An Absolute Game-Changer: Addiction as an Officially Recognized Subspecialty
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The complicated relationship between organized medicine and addiction took a significant turn for the better on March 14th, when the American Board of Medical Specialties officially recognized addiction medicine as a subspecialty. After years of advocacy by the American Society of Addiction Medicine (ASAM), the American Board of Addiction Medicine (ABAM) and The Addiction Medicine Foundation (TAMF) this recognition should have a significant impact on the way that substance use disorders are managed by the medical community. When Kevin Kunz, MD, the Executive Vice President of ABAM and TAMF, realized early in his career how prevalent and devastating addictive disorders were to the patients in his practice, he dedicated himself to caring for them and to bringing the prevention and care of unhealthy substance use to mainstream medicine. I hope that you find his insights about addiction and his perspective on ABMS recognition of interest; please leave a comment after the interview if you do.
Richard Juman: Congratulations on this achievement. Can you explain to our readers why this is such a significant development?
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Kevin Kunz, MD: To understand the significance, you have to understand a bit about the arcane world of organized medicine in this country. I’ll bring you right to the heart of it. There are two organizations that oversee the medical world in America. One of those organizations oversees the certification of physicians and the other organization accredits the training of physicians. The American Board of Medical Specialties (ABMS) is a federation that has 24 member boards. You know some of them: The American Board of Pediatrics, the American Board of Internal Medicine, etc. Medical specialists are certified by one of the member boards of the ABMS. ABMS Member Boards can also have subspecialties. Some subspecialties are only under one medical board—like pediatric cardiology is only under pediatrics, so family medicine doctors can’t become pediatric cardiologists. Other subspecialties are under multiple boards—like hospice and palliative medicine (HPM). There are ten boards that have HPM as a subspecialty. At any rate, the only job of the board is to certify by qualifications and examination physicians in that specialty, to have maintenance of certification programs and to provide verification of certification status to heath care institutions and the public. To become certified in a specialty or subspecialty you first have to go through specialized training, and all training of physicians in America is accredited by the ACGME (the Accreditation Council for Graduate Medical Education). So there are two completely separate entities, one that oversees training, and one that does the certification. When a new subspecialty becomes available, as now with addiction medicine, a physician is able to become certified in the new subspecialty without completing specialized fellowship training for the first five years. This is because these physicians were the pioneers, experts and addiction medicine practitioners who brought the field into existence. So for the next five years, physicians can become certified in the new ABMS subspecialty of addiction medicine by examination and other qualifications; after five years they will have to complete a training program that’s accredited by ACGME.
About 40% of American disease, which accounts for a third of all hospital costs today, is related to addictive substances.
ABAM initially became an independent board for the purposes of putting everything together so we could officially enter this “house of medicine,” so that the field of addiction medicine could rise to the level of being recognized by ABMS, the gold standard for both certification and training, and that addiction prevention and care could be integrated broadly throughout medicine and health care. I should add that osteopathic physicians—DOs who represent 10% of American physicians—have their own procedures that mirror these, and they are in the process of looking at the subspecialty of addiction medicine. But the bottom line is that addiction medicine finally has a “room” in the “house of medicine.” It’s a whole new ballgame.
RJ: So this should, and hopefully will, lead to a very significant increase in the number of doctors who are qualified, and motivated, to work with patients with addictive disorders?
KK: Right. In two ways. First, the physician who has already put many years into their training and is an ABMS certified physician is not very likely to leave his or her practice to spend a year in training, yet they can now take the new ABMS level certification exam in addiction medicine during the five year Practice Pathway, gaining both qualification in the field and recognition by medicine, health care systems, payers of services, etc. Second, the availability of addiction medicine fellowships—and there are already 40 twelve-month programs with 125 planned—will become a viable choice to be considered by medical students and physicians in residency training. These two paths to becoming a qualified addiction medicine physician will change the landscape of the care teams in our field. Many more physicians will be able to join the team care of counselors, nurses, psychologists, etc. to care for patients, and many more will be available in the primary care medical venues. Although ABAM has certified 3,900 physicians in addiction medicine, that’s not nearly enough. So let’s think ahead now. When a doctor goes through medical school and is later in a family medicine residency and they’re seeing the carnage of substance use problems, they’ll be able to do something about it—become a subspecialist in addiction medicine. That’s what is now possible. The number of physicians who are well-versed in substance use disorders will increase because with ABMS and ACGME, addiction medicine is in the major leagues.
