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Weekly UpdatesThe newly formed American Board of Addiction Medicine has certified more than 1,600 physicians as specialists in addiction medicine so far this year, including more than 200 internists. Doctors from multiple disciplines who meet expertise criteria are taking advantage of the opportunity to be "grandfathered in" to the nascent specialty by taking a special 6-hour certifying examination.
Certification efforts so far have been "very successful," Dr. Kevin B. Kunz, president of the American Board of Addiction Medicine (ABAM), said in an interview. "There has been an extraordinary response."
The 15 doctors on the ABAM board of directors will create a new examination to certify physicians after the grandfathering option ends in December 2009. Previously, only psychiatrists could claim addiction-related board certification. Official recognition of addiction expertise is being expanded to include internists, family physicians, emergency physicians, obstetricians and gynecologists, surgeons, pediatricians, preventive medicine physicians, and neurologists. "We need a cadre of physicians in each specialty," said Dr. Kunz, an addiction specialist in Kailua Kona, Hawaii.
"There are already folks out there toiling in relative obscurity in addiction medicine," internist Dr. Peter D. Friedmann said in an interview. "Creation of the ABAM was driven by the need for better recognition within medicine."
The American Society of Addiction Medicine provided a certification exam for years, "but it was not accorded the same respect and gravitas as fields that have their own subspecialty boards." Dr. Friedmann, professor of medicine and community health at Brown University in Providence, R.I., is one of the internists who took advantage of the grandfathering option.
Criteria for certification grandfathering include at least 1,950 hours over the past decade providing addiction-related care, research, and/or education; 50 hours of CME related to addiction medicine in the past 2 years; letters of recommendation supporting proficiency in this area; and successful completion of the examination.
Primary care physicians will continue to play a large role in addiction care because "there will never be enough ABAM-certified specialists to treat everyone," Dr. Friedmann said. "It would be like expecting everyone with hypertension to be treated by a cardiologist, or everyone with diabetes to be treated by an endocrinologist."
About 22% of patients presenting to primary care will need some form of intervention, and 6% will need an addiction medicine specialist, Dr. Kunz said. One full-time addiction specialist will be needed to serve 50,000-60,000 members of most U.S. communities, or 1 per 30,000 residents in smaller communities, he estimated.
Dr. Larry Gentilello, a surgeon now board certified in addiction medicine, said that greater awareness of this certification is needed. "1 don't think the surgical community really knows about it," said Dr. Gentilello, professor of surgery at the University of Texas Southwestern Medical Center in Dallas.
"Every single specialty needs to take ownership," Dr. Gentilello said. Instead of foreseeing addiction medicine as a turf issue between specialties, "the issue I see, since it cuts across all of medicine from pediatrics to geriatrics, is it could be like a 'hot potato' and no one takes ownership. Some may say, 'We should leave this to primary care or psychiatry.'''
Some surgeons and other acute care clinicians may be reluctant to treat addiction if they perceive it solely as a long-term condition with multiple relapses over time, Dr. Gentilello said. However, "before these problems become intractable and severe, a surgeon, when seeing a patient in the emergency room, can ask if they've used any street drugs or prescription drugs for a nonmedical use in the past 30 days," he said.
"Doing a brief intervention will benefit some of these patients," he added.
Surgeons are critical to addiction medicine because they care for patients with cardiovascular disease, cancer, and especially trauma, which are associated with alcohol use and tobacco use. The American College of Surgeons Committee on Trauma in 2006 became the first U.S. organization to pass a mandate that all level I trauma centers routinely screen for alcohol problems and, if possible, perform interventions. In the future, he would like to see all patients--not just trauma patients--routinely screened for addiction problems. "We can no longer ignore this," he said.
"So many of the more than 120 million emergency department visits each year are due to substance abuse of some kind," said Dr. Gail D'Onofrio, member of the ABAM board of directors and section chief of emergency medicine at Yale University in New Haven, Conn.
Emergency physicians are "on the front line" of this public health issue, Dr. D'Onofrio said. The special knowledge and skills learned through addiction medicine training and certification are an opportunity for emergency physicians to optimize prevention and treatment, she said. "We don't just screen and refer, we intervene," she said.
Involvement is imperative because for some patients, the ED visit is their only contact with a physician because they do not return or follow through on referrals, Dr. D'Onofrio noted.
"Treatment of addiction is not just a handoff, and we will do more in the future," she said. "We need to motivate more and more practitioners to learn about substance abuse and to enter fellowships in substance abuse."
The ABAM plans to establish addiction medicine residency programs and get them recognized by the Accreditation Council for Graduate Medical Education (ACGME). "We expect these programs to be in place by 2011, after which time we will add a residency requirement to ABAM certification, as well as a maintenance-of-certification program," Dr. Kunz said.
Although there is a core content shared among all specialties treating addiction, and therefore one examination, individual specialties could add their own content to fellowship programs. Dr. D'Onofrio said. For example, psychiatry could require extensive training in cognitive-behavioral therapy and pediatrics could add more intense training in the management of addiction in newborns.
"We want addiction prevention, screening, intervention, and treatment to become routine aspects of medical care, available virtually any place health care is provided," Dr. Jeffrey H. Samet, ABAM president-elect and professor of medicine and social and behavioral sciences, and chief of the section of general internal medicine, Boston University, said in a written statement.
Reimbursement for addiction-related services remains a challenge. "These are difficult patients who take time and for whom there has been little reimbursement," Dr. Kunz said.
Although reimbursement codes for addiction screening and brief intervention in addiction are recognized by Medicare, some states, and some private insurers, "reimbursement for doing this work is still quite low," Dr. Friedmann said. Better financial incentives are needed to encourage physicians to get into this field and make it a career, he added.
The next ABAM examination is scheduled for Dec. 11, 2010. Application deadlines are Oct. 31, 2009; Jan. 31, 2010; and April 30, 2010. More information is available at www.asam.org/ABAM.html.
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