Why should addiction medicine be an attractive field for young physicians?

FOR DEBATE
Why should addiction medicine be an attractive field
for young physicians?
Michael Soyka1,2 & David A. Gorelick3
Psychiatric Hospital, University of Munich, Munich, Germany,1 Private Hospital Meiringen, Meiringen, Switzerland2 and Intramural Research Program, NationalInstitute on Drug Abuse, National Institutes of Health, Baltimore, MD, USA3 ABSTRACT
The clinical practice and science of addiction are increasingly active fields, which are attracting professionals from diverse disciplines such as psychology and neurobiology. Our scientific knowledge of the pathophysiology of addiction is rapidly growing, along with the variety of effective treatments available to clinicians. Yet, we believe that the medical specialties of addiction medicine/psychiatry are not attracting the interest and enthusiasm of young physicians.
What can be done? Methods
We offer the opinions of two experience addiction psychiatrists. Results
has been a decline in the number of psychiatrists seeking training or board certification in addiction psychiatry; about one-third of graduates with such training are not practicing in an addiction psychiatry setting. There is wide- spread neglect of addiction medicine/psychiatry among the medical profession, academia and national health authori- ties. This neglect is unfortunate, given the enormous societal costs of addiction (3–5% of the gross domestic product in some developed countries), the substantial unmet need for addiction treatment, and the highly favourable benefit to cost yield (at least 7:1) from treatment. Conclusions
We believe that addiction medicine/psychiatry can be made more attractive for young physicians. Helpful steps include widening acceptance as a medical specialty or subspecialty, reducing the social stigma against people with substance use disorders, expanding insurance coverage and increasing the low rates of reimbursement for physicians. These steps would be easier to take with broader societal (and political) recognition of substance use disorders as a major cause of premature death, morbidity and economic burden.
Keywords
Addiction medicine, addiction psychiatry, profession, specialty, stigma, training, treatment.
Correspondence to: David A. Gorelick, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, 251 Bayview Blvd., Submitted 4 June 2007; initial review completed 31 July 2007; final version accepted 18 June 2008 INTRODUCTION
encouraging exceptions. The national psychiatric societ- ies in Australia [4] and the United States have addiction This is not primarily a scientifically oriented paper. It is psychiatry components (sections or councils) and addic- rather a personal comment by two physicians with expe- tion psychiatry is an officially recognized subspecialty in rience of three decades of substance abuse research, teaching and clinical practice. The term ‘addiction’ itself, We share some concern about a certain lack of inter- for a long time abandoned mainly by diagnostic manuals est and enthusiasm of young physicians for this field. Vis- and textbooks—although present in many journal titles iting national and international meetings on addiction such as this one—may find a renaissance in DSM-V [1], research leaves us with the impression that the field itself although perhaps not without controversy [2]. There is very active. Numerous new concepts and research per- are different, more or less comprehensive, definitions of spectives are visible. However, in contrast to the increas- addiction which will not be discussed here in detail.
ing number of psychologists, neurobiologists and others Most emphasize that addiction should be managed as interested in substance use, the number of physicians a chronic disease and requires an interdisciplinary involved is comparatively low. Although the situation approach [3]. We understand that addiction medicine may vary in different countries, our overall impression is or addiction psychiatry are not recognized medical that relatively few physicians, especially psychiatrists, are subspecialties in most countries, although there are choosing addiction as their primary medical or research 2008 The Authors. Journal compilation 2008 Society for the Study of Addiction Addiction, 104, 169–172
Michael Soyka & David A. Gorelick field or maintaining an interest in this area. For example, acceptance of addiction topics in the psychiatric world is in the United States there has been a gradual decline in notoriously low. Too many psychiatric congresses devote the number of psychiatrists seeking training or board cer- little program time to substance use topics, and often tification in addiction psychiatry [6]. Common reasons schedule what sessions they do include at early-bird or given by psychiatric residents for their lack of interest in addiction psychiatry include a perceived lack of training No one questions that treatment of child, geriatric or and employment opportunities and poor long-term job cognitively impaired patients requires specialized train- security. An earlier US study found that among graduates ing and qualifications. Most medical societies and regu- of addiction psychiatry training programs, only 64% latory authorities have developed defined curricula for were practising in an addiction psychiatry setting [5].
