Historic Day for Advancing Medical Education on Addiction

White House hosts second "Medicine Responds to Addiction" symposium

Imagine a day when all doctors are equipped with the basic knowledge and experience to address substance use disorders in a non-stigmatized way, with an informed appreciation for the complexity of the disease and the recovery process, as well as their role in preventing this common health issue.

We say “imagine” because, sadly, that’s not the reality today.

“We may cover addiction briefly in biochemistry. Some institutions may even have a course on tobacco dependence, but we come nowhere close to being prepared enough to address addiction with our patients when we graduate from medical school," said Kelly Thibert, DO, MPH, National President of the American Medical Student Association, who was among the speakers at an important and promising event in which we participated Oct. 25 at the White House.

The message was similar from Christen Johnson, President of the Student National Medical Association, who added this point: “When thrust in to the world of real medicine, we're also faced with bias by substance, socioeconomic status and race of patients.”

“The need for change is evident in the curriculum,” she continued, “but until the culture of medicine changes and opportunities are created to make socially conscious and culturally competent attending physicians, medical students will remain a product of their environment and will not be clinically excellent in treating addiction in America.”

To some, it may be startling to hear that one of the nation’s biggest public health problems continues to be marginalized by the mainstream medical field, starting with a lack of robust education on the topic in medical school. However, to those of us who work in the specialized industry of addiction prevention, treatment and recovery, this is a longstanding issue. In fact, it has been on our field's radar since long before we were born. 

While we’re proud of the work we do at the Hazelden Betty Ford Foundation—the nation’s largest nonprofit provider of addiction treatment and recovery resources— we also recognize that the scope of the problem demands the weight of the entire healthcare field be brought to bear against it.

As such, we’ve been raising the issue for decades and doing our part to provide medical education on addiction wherever we can.

That’s why we were so pleased to participate in the recent symposium hosted by the White House Office of National Drug Policy (ONDCP), along with our colleague Joe Lee, MD, Medical Director for the Hazelden Betty Ford Foundation’s Youth Continuum.

Medicine Responds to Addiction II was the sequel to an event held in September 2015 and brought together about 80 industry leaders, including medical school deans, associate deans, licensing and certification board representatives, and key partners and leaders in both the public and private sectors—all there to discuss advancing the education and practice of addiction medicine.

Dr. Lee was among an esteemed group of speakers, which included ONDCP Director Michael Botticelli; George Koob, PhD, Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA); Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA); Kana Enomoto, Principal Deputy Administrator for the Substance Abuse and Mental Health Services Administration (SAMHSA); and several other notable leaders. 

The Time is Now to Address Years of Neglect

“Our country’s prescription drug epidemic has been one tragic catalyst for our gathering here,” Dr. Lee said. “While much has been discussed about the causal factors behind the crisis, one critical cause is often left out: the decades-long and consistent marginalization of mental health and substance-related issues in our country. Put another way, aren’t we now paying the price for years of neglecting the fiscal and educational investments required to confront those most stigmatized of conditions?”

Indeed, according to a 2012 report by the National Center on Addiction and Substance Abuse, medical schools devote only a few hours over four years to teaching addiction medicine. Meanwhile, the current heroin and prescription opioid epidemic—driven largely by overprescribing—claims thousands of lives every year, including 29,000 in 2014. Many thousands more die annually from other substance-related causes.

Despite years of advocates calling for expanded medical education on addiction, the issue has proven a difficult one to move forward. Competition for curriculum time is great, and university independence guarded. Stigma plays a role too, with addiction care and the people who need it sometimes seen as difficult, complex, time-consuming, and—though it’s rarely said or acknowledged out loud—less worthy of time, energy and investment (due to the old vice v. disease debate).

Education, it seems, is the answer to both what we need and how to get there.

“Many who train in medicine are exposed only to the most stigmatizing aspects of addiction, drug-seeking behaviors, difficult patients in the ER, overdoses, and end-stage disease states,” Dr. Lee said.