Think about the reality of addiction’s status in the practice of medicine today. Let’s say that your neighbor has a son or daughter who’s addicted to pain pills, or shooting heroin, who’s overdosed three times, and your neighbor is looking for somewhere to get help. He brings the child to the emergency room but they can’t admit him because comprehensive treatment of the disease of addiction is just not on the radar there—only treatment of acute complications. Physicians can’t get on hospital staffs as addiction doctors, they can’t be on the insurance panels, they cannot even advertise in the phone book: a medical specialist can only be listed as such if they have ABMS certification. So it will change radically the way that health care will address people with substance use issues, and people will know that there are doctors out there who can help. Of course, it’s going to take a few years to build the workforce, yet we know it can be done.
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Let me tell you how I often break it down for people. The U.S. has the best medicine in the world—people come from around the world to get medical care here—we have the best trauma care in the world, the best cancer care, etc. Yet an Institute of Medicine report of a few years ago concluded that we rank 36th out of 37 countries with respect to overall health. How can that be? One reason is that we’re experts at treating symptoms and complications of substance use disorders and addiction, but we don’t do so well in terms of prevention, early intervention or disease management for addiction. We as a nation tended to treat the complications of the disease—with medical and social interventions (incarceration, etc.) but we’ve missed the boat in what we know about treating the primary etiology. About 40% of American disease, which accounts for a third of all hospital costs today, is related to addictive substances. So the big news here is that medicine, which has excelled at treating complications, has now recognized that addiction is a disease which is preventable and treatable. We have the science and we have a growing number of qualified and compassionate doctors out there, and medicine is starting to address this as something that medicine also is responsible for.
This comes at a perfect time, in a way, because of medicine’s involvement in the opioid epidemic. We know that we need to be part of the solution. Even aside from the opioid epidemic, we know that we have to address addiction better than we have been. All sectors—medicine, health care, state and federal government, society and the public—all now agree that we have to address this better and more effectively than before. There are other key forces influencing this change as well, especially the changes in payment formulas which incentivize everyone to keep people healthy and out of hospitals, and for that matter, jails, penitentiaries and other institutions. So there is a motivation here to say, “not only can we save lives but we can save money and improve the health of our nation,” and that makes sense.
RJ: In what other ways will this milestone impact the addiction treatment world?
KK: The medical system will be fundamentally more well-equipped to help people with addictive disorders. Prevention, screening, and early intervention will become widespread throughout healthcare. You know, we could build another rehab on every corner, just as we could build a jail cell on every corner, and that is not going to solve the problem. As you well know, there are more referrals to addiction treatment from the criminal justice system than there are from physicians! This is why we need and can celebrate this recognition by medicine as an absolute game-changer. Look at it this way.
When I was in medical school and in training, back in the ‘70s, you could go down a hospital hallway and there would be gurneys, often in isolated hallways, and there would be patients who looked quite ill on the gurneys—most of them had IV poles, and they were often curled up. When I first saw this scene, I thought, “Oh, they must be waiting for a procedure, there must be a procedure room around here.” But there wasn’t. These were patients who were dying, and their bed space was needed for other “critical care” patients, so these patients were not given the special care and dignity they deserved. Nobody sees that today, and the reason is because 12 years or so ago, medicine realized that there was a need for a specialty in hospice and palliative care, and so the subspecialty of hospice and palliative medicine came into being. Today, there is no hospital in America that doesn’t have somebody who can attend to the dying using the principles of hospice and palliative care. There are hospice care teams and nearly 7,000 hospice physicians. There are over 100 fellowships that train physicians in hospice and palliative medicine. Physicians, teams and hospitals who care for hospice patients are paid for it, and families have full coverage for this care. The beds are paid for, either in a hospital or residential hospice program, and the nurses and all the team are paid to do this work. The patients get better care, and these are dying patients—these aren’t patients that we can help keep alive if we can help them with their addictions.
