Landmark recognition for addiction medicine

A milestone for addiction professionals was reached this year on May 2, when National Institute on Drug Abuse (NIDA) Director Nora Volkow, MD, gave the keynote address and participated with the leadership of the American Board of Addiction Medicine (ABAM) in conferring board certification on 1,452 physicians during ABAM's first diploma ceremony. This first group of board-certified physicians, drawn from 17 medical specialties, opens a new pipeline for medical doctors to join other addiction professionals in the interdisciplinary care of patients with addictive disorders. Physician specialists in addiction medicine will bring unique skills and competencies to the treatment team, equally sharing in the care of individuals and families with a multitude of needs, using all appropriate treatment modalities available.

Historically, there have been too few knowledgeable physicians to serve with counselors, therapists, social workers, nurses, psychologists and others on the addiction care team. The creation of the American Board of Addiction Medicine signals a coming of age for physicians as team members, working side by side with others dedicated to the service of patients, families and communities.

Importance of board certification

Board certification is the highest level of practice recognition given to physicians. It indicates that an addiction medicine physician has met certain clinical and educational criteria, including eligibility to sit for and successfully pass a rigorous examination. It also means that he or she is participating in ongoing maintenance of certification activities, and will be periodically re-examined to ensure and document current knowledge and skills.

There are more than 120 recognized medical specialties and subspecialties. Even though the harmful use of addictive substances causes so many of our nation's health and social problems, addiction medicine has never been a specialty recognized in its own right by a certifying medical board-until now.

Specialty societies and boards

The American Society of Addiction Medicine (ASAM) is the specialty society that encouraged and assisted in the creation of the new American Board of Addiction Medicine. To fill the void left for many years by the lack of a certifying board in addiction medicine, ASAM conferred its own certificates on physicians who passed a rigorous examination. Many addiction professionals have worked with ASAM-certified physicians, and are familiar with or may have used ASAM's Patient Placement Criteria. Founded in 1954, ASAM is a membership organization offering education, advocacy and other benefits, and is recognized as the primary organizing group for physicians treating patients with addictions.

A physician membership society such as ASAM, however, cannot confer “board certification.” A medical board such as ABAM has a separate and distinct purpose and mission: to promote and improve the quality of medical care through establishing and maintaining standards and procedures for credentialing and re-credentialing medical specialists.

Physician's role on team

There is a great need for more highly qualified physicians who understand addictive disorders. Increasing the availability of addiction medicine physicians is necessary if rehabilitation centers, hospital and outpatient programs, specialized programs such as adolescent units and methadone clinics, and other treatment programs are to be fully staffed. Addiction medicine specialists perform essential duties in these settings: medical assessments; evaluation of alcohol- or drug-induced diseases; specific treatment interventions; client and family education; medication reviews; and referrals, consultations and continuous care for co-occurring medical problems.

Four years ago in a cover story in this magazine, addiction leaders lamented the lack of qualified physicians.1 Sheldon Miller, MD, a leader in addictions training, noted that rural areas in the Midwest were hurting desperately from the lack of qualified professionals. Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), reported that the nation's 1,150 methadone clinics rarely have relationships with qualified physicians. And Joseph Westermeyer, MD, director of mental health services at the Minneapolis Veterans Administration Medical Center, said his facility could easily take twice as many patients as it had treatment slots for, because more and more people are coming in with a dual diagnosis.

The American Board of Addiction Medicine seeks to solve this problem. We anticipate that more than 7,000 board-certified addiction medicine physicians will be credentialed by this new board within the next 10 years.

Making treatment more widely available

Physicians also routinely evaluate and treat patients with substance-induced illnesses and trauma on a daily basis in many venues outside of traditional addiction treatment settings. These include physician offices; public and private clinics; emergency departments; hospital wards; jails and prisons; and college health centers. Having an addiction medicine specialist in these settings, or readily available as a consultant, will ensure that the patient is medically attended and then referred, or immediately engaged, in treatment for a primary substance use disorder.

Yet it is a fact that most physicians feel unprepared to diagnose substance abuse and lack confidence in how to treat it.2 Separate courses in addiction medicine are rarely taught in medical school3, and there are no addiction medicine residencies among the 8,200 accredited U.S. residency programs.4 Board certification will ultimately lead to specialist placement on medical school faculty, improved training of medical students, and the development of residency programs in addiction medicine throughout the country.