geriatrics. There are university chairs, qualifying exami- What are the reasons for this? Is there a cure? nations and specialists who may call themselves ‘geri- atricians’. The diagnosis and treatment of substance use disorders is by no means less complex than treatment THE CONCEPT OF ADDICTION
of the elderly. It seems therefore more than justified to MEDICINE
ask for specialized training in the addiction field as The potential role of physicians (especially psychiatrists) in addiction has increased dramatically over recent decades, parallel to an increase of medical knowledge in RESEARCH PERSPECTIVES FOR
this area. Addiction is now recognized as a disease in all PHYSICIANS
official diagnostic systems (e.g. ICD-10, DSM-IV) and by major national and international health organizations Young physicians who may consider an academic career [e.g. World Health Organization (WHO)]. For relapse pre- must consider: is there enough potential in this field of vention, several pharmacological agents have been devel- addiction medicine to warrant entering it? Research pros- oped which improve the prognosis and long-term pects are much brighter than many outside the addiction outcome: full and mixed opioid agonists (methadone, field may think. Unlike other psychiatric disorders such as buprenorphine) and antagonists (naltrexone) for opioid depression and schizophrenia, there are excellent animal dependence; disulfiram, acamprosate and naltrexone for models which allow the study of basic mechanisms of alcoholism [7]. The search for other agents, especially for addiction such as craving, withdrawal, tolerance and cocaine and amphetamine use [8], is very active. There dependence [13]. The efficacy of new pharmaceutical is increasing hope for more therapeutic options in this agents or abuse liability of drugs can be studied in animal models. It is increasingly evident that certain brain The societal costs of lost economic productivity, law regions such as the prefrontal cortex and the limbic enforcement, criminal behavior and disrupted families system play a substantial role in the development of are high. The total annual cost of addiction to both legal substance use disorders. We know the major neuro- and illegal drugs has been estimated at more than transmitters that are involved in the mediation of US$400 billion [around 5% of gross domestic product (GDP)] in the United States [9], more than €30 billion gamma-aminobutyric acid (GABA), opioid–endorphin (2.7% of GDP) in France [10], more than €37 billion and endocannabinoids. Thanks to modern neuroimaging in Germany [11] and more than CDN$18 billion (2.7% techniques, we can visualize drug effects on neurons or neurotransmitters and study the basic mechanisms However, there is a widespread neglect of addiction underlying drug dependence and craving in vivo, even in medicine—and addiction psychiatry—as an independent humans [14]. Advances in genetic methods offer the discipline. Some physicians, and especially psychiatrists, potential to unravel the genetic contribution to the vul- oppose addiction medicine as a defined medical subspe- nerability for substance use disorders, even though such cialty, especially in the academic field. Health authorities disorders are undoubtedly genetically complex [15].
in some countries regulate heavily the provision of These modern techniques enable the study of the patho- agonist substitution treatment for addiction (with the physiology of substance use disorders from gene to cell common exception of nicotine replacement therapy), but to brain to organism, offering unparalleled opportunities do not acknowledge addiction medicine as a defined sub- specialty. The field would benefit dramatically from addic- Research on the pathophysiology of substance use dis- tion medicine being accepted as a medical subspecialty.
orders will also benefit our understanding of so-called This would hopefully prompt universities and medical behavioral addictions, such as obesity and pathological schools to increase their activities in the field. There are gambling [16]. Because abnormalities in the biological few chairs for addiction medicine world-wide and the mechanisms of reward, learning and memory are likely 2008 The Authors. Journal compilation 2008 Society for the Study of Addiction Addiction, 104, 169–172
to be involved, research in addictions is likely to improve the attempt to improve cognitive, emotional or social understanding of a wider range of behaviors and psychi- functioning (even love and marriage) in those without a diagnosable abnormality or disease [23–25]. This effort Funding for research is available to those who qualify, has been compared to the use of performance-enhancing at least in developed countries. The US National Institute drugs in sports or to aesthetic cosmetic surgery [26].
