The Drive for Substantive Change in Addiction Treatment
Preventable, addiction-related tragedies impact families every hour of every day. But we can make a difference by taking steps to reframe our approach to substance use disorder in America. Specifically, we need to:
- Train today’s doctors on the fundamentals of addiction and addiction treatment.
- Ensure tomorrow’s doctors have a solid understanding of addiction by reshaping how and what medical students learn about addiction
- Support legislative efforts to establish and fund programs that address the tremendous unmet need for quality addiction treatment.
Training today’s doctors
Traditionally, primary care physicians have not been trained to understand addiction, treatment or recovery so they often missed the early warning signs of substance use disorder (SUD). Like other chronic diseases, early intervention of a SUD can help mitigate more severe consequences and facilitate a quality continuum of care to make recovery manageable. To address this need, ASAM offers a Fundamentals course for doctors who are not currently trained in addiction medicine.
The ASAM Fundamentals class teaches healthcare providers to identify their attitudes that promote or prevent therapeutic responses to patients with substance use disorders, understand the addicted brain, use screening tools to detect substance use in a patient and interpret a spectrum of results, learn motivational interviewing to enhance patients readiness to change risky behavior and offer interventions appropriate for specific substances and severity of use.
The course is also designed to educate providers on how to conduct a biopsychosocial assessment to provide a diagnosis and match the patient to an appropriate level of care if substance use problems are detected. Likewise, providers learn how to prescribe pharmacotherapy appropriately for alcohol, tobacco, and opioid use disorders. A critical takeaway from the class is that patients and their families must be able to access information and referral to behavioral interventions including support groups and mutual aid groups that assist in the recovery process.
Several of Caron’s physicians, including myself, are trained faculty of this course and Caron will be offering the ASAM Fundamentals course on October 24 for primary care doctors, nurse practitioners, PAs and other healthcare providers who find themselves dealing with addiction every day in their practices without a solid understanding of how to recognize the disease or offer best practices in ongoing wellness management. In addition to the course, Caron’s 6th Annual Addiction Research Symposium will be held October 25th. The Research Symposium features leading experts from Stanford, Johns Hopkins, the University of Pennsylvania and the Penn State College of Medicine who will present on cutting-edge addiction research and treatment protocols.
Training tomorrow’s doctors
While the ASAM Fundamentals class is a great effort to reach currently practicing health providers, we really should begin training medical professionals on treating addiction while they are still in school. Most medical schools spend inadequate time on addiction treatment, compared to the more than adequate time spent on other illnesses. Yet, most of these soon-to-be doctors will have to manage a patient with substance use disorder in their practice. In addition, they will also have the responsibility to prescribe medications – and they really need to understand not just what these medications treat, but how they work and the risk for addiction. Moving this training upstream, into medical schools will take time, but is so critical to addressing how we treat addiction.
I’m fortunate to be in a position, as chair of the Physician-in-Training Committee for ASAM, and an ex-officio member of its Board of Trustees, to work alongside Dr. Jean Bennett of the Substance Abuse and Mental Health Services Administration (SAMHSA) to help identify the core competencies in treating addiction that should be required of doctors before they graduate. In fact, Dr. Bennett and I meet quarterly with the student affairs representatives of Philadelphia-area medical schools to discuss these issues.
The competencies under consideration include:
- Understanding the neurobiology of the chronic disease of addiction
- Knowing the systems within the brain that addiction affects and how they are affected
- Being able to diagnose effectively, using the DSM-V criteria, mild, moderate, and severe substance use disorder
- Determining the proper level of care according to ASAM placement criteria
- Understanding medication assisted treatment (MAT) both for opioid use disorder and alcohol use disorder
We’ve also engaged the National Board of Medical Examiners to incorporate questions on these core competencies in Board tests, and the Accreditation Council for Graduate Medical Education (ACGME) to weave the core competencies into the primary care residency requirements.
We’ve made a tremendous amount of headway as a group. Philadelphia’s medical school community has been fertile ground for our efforts.
Lobbying the legislature
The third piece of the puzzle is federal legislation and funding to put addiction treatment in the country on sound footing. In 2018,an estimated 21.2 million people needed substance use treatment, but only 11% of those people actually received treatment from a trained professional, and only 50% of these individuals received adequate treatment. Those numbers are a grim reality that must be addressed with more and better-trained addiction medicine professionals. That is why I joined 80 other doctors concerned about our country’s addiction crisis at the American Society of Addiction Medicine’s (ASAM) Hill Day to meet in Washington, DC with legislators and their staff to lobby for substantive action and, more importantly, funding to address addiction.
The theme of ASAM’s Hill Day was “Teach It. Standardize It. Cover It.” We support legislation that will lead to better education for doctors and medical students about the disease of addiction, standardize the treatment of addiction to improve outcomes, and cover the treatment of addiction through insurance just like we would any other chronic illness.
The centerpiece of our ask was the Comprehensive Addiction Resources Emergency (CARE) Act, co-sponsored by Senator Elizabeth Warren (D-Mass.) and Representative Elijah E. Cummings (D-Md.). The CARE Act will provide the resources needed now and over the next decade to treat addiction and the opioid overdose epidemic like the critical national public health emergency it is. It will:
- Teach addiction medicine by allocating billions of dollars in funding to train health professionals in the diagnosis, treatment, and prevention of substance use disorder.
- Standardize addiction medicine by directing the Department of Health and Human Services, in consultation with the American Society of Addiction Medicine (ASAM), to develop model standards for the regulation of treatment services based on the Levels of Care framework set forth by ASAM in 2013.
- Cover addiction medicine services by allocating funding to states, local governments, and other institutions to support prevention, treatment, and recovery.
Among the other legislation we lobbied for was:
- The Opioid Workforce Act of 2019 (H.R. 3414). This legislation will increase the number of residency positions eligible for graduate medical education payments under Medicare, for an aggregate increase of 1,000 positions over a five-year period.
- The Medication Access and Training Expansion (MATE) Act, legislation designed to ensure all prescribers of DEA controlled medication have a baseline knowledge of how to prevent, identify, treat, and manage patients with substance use disorder. A key part of this is including substance use disorder training as part of a normal medical school education, which supports the other efforts outlined above.
- Funding for the Substance Use Disorder (SUD) Treatment Workforce Loan Repayment Program to provide student loan repayment for addiction treatment professionals who commit to working in underserved or high-risk communities and the Mental and Substance Use Disorders Workforce Training Demonstration Program to provide grants to institutions that train medical residents and fellows in psychiatry and addiction medicine, along with nurses, NPs, and PAs. Both programs have already been passed into law but need to be funded.
- The Humane Correctional Health Care Act (H.R. 4141 / S. 2305) and the Community Re-entry through Addiction Treatment to Enhance (CREATE) Opportunities Act (H.R. 3496 / S. 1983), to provide access to mental health treatments and evidence-based opioid use disorder treatment to those in prison and support and access to medication when someone leaves prison.
I said it before and I’ll say it again, we must change the way we approach addiction in this country if we are ever going to effectively combat the addiction crisis. We must educate and empower our healthcare professionals to understand and identify addiction and give them the tools to facilitate treatment and help manage recovery.
What Family Doctors Need to Know About Addiction
By Dr. Joseph Garbely