pade’s chronic pain consult service; and methadone treatment offered through CU’s ARTS (Addiction Research and Treatment Services) program. But those 40 programs, important as they are, can’t do nearly enough alone to stem the tide of addiction, Pade said.
“Even with the programs we have today, we couldn’t possibly train enough people to meet the needs. The Addiction Medicine certification will help to expand the provider source,” Pade said.
The expansion is on the docket at CU and UCH. Pade said her fellowship program will have two physicians – up from one – in fiscal year 2017, which begins July 1. In addition, CeDAR will bring on a new attending physician in July who will also provide some coverage for UCH’s Boulder Clinic.
An orphan no longer
The ABMS decision reflects an emerging view among health care providers, administrators, and insurers that addiction, mental and behavioral health issues, and medical conditions cannot be easily compartmentalized, said Steve Millette, executive director of CeDAR, who successfully advocated for an accredited addiction medicine fellowship after joining UCH in 2011.
“For a long time, the average medical person believed that addiction was the province of psychiatry,” Millette said. “That created a problem because we now know that addiction is often not solely a symptom of an underlying psychological problem. It’s frequently multifactorial.”
Yet for many years, managed care “carved out” behavioral health and addiction treatment services from their medical benefit, essentially relegating prevention and early treatment to a poorly reimbursed and rationed health care backwater, Millette said. The result was millions of people engaging in risky use of drugs and alcohol with spotty access to services. Many struggled to cope, while residential treatment centers like CeDAR were left to care for the “sickest of the sick,” as Millette puts it.
That system will not yield solutions to the problem of addiction and the behaviors that contribute to it, he said. “We can build 1,000 CeDARs, but that won’t address the issues of a fragmented system of care that fails to offer services where, when and how patients need them,” he said. “We can’t continue to exist in a parallel process that is outside the mainstream scope of health care. We have to redefine the continuum of care so we can get upstream and provide early-intervention and preventive services for patients.”
In Millette’s view, that will require giving additional support to primary care physicians managing patients with chronic pain and behavioral health and social issues, as is the case at A.F. Williams and UCH’s other primary care and internal medicine clinics. It also means training a new generation of health care providers in the complexities of addiction medicine. The ABMS noted that its recognition of Addiction Medicine as a board-certified specialty “opens the door” for fellowship programs like CU’s to seek recognition for residency training from the Accreditation Council on Graduate Medical Education (ACGME).
Millette considers ACGME accreditation as another important step in bringing addiction medicine into the mainstream, much as occurred with hospice and palliative medicine a decade ago.
“Medical education has to change,” he said. “The pressure is on to look at the problem of addiction and train enough physicians who understand it. The system also has to change to make primary care about providing holistic care to people before they have problems.”
Pade sees progress in that regard. “We’ve gotten more requests from residents for information about addiction medicine. That’s exciting,” she said. “It’s about an attitude change as much as a knowledge change.”
For Millette, the complexities of addiction medicine ultimately boil down to a simple calculus. “When we get people the treatment they need, more get well than die,” he said.