“But with the right education, they see these same patients through the lens of humanism,” he continued. “They witness the spirit of redemption in these individuals and recall their capacity to empathize with the most human and ubiquitous of diseases. They remember why they signed up to be healers, and develop the ability to love those they care for by looking past their stereotypic intuitions. What a healthcare system we would have if we fully developed this capacity in all of our clinicians.”

Medicine Responds to Addiction

Partial proceedings from the "Medicine Responds to Addiction II" symposium held at the White House on Oct. 25, 2016 ...

Hazelden Betty Ford Medical Education Programs

Our belief in the power of education is buoyed by years of providing experiential learning opportunities to both medical students and practicing professionals.  At the White House event, Dr. Lee spoke of his own experience training Mayo Clinic “residents” and “fellows” in a one-month immersive, hands-on clinical rotation at Hazelden in Plymouth, Minn. He also shared about our one-year addiction medicine fellowship at the Betty Ford Center, as well as the 180 full annual scholarships we now have, thanks to generous donors, for our Summer Institute for Medical Students. SIMS places medical students from all over the world on our residential addiction and day treatment units. There, they learn alongside patients and clinicians in a weeklong immersion experience that usually is their only in-depth exposure to substance use disorders during medical school. Time and again, they report it is life-changing.

In fact, just a day after presenting at the Washington, D.C. event, Dr. Lee went to New York City for a conference where he co-hosted a career forum table for new child psychiatrists and medical students interested in addiction medicine. He and his co-facilitator talked to three groups for 30 minutes each.

“Turns out that there was an individual in each of the three groups that shared their experience at the SIMS program as a catalyst for their interest,” Dr. Lee wrote to us that evening. “At the time they disclosed, they did not know I worked at Hazelden Betty Ford. They talked about it being life changing. I was blown away not only by the randomness but by the similarities in how they talked about the experience as profound—again, without knowing I worked there. It’s obvious that their experiences at SIMS fueled long-lasting changes in their perception of addiction.”

One thing history tells us is that social stigmas tend to dissipate when folks get to know the people and problems that are stigmatized—and, in the case of our education programs, when trainees get to witness the spirit and science of recovery—up close.  Trainees quickly learn to appreciate addiction as a chronic illness that can affect anyone and can also be overcome. And they learn that caring for patients with substance use disorders requires much more than diagnosing symptoms and prescribing medication—that, more often than not, it also requires assisting people in a personal transformation.

Unfortunately, that latter reality is lost even on some doctors who practice addiction medicine today, thanks—in part, we believe—to insufficient education.

At the White House event, Anna Lembke, MD, from Stanford University pointed to the example of doctors who prescribe buprenorphine to treat opioid use disorder but fail to provide or connect their patients to the behavioral health support that is also needed, describing that as “bad addiction medicine.” We couldn’t agree more.

Momentum is Building

Things are definitely looking up, though. The American Board of Addiction Medicine (ABAM) was launched in 2007 due to the work of the American Society of Addiction Medicine and its Medical Specialty Action Group (which held its inaugural meeting the year before at Hazelden in Center City, Minn.). Soon, ABAM set out to independently certify physicians in the subspecialty of addiction medicine, and the related ABAM Foundation began accrediting addiction medicine fellowship training programs, like ours at the Betty Ford Center. Though the subspecialty was not initially recognized by the American Board of Medical Specialties, recognition came earlier this year, a historic occasion that made addiction medicine one of more than 100 officially recognized medical disciplines in the United States. With the opportunity now to earn an officially recognized certification, more medical students are likely to pursue this area of practice. At the same time, the number of fellowships has exploded recently, more than doubling since 2014 to 42 today. Our friends at the Addiction Medicine Foundation (formerly the ABAM Foundation) are spearheading the fellowship expansion, with a goal of 125 by 2025.

The proliferation of fellowships and certified addiction medicine specialists serves two especially important goals, among others: 1) expanding the workforce of specialists and, thereby, getting expertise into more healthcare settings throughout the United States; and 2) creating more champions for expanded education and practice, both at medical schools, where most fellowships are based, and throughout the industry of practice.  