ABAM will, in fact, be certifying physicians who have been trained in a variety of specialties, including family medicine, internal medicine, pediatrics, obstetrics and gynecology, psychiatry, preventive medicine, emergency medicine, surgery and neurology-so that patients may have access to treatment wherever they enter the health care system. This will open communication and patient flow between our nation's medical care settings and community-based treatment centers and recovery networks.

Until ABAM's formation, only one medical specialty-psychiatry-offered specialized training and board credentialing in addictions. In most cases, a patient will need a referral to an addiction psychiatrist, or must be receiving psychiatric treatment, in order to gain access to these services. There are currently fewer than 1,300 addiction psychiatrists located across the U.S. Now, physicians in almost any specialty who are board-certified or board-eligible in their primary field, and who pass ABAM'S examination requirements, may also become board-certified in addiction medicine.

While some ABAM-certified physicians will choose to leave their primary field and work full-time helping those with addictions, many others will continue to work in their primary specialty. This means that board-certified addiction medicine specialists will be available to help a broad range of patients.

Becoming board-certified

While there is a shortage of physicians who can treat addiction, there also are many who have taken the ASAM examination and have gained extensive experience in the field. It is not feasible to expect them to leave their practice and return to postgraduate training. In a process called “grandfathering,” these individuals receive board certification status if they meet certain clinical criteria, pass an examination, and document significant experience and evidence of competence.

Currently, physicians who are already certified by ASAM may be grandfathered as ABAM diplomates. This means that the physician must have successfully passed the ASAM six-hour written examination. Eligibility criteria also include certification by a member board of the American Board of Medical Specialties (ABMS) or successful completion of a residency training program in any medical specialty; graduation from an accredited U.S. or Canadian medical school; an unrestricted license to practice medicine; 1,920 hours over the last 10 years in teaching, research, administration and clinical care of the prevention and treatment of individuals who are at risk for or who have a substance use disorder (with at least 400 of these hours in direct clinical care of patients); 50 hours of CME in addiction medicine; and letters of recommendation documenting proficiency.

The grandfathering period for ASAM-certified physicians will end on Dec. 31, 2009. Beginning in 2010, all new diplomates will need to meet similar criteria, and must pass the ABAM certifying exam, which will be offered every two years.

ABAM also has taken steps to create addiction medicine training programs affiliated with the nation's top medical schools, and will apply to the Accreditation Council for Graduate Medical Education (ACGME) to accredit these programs. Completion of a residency or fellowship in addiction medicine will be added to ABAM certification requirements once these programs are in place.

Next up: ABMS recognition

ABAM's goal is to become a member board of the American Board of Medical Specialties. Certification by an ABMS member board is considered the “gold standard” in physician credentialing. This process involves a number of components and may take several years, but ABAM is working toward achieving this important level of recognition.

In a statement released on ABAM's founding, NIDA Director Volkow said, “Years of scientific research have proven drug addiction is a brain disease caused by biological, environmental and developmental factors-a disease which can have far-reaching medical consequences. Given the proper training, tools, and resources, physicians can be the first line of defense against substance abuse and addiction-identifying drug use early, preventing its escalation to abuse and addiction, and referring patients in need to treatment.”

The time for expanding the number of competent, trained addiction medicine physicians is here-and the need has never been greater. ABAM is being launched at a time of increasing promise for addiction treatment. There is a great need across the health care system for trained, competent physicians to become members of the addiction professional team. Working together we can bring greater benefit to patients and their families.

As the recently signed federal legislation on parity is expected to reduce insurance discrimination against those with addictions, the need for addiction medicine physicians will only increase. ABAM wants to collaborate with all who work in the field in providing treatment for addictive disorders, and make sure that physicians also contribute to evidence-based addiction treatment that is available to all who need it. For more information on ABAM, visit https://www.abam.net.

References

1. Jackim LW. A field that could use some doctor shopping: Can addiction be a viable medical subspecialty? Addiction Professional 2005; 3:16-22.
2. National Center on Addiction and Substance Abuse.Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. New York City: 2000.
3. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance Use Conditions. Washington, D.C.:National Academy Press; 2005.
4. Accreditation Council on Graduate Medical Education.Annual Report on Graduate Medical Education. Chicago: 2006.