on Drug Abuse spent almost US$5 billion on research Addiction medicine—and addiction psychiatry—have grants from 1996 to 2006 (personal communication, much to say in this area. The scientific training and Donna Jones, Budget Office, US National Institute on evidence-based approach of the addiction psychiatrist Drug Abuse). The funding success rate for physician may help to put some of these ‘innovations’ into proper investigators has been comparable to that for non- physician (PhD) investigators for most of this period.
From 2000 to 2006, the European Community spent THE WAY FORWARD
more than €50 billion on drug abuse-related research,treatment and public health projects We believe that the concept of addiction medicine can be attractive for many young physicians, including psychia- trists. Support may come from the societal and political levels when substance use disorders have been recognized as a major cause of premature death, morbidity and eco- TREATMENT PERSPECTIVES
nomic burden. A wider acceptance of addiction medicine We know from many studies that most individuals with as a medical subspecialty may also help to reduce stigma.
substance use disorders are not in treatment. Very few are We would like to open this debate on addiction medicine seen by an addiction medicine specialist. The level of acceptance by general psychiatrists and psychotherapists is low; many refuse to treat patients with addictive disor- ders at all. The reasons offered include poor compliance, Declarations of interest
the difficulties of treatment and lack of the special exper- tise considered necessary. Other barriers to treatment include social stigma, poor or absent insurance coverage and low rates of reimbursement for physicians. The low Acknowledgement
rates of treatment participation exacerbate the human Dr Gorelick is supported by the Intramural Research and societal burden of addiction. Studies in both the Program, US National Institutes of Health, National United States and United Kingdom show at least a 7 : 1 benefit to cost yield ratio from addiction treatment [18,19], i.e. each dollar (or pound) spent on addiction treatment results in at least 7 dollars-worth of reduced References
costs from the consequences of addiction.
1. O’Brien C. P., Volkow N., Li T. K. What’s in a word? Addiction Despite their high rate of comorbid psychiatric versus dependence in DSM-V. Am J Psychiatry 2006; 163:
disorders, very few psychiatrists engage in substitution treatment of opioid-dependent patients [20]. Addiction 2. Erickson C., Wilcox R. Please, not ‘addiction’ in DSM-V.
medicine must be accepted as a legitimate medical sub- Am J Psychiatry 2006; 163: 2015–16.
3. McLellan A. T., Lewis D. C., O’Brien C. P., Kleber H. D. Drug dependence, a chronic medical illness: implications for
treatment, insurance, and outcomes evaluation. JAMA
2000; 284: 1689–95.
‘RISK MANAGEMENT’
4. Lubman D., Jurd S., Baigent M., Krabman P. Putting ‘addic- Addiction medicine may, in the future, also serve as tion’ back into psychiatry: the RANZCP section of addiction
psychiatry. Australas Psychiatry 2008; 16: 39–43.
a form of ‘risk management’ arena for new medical 5. Tinsley J. A. Workforce information on addiction psychiatry approaches, especially in the light of the increased use of graduates. Acad Psychiatry 2004; 28: 56–9.
‘life-style drugs’ or ‘life-style habits’ such as excessive 6. Renner J. A. Jr, Hennessy G., Levin F., Waldbaum M., Eld B.
internet use [21,22]. For example, there is increasing use APA addiction psychiatry career survey: Residents’ narra- of psychostimulants in adults with symptoms of atten- tive responses. Presented at the American Academy ofAddiction Psychiatry annual meeting, December 2006.
tion deficit disorder. Does this use pose a risk of addiction? 7. Rosner S., Leucht S., Lehert P., Soyka M. Acamprosate sup- Who will monitor for these risks and care for any affected ports abstinence, naltrexone prevents excessive drinking: individuals? Another example is the use of psychoactive evidence from a meta-analysis with unreported outcomes.
drugs for ‘neuroenhancement’ in normal individuals, i.e.