Another development in 2016—in addition to the subspecialty recognition—was the pledge that 61 of the nation’s approximately 180 medical schools made to the Obama Administration, promising to teach their students about safe opioid prescribing. Several other schools signed an alternative statement acknowledging the role of medical schools in addressing the opioid epidemic, though stopping short of making any particular pledge.

Medical students themselves stood up and spoke out this year about the need for more education on addressing opioid overdoses and addiction, with some in Massachusetts deciding to organize their own learning.

Add it up, and this has been a significant year of dialogue and developments related to addiction medicine, all on the heels of the “Medicine Responds to Addiction” meeting held last fall at the White House.

The sequel event in which we were honored to participate on Oct. 25 sought to build on that momentum by looking beyond growth of the addiction medicine specialty to also pursuing the expansion and integration of core addiction medicine curriculum across all medical education. It was an important high-level and public acknowledgement that substance use disorders are so prevalent and affect health in so many ways that all doctors need to be trained on the critical aspects of preventing, identifying and treating addiction. That it’s not enough to train specialists. That it’s not enough to beef up education on opioid prescribing. That it’s not enough to add continuing education requirements. That, in fact, all doctors need and deserve sufficient training on all substance use disorders, starting early in medical school and continuing throughout their clinical years and beyond.

The Way Forward

For the reasons we mentioned earlier—competition for curriculum time, medical school independence and stigma—this effort will likely require strategic work and advocacy over a sustained period of time. The key idea discussed at the White House was exploring and promoting “Centers of Excellence in Addiction Medicine” at academic medical centers. Such centers would be anchored by addiction medicine fellowship programs and would lead the way in integrating addiction research, practice and education (all the way through medical school, residency and fellowship training, across all medical specialties). The idea, as we see it, is to encourage those leaders most motivated to address this issue to establish centers of excellence that produce enough value to the institution, community and field that other academic medical centers will naturally want to follow suit.

It’s a systemic, influence-from-within strategy. Some worry it’s a trickle-down approach that will take too much time—based on the hope that addiction medicine can seep its way from fellowships down to residency training and medical school curriculum, and from centers of excellence to other institutions.

Only time will tell if advancements follow the envisioned path. But if the previous year’s event is any indication, much good will come—some anticipated and some unexpected—from gathering the industry’s top leaders in a high-profile, public setting like the White House to discuss opportunities, challenges and forward-thinking ideas.

For us, this topic is an ideal opportunity for collaboration between our Institute for Recovery Advocacy and our Medical and Professional Education (MPE) teams. By working together, we can continue to advocate for advancements in this area, which is critical to improving addiction care in America, and also support some of those advancement efforts with programs like our Summer Institute for Medical Students.

We are committed to sharing the wisdom our organization has gained in 67 years of helping others recover. Committed to educating others about the fact, as Dr. Lembke said, that addiction medicine needs to be about much more than prescribing medicines. And committed to integrating the emerging addiction medicine field with the existing behavioral health field as necessary partners in an addiction care ecosystem that also needs to include specialized prevention and recovery support resources.

Changing the healthcare system to more thoroughly and effectively address addiction is no small feat. But emphasizing substance use in the education of our healthcare professionals is a good start.
Jeremiah Gardner, Mgr of Public Affairs and AdvocacyJeremiah Gardner, manager of public affairs and advocacy at the Hazelden Betty Ford Foundation, is a person in long-term recovery with a master's degree in addiction studies and a background in journalism, public affairs, business and music.
Joseph Skrajewski, MA, MFTI, is executive director of Medical and Professional Education at the Hazelden Betty Ford Foundation. He heads up the Summer Institute for Medical Students, Professionals in Residence program, Addiction Medicine Fellowship, and Course on Addiction and Recovery Education, while also overseeing program design and development and medical education partnerships. Joseph serves on the board of the Desert Chapter of the California Association of Marriage and Family Therapists and as an Adjunct Clinical Instructor of Family Medicine at the University of Southern California's Keck School of Medicine. He has presented all over the world on numerous topics related to addiction, and is a person in long-term recovery himself. Before entering the fields of psychology and healthcare, Joseph worked on Wall Street. 
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