21.2 million Americans have a substance use disorder. In 2018, just 11% of those patients received the treatment they needed. And one in five people wrestling with an addiction say they do not know where to turn for help.
In many places, there’s no one nearby with specialized expertise.
Just 1,883 physicians nationwide are certified in addiction medicine, while an additional 1,288 physicians are qualified to practice addiction psychiatry, according to the American Board of Medical Specialties (ABMS). Meanwhile, the American Board of Pain Medicine counts just 2,200 certified and practicing pain management physicians.
“The rural parts of the United States suffer the most when it comes to addiction medicine,” says Scott Teitelbaum, MD, a professor of psychiatry at the University of Florida College of Medicine.
Indeed, “in some parts of the country, patients have nowhere locally available to access effective treatment,” says Sarah Wakeman, MD, medical director for the Massachusetts General Hospital Substance Use Disorder Initiative and an assistant professor of medicine at Harvard Medical School. She cites a 2015 study that found that half of all US counties did not have a single physician able to prescribe buprenorphine to treat opioid addiction. National data from 2017 show that rural counties are even harder hit: 60% lack a physician provider able to prescribe buprenorphine, though that’s down from 67% in 2012.
“In some parts of the country, patients have nowhere locally available to access effective treatment.”
— Sarah Wakeman, MD, Massachusetts General Hospital
The lack of physicians with specialized expertise in treating substance use disorders is due to a multitude of factors, not least of which is a scarcity of residencies in addiction medicine and addiction psychiatry. The Opioid Workforce Act of 2019 would create 1,000 new residencies in those subspecialties and pain medicine.
In the meantime, all medical schools include training in treating pain and addiction within the curriculum, and many are enhancing that content to ensure all future physicians are prepared to recognize and treat patients with substance use disorders. Academic medical centers are also redesigning addiction care and introducing new pain management protocols to help better connect patients with the most effective treatments.
A nascent field
While physicians have been treating addiction since the 1800s, addiction medicine as a medical specialty has emerged only in the last 50 years.
The American Medical Association first recognized “alcoholism” and “drug dependence” as diseases in 1966 and 1987, respectively, according to a 2014 article in JAMA Internal Medicine. An “explosion of new knowledge through research” followed with the founding of the National Institute of Drug Abuse and the National Institute of Alcoholism and Alcohol Abuse in the 1970s, according to the same report. Addiction psychiatry was recognized as an official subspecialty in 1991.
Additional progress followed when the ABMS recognized addiction medicine as an official multispecialty subspecialty in 2016, says Teitelbaum.
However, the federal government has had a freeze on the number of all Medicare-funded residencies since 1996.
Teitelbaum says there are just 59 addiction medicine fellowships around the country, including six at his institution. Until a few years ago, these fellowships were reserved for those who had completed a psychiatry residency program, explains Jeanette M. Tetrault, MD, associate professor of medicine and program director for the Addiction Medicine Fellowship at Yale School of Medicine. “It really limited the number of addiction medicine doctors,” she says.
“You need to train your ancillary specialties as well — nurses, physical therapists, social workers, dentists. The more people you have looking [for signs of substance use disorders] in a less judgmental way, the better.”
— Scott Teitelbaum, MD, University of Florida College of Medicine
But underlying the shortage is another less tangible, though no less significant, barrier: The stigma of the illness at times has rubbed off on the profession.
America has long wrestled with the question of what, exactly, addiction is: “Is this an illness? Is this a sin? Is this a crime?” says Teitelbaum. In addition, “it’s not a pretty illness. The behavior that comes out is often, not all the time, immoral.”
Wakeman agrees that “many people — physicians included — I think still carry stereotypes about people with addiction and see the disorder as a matter of bad behavior.” Because “addiction was not really viewed as a medical illness” over much of the past century, she adds, “treatment for addiction was carved out from the rest of the health care system.” For years, then, there wasn’t even much of “a field” for an eager young doctor to enter.
Legislation to bolster the workforce
Bipartisan legislation, in the form of the Opioid Workforce Act of 2019, would add 1,000 graduate medical education positions over the next five years in hospitals that have, or are in the process of establishing, accredited residency programs in addiction medicine, addiction psychiatry, or pain medicine. The legislation, which would boost the number of health care workers on the frontlines of the opioid epidemic, has already passed the House Ways and Means Committee and now awaits a vote in the House Energy and Commerce Committee. A companion bipartisan bill was recently introduced in the Senate.