So what we expect to happen is very similar to what occurred with hospice. There is going to be a change—it might take a little while, but it will happen. That’s what we expect. There is still a lot of work to be done, and we have to keep the momentum going now that we are a legitimate subspecialty in the “house of medicine.” We’ve got to beef up our training programs so that we produce enough physicians. We currently have 3900 addiction medicine certified doctors through ABAM, not through ABMS—many of them will come into the new field, transfer over. And there are around 1000 practicing addiction psychiatrists. So there are still not enough of a work force of people who understand addiction out there. We estimate that we need 7,000-8,000 addiction medicine qualified physicians by 2020. As you know, in health care it takes some time to ratchet things up. So it is starting, but there is still a lot of work to do.
RJ: With respect to the type of training that people in ABAM fellowships receive, would it be safe to assume that much of the training is around pharmacological approaches to working with substance use disorders, medication-assisted treatment, etc.?
KK: I would say that would only be partially correct. The training involves all evidence-based modalities that are used in the prevention and treatment of addiction. So unlike so many doctors today who are vendors of drugs, in addiction medicine we probably spend more of our time taking people off of drugs. As you know, there are only a few FDA-approved medications for addiction, and they do work quite well for alcohol and opiates but not usually when they are used without other treatment modalities and long-term monitoring. There is a whole range of non-medication treatments, and there are the concepts of prevention and early intervention that are a very significant component of future in substance use disorders. For instance, we know that 95% of adults with an addictive disorder began using alcohol, nicotine or other drugs in their youth. So there is a window for prevention for what is now realized to be, virtually, a pediatric disease. Also, treating the medical and social complications of the disease play a large role once addiction is established. So treatment is not all geared toward drug therapy. It can’t be. Medication treatment for alcohol and drug addiction is insufficient to solve the problem on any level.
RJ: I’m curious about how you became so involved in addiction medicine. Was it something that you were always drawn to?
KK: No, it was not always on my radar. I was practicing primary care in a small town in Hawaii. As the town grew, it became obvious after a while that the cause for many of the patients’ presenting problems was the use of substances and addiction. As you know, in primary care it’s at least 30% of patients that have some issue connected to or resulting from problematic substance use. There just came a time when in this small town I just got tired of watching children die, or having children watch their parents die, plus watching the other dysfunction that came with it. For example, the missed opportunities for people and families to thrive rather than be engulfed in problems related to nicotine, alcohol and other drugs. And the incarceration of young people who never intended to do the things they did, but the drugs took over their brains and they got into trouble because of or to support their substance use. In coming to understand the brain disease model, as we have over the last 25 years, once you know it, you can’t treat these people like they’re subhuman, that it's all their fault and so, just good luck to you. They are people deserving of preserved dignity despite their illness. They did not bring about their problems on purpose, although society often views it this way. So in my small town I had the chance to do something a little different, and it was really rewarding. I cannot imagine that any physician could get more satisfaction than one who sees a patient and family, in despair and on the brink of tragic loss, return to normal, healthy lives. And the more I learned, the more I saw that all of medicine needed this. Fortunately there was ASAM, and there has been a group of very dedicated physicians for a long time, as you know, trying to deal with this, and so I joined with them. One thing led to another, and here I am talking with you.
RJ: Well, I’m glad that you took the journey that you did. It will be interesting to watch for the ramifications of this breakthrough in the field.
KK: This is a rallying call for all physicians in America who have had in front of them a patient at some stage in the disease of addiction and haven’t been sure what to do. And so often, they do nothing—and that is hard for them. So now there is a place where they can go to learn more and become certified—and that is a game changer. We know that if you want transformative change in healthcare, physicians need to be involved, and this is an opportunity for physicians to do probably the most rewarding job that I for sure have ever done in my practice of medicine—to have relationships with patients and families and watch them get better. Their lives improve, their families improve. It’s really rewarding, and I believe that most doctors get into medicine because of that. They’ve been hurt by the fact that they often don’t know what to do and there haven’t been resources in the medical arena to address the prevention and treatment of addiction. Now that is all changing.
Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [[email protected]] Find him on twitter—@richardjuman