J Psychopharmacol 2008; 22: 11–23.
2008 The Authors. Journal compilation 2008 Society for the Study of Addiction Addiction, 104, 169–172
Michael Soyka & David A. Gorelick 8. Gorelick D. A., Gardner E. L., Xi Z. X. Agents in development Jourabchi M. et al. Benefit–cost in the California treatment for the management of cocaine abuse. Drugs 2004; 64:
outcome project: does substance abuse treatment ‘pay for itself ’? Health Serv Res 2006; 41: 192–213.
9. McGinnis J. M., Foege W. H. Mortality and morbidity attrib- 19. Godfrey C., Stewart D., Gossop M. Economic analysis of utable to use of addictive substances in the United States.
costs and consequences of the treatment of drug misuse: Proc Assoc Am Physicians 1999; 111: 109–18.
2-year outcome data from the National Treatment Outcome 10. Fenoglio P., Parel V., Kopp P. The social cost of alcohol, Research Study (NTORS). Addiction 2004; 99: 697–707.
tobacco and illicit drugs in France, 1997. Eur Addict Res 20. Soyka M., Apelt S. M., Wittchen H. U. Die unzureichende 2003; 9: 18–28.
Beteiligung von Psychiatern an der Substitutionsbehand- 11. Andlin-Sobocki P., Rehm J. Cost of addiction in Europe.
lung [Insufficient involvement of psychiatrists in substitu- Eur J Neurol 2005; 12: 28–33.
tion treatment]. Nervenarzt 2006; 77: 1368–72.
12. Single E., Robson L., Xie X., Rehm J. The economic costs of 21. Liu T., Potenza M. N. Problematic internet use: clinical alcohol, tobacco and illicit drugs in Canada, 1992. Addiction implications. CNS Spectr 2007; 12: 453–66.
1998; 93: 991–1006.
22. Dell’Osso B., Altamura A. C., Allen A., Marazziti D., Hol- 13. O’Brien C. P., Gardner E. L. Critical assessment of how to lander E. Epidemiologic and clinical updates on impulse study addiction and its treatment: human and non-human control disorders: a critical review. Eur Arch Psychiatry Clin animal models. Pharmacol Ther 2005; 108: 18–58.
Neurosci 2006; 256: 464–75.
14. Volkow N. D., Fowler J. S., Wang G. J. The addicted human 23. Farah M. J., Illes J., Cook-Deegan R., Gardner H., Kandel E., brain viewed in the light of imaging studies: brain circuits King P. et al. Neurocognitive enhancement: what can we and treatment strategies. Neuropharmacology 2004; 47:
do and what should we do? Nat Rev Neurosci 2004; 5:
15. Uhl G. R. Molecular genetics of addiction vulnerability.
24. Hall W. Feeling ‘better than well’. EMBO Rep 2004; 5:
NeuroRx 2006; 3: 295–301.
16. Grant J. E., Brewer J. A., Potenza M. N. The neurobiology of 25. Savulescu J., Sandberg A. Neuroenhancement of love and substance and behavioral addictions. CNS Spectr 2006; 11:
marriage: the chemicals between us. Neuroethics 2008; 1:
17. Reuter P. What drug policies cost. Estimating government 26. Chatterjee A. Cosmetic neurology and cosmetic surgery: drug policy expenditures. Addiction 2006; 101: 315–22.
parallels, predictions, and challenges. Camb Q Healthcare 18. Ettner S. L., Huang D., Evans E., Ash D. R., Hardy M., Ethics 2007; 16: 129–37.
2008 The Authors. Journal compilation 2008 Society for the Study of Addiction Addiction, 104, 169–172

Source: http://premos-studie.de/Addiction_2009_Soyka.pdf