Medical Training for Addiction is Still Mostly Unchartered Territory
According to the Centers for Disease Control and Prevention, addiction is a disease that contributes to 632,000 deaths in the United States annually. However, comprehensive addiction training is still rare in medical school education. A report by the National Center on Addiction and Substance Abuse at Columbia University detailed “the failure of the medical profession at every level — in medical school, residency training, continuing education and in practice” to adequately address and prevent the crisis.
Dr. Timothy Brennan, who directs an addiction medicine fellowship at Mount Sinai Health System, said that combating the epidemic with practicing providers is “like trying to fight World War II with only the Coast Guard.” They haven’t been prepared to tackle it head-on.
Now, however, after a decade-long push by doctors, medical students and patients to legitimize addiction medicine, slow but steady change is taking root. The U.S. Department of Health and Human Services (DHHS) requested that the National Academies of Sciences, Engineering, and Medicine host a workshop, “Integrating Infectious Disease Considerations with Response to the Opioid Epidemic” on March 12 and 13, 2018, to address an urgent need to implement effective opioid use disorder treatment in health care settings and to address the intersecting epidemics of opioid misuse and its infectious disease (ID) consequences.
Also, in June, the House of Representatives authorized a bill to reimburse education costs for providers who work in the addiction arena. There are only 52 addiction medicine fellowships nationwide, and in August, the first twelve received gold-standard board certification status from the Accreditation Council for Graduate Medical Education.
Boston University includes pioneering addiction training into all four years of its medical program. The students learn about “motivational interviewing,” a technique that encourages patients to formulate health goals. Students are being taught to engage patients with a joint-decision-making, rather than offering provider-only solutions.
Dr. Bradley M. Buchheit of Boston University teaches his students, “Substance use disorder is a chronic, relapsing disease. So is diabetes. Diabetics don’t follow a diabetic diet 100 percent of the time. If they were to have a slip-up, we would figure out what went wrong and say. ‘Is there anything else we can do?’”
Dr. Daniel Alford, a professor and associate dean at Boston University, who helps create the curriculum, said that because addiction medicine is relatively new, however, the program can’t rely on fellows. Thus, the team is still having a hard time solidifying its presence. “The biggest challenge now is how do you sustain it?” he said. “Who keeps updating it? When faculty leaves, who will replace them?”
There is not much incentive to specialize in addiction medicine, either. Because patients are stereotypically viewed as manipulative and doomed to repeat destructive behaviors, the field is viewed as a thankless one from a medical student perspective. Also, according to a 2017 study, insurance companies view addiction treatment as an afterthought to mental health care, so much of the treatment remains uncovered by most policies.
Perhaps Dr. Buchheit is an anomaly. “I really enjoy working with these patients,” he said. “They have often been kicked to the curb by the formal medical system. They don’t trust us. So, for them to walk into a room and have a doctor say, ‘It’s great to see you, thank you for coming in,’ is very powerful. And then you can see them get better with treatment. It can be very rewarding work.”
There are some issues that commonly come up in conversation. Students are often concerned they are being naïve when they opt to trust their hypothetical patients while intuitively knowing they should practice caution. They wonder if increasing doses of pain medications will protect these individuals from seeking alternatives on the streets. They are confused regarding which route to take.
And, although traditional medical training typically encourages its pupils to come up with definitive solutions, treating addiction means getting comfortable with ambiguity. Practitioners need to learn to follow their gut.
Integrating Treatment at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics in Medical Settings: A Call for Action After a National Academies of Sciences, Engineering, and Medicine Workshop