NEW IMPETUS TO AIM ‘HIGHER, FASTER, STRONGER’
Setting the scene
Professors Soyka & Gorelick should be congratulated for re-igniting this vital debate . I consider their contribution from the UK perspective, with a particular concentration on the clinical and academic addiction psychiatrist, and on the assumption that the term ‘addiction medicine’ embraces addiction psychiatry and physicians practising in addiction.
Thirty years ago it was undoubtedly a leap of faith for me to choose addiction psychiatry as a credible career. Although inherently fascinating, challenging and dynamic, the scientific basis was unconvincing and treatment uncertain, although recovery was possible. These problems have not abated, and addiction costs the UK economy a great deal (latest estimates are about £20 billion per annum for alcohol-related problems and £15 billion per annum for drug-related problems [2–5].
The ‘concept of addiction medicine’
In 1998 an Addictions (formerly Substance Misuse) Faculty was established as one of 10 Faculties of the Royal College of Psychiatrists (RCPsych) to acknowledge the distinct contribution of addiction specialists within psychiatry. The RCPsych is the only Royal Medical College to have an accredited recognized training curriculum for those psychiatrists who wish to practice in the addictions, although this is still a subspeciality of general psychiatry. To complement this, there is the support of the successful Specialist Clinical Addiction Network (SCAN). As a result, the numbers of specialist addiction consultant psychiatrists have roughly tripled in the last 10 years. The Royal College of General Practitioners (RCGP) has actively developed short courses for primary care and other professionals, and general practitioners with a special interest take on a substantial role in shared care, along with addiction psychiatrists, with a keen awareness of the need to set standards and an accountability framework for practitioners and commissioners . While there is involvement from some colleagues in general medicine and public health, stigma both inside and outside the medical profession remains a real issue, and there are no formally approved specialist competencies, curricula or qualifications.
The treatment scene
The UK National Institute for Clinical Excellence (NICE) was established 10 years ago to evaluate the effectiveness and cost-effectiveness of the treatments for application in the National Health Service. The tremendous developments in the pharmacological and psychological treatment of addiction are beginning to be assessed for national implementation [7,8]. Added to these detailed reviews and guidance, there is an appreciation that, for treatment to achieve sustainable outcomes, it is the aftercare and continuing support, especially for social predicaments, that bind the impact of early and intensive treatment interventions to future success . Addiction is not a ‘stand-alone’ disorder—comorbidities are the norm and the disorder is often chronic and life-long, with ramifications for the family, community and country—even crossing national and international boundaries [25,10,11].
Service development—the 60th anniversary of the National Treatment Service
While we celebrate the extraordinary institution that is the National Health Service (NHS), there is distinct disquiet that the expertise of medical professionals is being devalued and eroded [12,13]. While numbers in treatment have doubled as a result of the National Treatment Agency for Substance Misuse (NTA), quality and outcomes now require urgent appraisal, as well as parity for alcohol treatment which is seriously under-resourced [5,14]. There are considerable qualms about the commissioning process and destabilization of the contribution of addiction psychiatry, but insurance and remuneration do not constitute a significant component of the health-care structure in the United Kingdom.
The training and education scene
Multiple initiatives are under way. Because undergraduate medical training is a critical point for trainee doctors, a model curriculum is currently being implemented in all medical schools in the United Kingdom . A pivotal role of the RCPsych is to administer, examine and monitor postgraduate and continuing professional training. The Addictions Faculty has regular opportunities at the Annual General Meeting and a 2-day residential meeting. In Europe, the Section on Alcohol and Drugs of the European Psychiatric Association (EPA) and, in the United Kingdom, the Society the Study of Addiction (SSA) attracts consistent audiences, including addiction psychiatrists. Similarly, 10 university-accredited Masters courses on addiction topics regularly recruit addiction psychiatrists. These initiatives are building-blocks for future joint European training and research projects.
The research scene
Despite the compelling energy of the clinical and educational landscape, it remains the case that there is very little funding for addiction research. Indeed, it is difficult to gather a precise estimate as funding may percolate through many sources. A ‘guesstimate’ would be in the order of £15 million over the last 10 years . It is also the case that there are less than a handful of Chairs of Addiction Psychiatry, all except one of which is in London . As a result, few opportunities exist for clinical academics to pursue an attractive and secure career in addiction psychiatry, which is exacerbated further by concern about the paucity of research options for medical students . These difficulties were compounded by mismanagement of the overall medical training programme, including those elements for clinical academics, during 2007 .
The Foresight project on Brain Science, Addiction and Society was a stunning summation of research in the addictions, which explored achievements, many British, in the addiction field over the last decade and included contributions from epidemiology, neuropharmacology, cognitive psychology, genomics, economics and psychiatry, among others . As a result, the Academy of Medical Sciences (2008) recommended that UK research agencies ‘Enhance basic, translational and multidisciplinary research, create additional academic and clinical posts, and invest in state-of-the art brain imaging and other technological facilities’.
Still a leap of faith, we have aim ‘higher faster stronger’
Empirical evidence has expanded immeasurably and has the potential to radically alter clinical practice. Translation of recent neuroscientific findings directly into everyday clinical practice is a gap still to be bridged . Patients are undermined by shortfalls in treatment for associated physical and mental health problems which may, in turn, minimize the impact of the most effective treatments for addiction [7,8]. Treatment services still do not offer sufficiently comprehensive services for long enough. The socio-economic barriers to treatment, and its benefits, are all too prevalent .
Do the choice and the chance to study addiction behaviour still have to be the leap of faith? Despite the cumulative efforts of clinical and academic programmes, networks, associations and societies which are both reflective of, and electrify, the rich potential in the field, I would argue that it is. To attempt to entice the brightest and most compassionate of psychiatrists into academic medicine with vague prospects for career development is patently absurd. We cannot yet ‘go for gold’, but we could be competitive in the world academic market if substantial funding was made available to promote innovation. Fortuitously, as I write, the Medical Research Council has announced £6 million to support an addiction research strategy. Hopefully this will be one catalyst to enable us to achieve at the highest level scientifically, to reach goals faster and to develop a stronger collaborative team of clinical academics working with other disciplines to build capacity for the future. A national network of clinical researchers, the Treatment in Addiction Research Group (TARG), promotes collaborative clinical research programmes, but a national research institute would be the prize. Perhaps by the 2012 London Olympics?