Several months ago, I was asked by an attending about my future plans. “So I can pimp you,” he said. I told him that I am pursuing further training in addiction medicine.
He looked at me as though I had answered, “Orbiting Jupiter.”
“Isn’t that just for psychiatrists?”
More than 20 million Americans suffer from a substance use disorder, from white-collar professionals to chronically homeless individuals. Headlines and reports abound regarding the growing epidemic of opioid overdose, with heroin claiming more lives in the United Stated than gun homicides for the first time in 2015. Addiction is a pervasive and growing public health challenge … but are non-psychiatrist physicians well suited to help tackle it?
To address this, I have put together a list of frequently asked questions on the subject:
What is the field about?
Addiction medicine specialists diagnose, treat and coordinate care for patients with substance use disorders. This includes addressing, sometimes pharmacologically and commonly in a multidisciplinary team, the substance use itself, its comorbid conditions, and the profound effects that addiction has on family members and society at large. There is overlap and interaction with psychiatrists, pain specialists, toxicologists, primary care physicians and emergency medicine doctors, among others. Some medications commonly used that have received media attention include naloxone, naltrexone and buprenorphine. Additional pharmacotherapy may be on the way, including sustained release amphetamines for cocaine use disorder and ketamine for alcohol use disorder.
Is it a real subspecialty?
In October 2015, the American Board of Medical Specialties (ABMS) voted to recognize addiction medicine as a medical specialty, with the official announcement in March 2016. As of December 2016, there were 44 accredited addiction medicine fellowships affiliated with the American Board of Addiction Medicine. Addiction medicine fellowships are now in the process of achieving ACGME accreditation with the support of the Addiction Medicine Foundation.
Isn’t this field more related to psychiatry than internal medicine?
Traditionally, addiction has been in the sole jurisdiction of mental health, but the field is expanding and changing. A key distinction between addiction psychiatry and addiction medicine lies in the concept of harm reduction. It is helpful to consider Type II diabetes for comparison. In Type II diabetes, much of the disease etiology is related to behavior. One could argue a psychological intervention alone could fix the problem. However, this would be an unrealistic and incomplete approach for the vast majority of diabetics. Instead, primary care physicians make sure that diabetic patients’ kidneys, nerves and retinas are not failing. We try to moderate other risk factors for cardiovascular disease and make changes to help manage blood glucose. We reduce harm with this chronic disease to maximize patient life expectancy and quality of life.
Addiction is also a complex syndrome, not just a single disease with an isolated behavioral fix. It incorporates a host of social, psychiatric, neurologic, infectious, cardiovascular, hepatic and pulmonary comorbidities. In settings of intoxication, withdrawal and treatment, addiction medicine specialists seek to arrange and deliver stigma-free, effective therapies with an awareness of co-occurring psychiatric and medical conditions. For example, some of these patients have conditions such as lung disease (from smoking), hepatitis C and skin infections (from injecting), and HIV (from injecting and high-risk sex). These issues fall squarely in the realm of internal medicine.
Isn’t this population … unpleasant?
I have cared for a wide range or patients suffering from substance use disorders, from largely functional and gracious individuals to those with volatile behavioral issues and personality disorders. Many of the patients that I saw during inpatient medicine rotations were actively intoxicated or withdrawing, and I admit that I struggled to find empathy. It is easy to view substance use as a nuisance, or something getting in the way of “real” clinical medicine. And most clinics and hospitals are ill equipped to address addiction, with little infrastructure to help clinicians navigate the issue.
But when you dedicate time and resources to focus on addiction as a biopsychosocial disease that necessitates non-judgmental care, the experience becomes much more rewarding. Instead of simply dealing with the disease ad hoc, addiction trained physicians create a structured environment of empathy, trust, and accountability that allows for creative and realistic solutions for the patient. I have had the privilege of caring for patients active in their recovery who are some of the most honest, insightful, and grateful individuals I have ever met. They may have relapses, but those episodes should be treated accordingly, not as moral failings.
What jobs exist?
Addiction trained physicians go into both inpatient and outpatient roles. Some examples are hospital consult services, clinics focused on managing controlled substances like buprenorphine, and residential treatment programs with built-in medical detoxification and/or medication assisted treatment. Many are involved in research. Many remain in primary care with an emphasis on co-occurring medical and substance use disorders. And interestingly, many specialists in fields such as obstetrics and infectious disease are receiving further training in addiction medicine to augment their care of high-risk panels.
There is indeed a role for addiction medicine. I am hopeful that more medical trainees will consider this specialty, and more attendings will support and encourage exploration into this field. Unfortunately, this Jupiter-size disease is not going away any time soon.