Wakeman believes the legislation “would be a huge step forward” and “a dramatic improvement. The country is in desperate need of an addiction medicine physician workforce.”
Increasing the number of residencies will increase the ranks of specialists to treat addiction and pain over time. In the meantime, institutions are actively pursuing efforts to ensure that all physicians are prepared to prevent, identify, and treat both pain and addiction to serve as an important complement to the specialized workforce.
Joshua J. Lynch, MD, clinical assistant professor of emergency medicine at the Jacobs School of Medicine and Biomedical Science at the University of Buffalo, has developed a program to train other physicians to treat opioid addiction. Originally, Buffalo MATTERS focused on training emergency department physicians to prescribe buprenorphine, since special training is needed to obtain the necessary license from the U.S. Drug Enforcement Administration. But Lynch’s program now educates internal medicine doctors and OB/GYNs as well.
Teitelbaum argues that all physicians should receive training in order to be able to “spot the patient,” including those at high-risk, and then intervene and prevent the onset of illness. After all, this is not only about the current crisis of opioid addiction, he says. Drugs such as alcohol, marijuana, and cocaine have and will continue to be abused by patients, so doctors need to understand addiction medicine overall.
“You need to train your ancillary specialties as well — nurses, physical therapists, social workers, dentists,” he says. “The more people you have looking [for signs of substance use disorders] in a less judgmental way, the better.”
Tetrault “100%” agrees that every health practitioner should be able to recognize early stage addiction, so they might intervene and treat earlier stage cases, while referring more advanced or difficult cases to fellowship-trained psychiatrists and other specialists.
“We need to expose students to patients who are doing well in addiction treatment.”
— Jeanette M. Tetrault, MD, Yale School of Medicine
Recently, an addiction medicine certification was developed as a subspecialty of preventive medicine, which means that any doctor, not just psychiatrists, can now become an addiction medicine subspecialist, she adds. The American Board of Preventive Medicine will have certified over 2,000 physicians in addiction medicine as of Jan. 1, 2020.
“An interesting, rewarding, valuable field”
At Massachusetts General Hospital, physicians are also redesigning addiction care, not only to benefit patients but also to attract students to the field, according to Wakeman. These “new care models” demonstrate to trainees “that addiction medicine is an interesting, rewarding, and valuable field,” she says.
Tetrault also believes that working in team-based care settings would draw interest to the field. “We need to expose students to patients who are doing well in addiction treatment,” she says. If they were not “disproportionately exposed” to patients in crisis — the person who has end stage liver disease due to excessive alcohol use or the one who arrives in the emergency department with an abscess caused by injecting drugs — students and residents might see the field in a more positive light.
Teitelbaum agrees that students “need to see the face of the illness” and both he and Lynch believe it is best for students to see every stage of addiction sooner rather than later. “If you expose students earlier in their education, you’ll generate more interest,” says Teitelbaum. But he expects to have no trouble attracting students if the new residency slots are approved. Already, he receives far more applications for the six fellowship positions his institution offers than he can accommodate, and adds that colleagues at other universities say the same.
Despite too few hands now, those who have devoted themselves to treating addiction remain upbeat.
Says Lynch: “We are doing a better job of opening up students’ minds.” When students tell him, “I want to be an orthopedic surgeon; Why is it necessary for me to learn addiction medicine?” his response is: Your future patients will need pain management — how will you treat them if you know nothing about the potential for addiction? These days, students understand this, he says.
Tetrault says her mind was opened when she started working with patients: “I thought to myself, ‘I could really make a dent here.’”
She adds that previously “there was a lot of variability in treatment practices and confusion for both doctors and patients about what exactly is evidence-based care,” but the most current specialty training programs, all overseen by the American Board of Addiction Medicine, have set “the standard for what evidence-based practice and care looks like.” This, too, has raised the profile of the field.
“Medical students largely understand that this is the social justice issue of our time,” Wakeman says.
“When people and students see changed lives, that influences them,” adds Teitelbaum.