Primary care doctors and medical students will now be able to gain accreditation as addiction medicine specialists. The American Board of Medical Specialties announced this week its approval of a new medical subspecialty intended to increase the number of physicians qualified to help patients with addiction.
One person leading the push to create the specialty was Richard D. Blondell, professor of family medicine at the University at Buffalo in New York and an expert in addiction medicine. Over the last several years, he worked with the American Board of Addiction Medicine to establish standards and an accreditation process for new training programs in dozens of medical schools around the country. Now, graduates of these programs will be able to be certified in the subspecialty. The new certification means doctors in the field have been trained and tested at consistent high standards recognized by their peers.
Side Effects’ Michelle Faust spoke with him about his efforts to build a workforce of physicians trained to work with substance use disorders.
Michelle Faust: Addiction medicine has been in the news lately because of the spike of people who are addicted to opioids. Do we have enough medical professionals trained to help people who have addiction?
Richard Blondell: We do not. We think that the demand for physicians who have special expertise in addiction medicine is greater than the supply of physicians who have that expertise. So, one of the things that we are trying to do with building training programs is to increase the supply of well-trained addiction medicine specialists.
MF: What is the difference between the kind of treatments a therapist or a counselor would be giving, as opposed to what a doctor specializing in addiction medicine would be giving?
RB: For a long time, addiction was felt to be a moral problem or problem of behavior. And the treatment for people with addiction generally focused on improving their spiritual health or behavioral counseling. And those techniques have met with some success, but limited. We think that successful treatment in those realms occurs in about 20 percent of the cases. So the question is how do we help the other 80 percent?
People say that addiction is just a behavior problem. But if you think about it, it is the brain that produces behavior. If someone had a heart attack and has damaged their hearts, you may not expect that their heart would function normally. If people have an addiction and their brain is has been changed by exposure to drugs, the basic workings of the brain become different. Then too, the resulting behavior that's created by the brain may change.
We now know that medical treatment aimed at correcting the deficits in the brain might actually help to improve the outcomes with addiction. Because we’re talking about using medications and medical approaches towards the treatment of addiction, now we need, more than ever, a workforce of physicians who can apply this new knowledge in the treatment of people with addiction.
For a long time, addiction was felt to be a moral problem or problem of behavior. And the treatment for people with addiction generally focused on improving their spiritual health or behavioral counseling. And those techniques have met with some success, but limited.
MF: Now that you’ve got this recognition from the American Board of Medical Specialities, what are the next steps?
RB: The next step is to expand our training programs so that they occur in every medical school. [Already], we went from an initial eight programs nationwide to 40. Thirty-seven of them are in the United States and three are in Canada. All of these programs are accredited and follow the same rigorous training requirements across the country. We now have standardization of training, and we now hold these training programs to a high level of expectation. So, the doctors that they produce are going to be highly qualified to practice addiction medicine.
We need a workforce, obviously. If we only have 40 programs in North America and they're about 150 medical schools, we have a long ways to go.
A workforce of experts [trained] in addiction medicine can do three major things: Number one: provide state of the art care to patients. Number two: They serve as teachers to medical students, physicians in training, and physicians who in practice in the field. The third thing that they do is do research in clinical medicine to try to find better treatments for the addictive disorders.
Now, just like if we wanted to send men to the moon in the sixties. In order to do that we need to build rockets. And in order build rockets we needed rocket scientists. And so we need a workforce of rocket scientists and more even more important we needed people who could train the rocket scientists.
So, since we're dealing with this epidemic of addiction, we need a workforce of specialists to deal with the epidemic. And to train their peers on how to recognize addiction in its early more treatable phases. Or even to prevent addiction from occurring in the first place by having appropriate prescribing standards for the prescription of opiate medications.
MF: Just this week the CDC released new guidelines for doctors prescribing opioids. As an addiction specialist, what are your thoughts about the new guidelines?
The CDC guidelines represent at least some start that trying to take a rational approach to prescribing opiate medications. Now, what has to happen next is physicians need to be educated about these guidelines and how to apply them. And again that's where the experts in addiction medicine come in, because in general physicians don't take too kindly to having non-physicians advise them about how to practice medicine. Another physician, particularly a physician who has some expertise in this area, can be a more effective teacher for practicing physicians. So will need to will need to translate these guidelines into practical educational efforts directed at practicing physicians.
MF: What stood out to you as some of the most important recommendations in the new guidelines?
RB: I think a lot of the guidelines comes down to this: If you're prescribing for chronic pain, for patients with non-cancer pain, the guidelines here are basically: lowest possible dose, shortest possible duration.
Now, we're not talking about end of life care here. Nobody is talking about withholding medications for people who are suffering with cancer and dying. We're talking about the treatment of chronic pain, not due to cancer, not necessarily a threat to life.
MF: And how does that differ from what's been going on with prescribing opioids?
RB: This is what physicians were taught to do prior to about 1985. I was one of those physicians who was taught at that time and we were taught not to prescribe narcotics, that they were highly addictive, that the over prescription of them could lead to people with addiction, and that we should severely limit the number of drugs that we prescribed. And we did that. And we didn't really have the problem of prescription opiate addiction at that time.
It makes more sense to try to put a guard rail at the top of the cliff so people don't fall off [into addiction] in the first place.
In the late 1990s, aggressive marketing from pharmaceutical companies directed at physicians told physicians that we are being too stingy with our pain meds, that we should prescribe more liberally, and if patients have real, honest-to-God pain there was no risk for developing addiction. And we were encouraged - it was actually beaten into our heads - to prescribe pain meds. And pain became a fifth vital a sign in the hospital, and if patients racked up more than four points on a ten point scale we were told, “You have to give them medication. You have to relieve the pain. And don't worry about addiction.” But we were wrong.
And we have now prescribed ourselves into an epidemic of drug abuse that that we have never seen before. So part of the guidelines are actually returning to sensible prescribing guidelines that existed before the big marketing push by pharmaceutical companies.
And I’d like to add one more thing. This epidemic came from doctors writing too many prescriptions, through aggressive marketing from pharmaceutical companies, with patient demand. And they took them to drug stores and got them filled. And it was paid for by dollars from health insurance companies. In some ways these dollars financed the current drug epidemic.
MF: And how can developing a workforce of addiction medicine specialists help now that we’re in the middle of this crisis?
RB: We have created an epidemic. The good news is we know how to deal with epidemics. And we've known this for over 2,000 years.
The Romans first figure this out when they had contaminated water that led to dysentery and other intestinal infections. They figured out that if they built aqueducts and bring in fresh water, and built sewers to take away the waste, they could actually build a city where people are healthy. So, they were the engineers of public health and we've known this for a long time.
Polio was an epidemic in the 1950s. We did not treat our way out of that epidemic with iron lungs; we had a vaccine.
The downside of what a lot of people are talking about now with this opiate epidemic is they’re talk about more methadone maintenance, more suboxone, more treatment programs, more detox beds. That's like building treatment centers at the bottom of the cliff, after people fall off into addiction and develop addiction and they fall to the bottom of the cliff and now we’re going to start treating them. It makes more sense to try to put a guard rail at the top of the cliff so people don’t fall off in the first place.
And that guard rail is going to be a well-educated physician workforce who knows what they're doing, and is prescribing appropriately so we don't create people with addiction in the first place. And physicians who are very astute and can recognize the early signs of addiction and intervene then, before people totally screw up their life.
MF: And it's it sounds like a from our conversations today that this is really kind of your mission is to create that guardrail?
RB: That's right that's right then dedicated last twenty-some years my life doing.
This story was produced by Side Effects Public Media.
