SEARCH

SEARCH BY CITATION

Keywords:

  • Addiction;
  • brief intervention;
  • medical education;
  • primary care;
  • treatment

In May 2007, the Australian Health Minister accepted a recommendation from the Australian Medical Council to recognize addiction medicine as a distinct medical speciality. The Australasian Chapter of Addiction Medicine (AChAM) is now undergoing accreditation of its training programme, and if accreditation is achieved, fellowship of the Chapter will be recognized as a specialist qualification.

Training in addiction medicine is open to people with an initial basic training in several branches of medicine—including general practice, psychiatry and internal medicine. In most English-speaking countries, consultants in addiction are generally psychiatrists. In the United Kingdom, the Royal College of Psychiatry offers advanced training in addiction psychiatry. In the United States, addiction psychiatry is an approved and examinable subspeciality of psychiatry. In the United States, the American Society of Addiction Medicine (ASAM) provides professional support, training and certification by examination for (non-psychiatry-trained) medical practitioners who practise at a specialist level in addiction medicine. Although not yet a Board-certified speciality, ASAM was admitted to the American Medical Association (House of Delegates) as a voting member in 1988. In 1990 the American Medical Association added addiction medicine to its list of designated specialities.

In the Netherlands and Portugal, attempts to establish addiction medicine as a speciality have been opposed by general practitioners and in Australia, too, the impact of speciality recognition on primary care was seen as the greatest potential negative impact of speciality recognition. General practitioners (GPs) are readily accessible and are well placed to provide a range of interventions, including brief advice [1], monitoring, referral and prescribing methadone and buprenorphine [2]. If speciality recognition meant that GPs would no longer manage addictive disorders, this would be a retrograde step.

Currently, alcohol and other drug use are seldom addressed in primary care settings [3–5]. This is partly attitudinal, arising from a belief that alcohol and drug issues are matters of personal responsibility, or from fear of antagonizing patients by asking about smoking and drinking. It may be due in part to lack of knowledge and skills, and pessimism about outcomes of intervention [4,5].

Declining to be involved in treating drug dependence is disappointing, but failing to diagnose is dangerous. Prescription drug dependence is a growing public health problem in many jurisdictions [6]. An Australian study of 203 fatal opioid overdose deaths among people aged 15–24 years reported that prior to death these subjects had accessed medical services at six times the rate of the general population, usually obtaining prescriptions for benzodiazepines and opioids. Prescription drugs were detected in more than 90% of subjects at autopsy [7].

Many doctors appear to be disengaged, preferring not to respond to, nor even recognize, alcohol- and drug-related problems. This is not a new phenomenon. The first hospital for alcoholics was founded in 1841 in Boston because alcohol-dependent people could not obtain treatment in mainstream hospitals. George Vaillant has suggested that there remains an unwritten rule at the entrance to general hospitals—‘Alcoholics need not apply’. Instead, we have had specialist services for treatment of alcohol and drug problems; marginalized services for marginalized patients.

The primary objective of establishing a medical speciality in addiction is to support the health system—from undergraduate training, postgraduate training, general practice, hospitals, mental health services—to engage with addictive disorders and respond more constructively. Medicine is based on specialities, and a discipline as distinctive (and for many doctors, as alien) as addiction medicine needs representation as a speciality, or it risks remaining a peripheral, optional activity for many doctors. Speciality recognition provides role legitimacy—and imposes responsibility—on doctors, promoting, rather than diminishing, GP involvement with drug and alcohol problems.

In Australia, as elsewhere, doctors make up a small component of the addictions work-force; currently medical salaries are 4–7% of publicly funded treatment budget in the largest Australian State, New South Wales. Despite the small numbers, there is a risk that bringing addiction services into mainstream health care will diminish the role of other professionals. Quite apart from competition for professional ‘turf’, bringing addiction treatment under the prevailing medical hegemony may be another step in the ‘medicalization’ of experience, creating pathology out of people's life choices. Addiction treatment may come to be dominated by the unholy alliance of doctors and pharmaceutical companies, relentlessly expanding the areas of life in which ‘treatment’ is indicated.

This challenge faces communities whether or not doctors working in addiction services have specialist training. Indeed, training might even help. Training in addiction medicine is based in multi-disciplinary teams, and is designed not only to certify that people have specified competencies, but that practitioners emerge with an inkling of the limits of their competence. Specialist training is not simply a licence to practise, but a discipline.

The addictions field has been prone to fluctuating enthusiasms. To the uninitiated, the solution to drug and alcohol misuse often seems maddeningly simple, yet frustratingly difficult to impose upon patients. At one extreme, practitioners filled with charismatic enthusiasm offer cures; at the other, burnt-out and cynical practitioners can exploit patients. Speciality recognition will not solve all the problems of conviction-driven or profit-driven treatment; but it should help. Speciality recognition provides a professional body with the mission of promoting and certifying professional competence, and adds a small, slightly authoritative voice in the general clamour over drug problems. By providing initial training and continuing professional development, the Chapter reduces the risks of doctors working in isolation, or in closed teams which have developed their individual idiosyncrasies.

Most importantly, speciality recognition helps to attract and retain young doctors to work in the field by providing a career path. The long-term aim is to enhance the health system's response to the burden of disease associated with misuse of drugs. It will be some years before an estimate can be made of how successfully we achieve this aim. However, in the shorter term, speciality recognition should at least reduce the hazards and stigma associated with marginalized doctors treating marginalized patients.

Acknowledgements

  1. Top of page
  2. Acknowledgements
  3. References

Dr Deborah Zador reviewed and commented early drafts of this paper.

References

  1. Top of page
  2. Acknowledgements
  3. References