An addition medicine specialist provides prevention, screening, intervention and treatment to patients with substance use and addiction problems. They also treat the psychiatric and physical complications associated with addiction and substance abuse. An addiction medicine specialist combines knowledge of public health, psychology, social work, mental health counseling, and internal medicine to treat patients suffering from addiction. These specialists are typically either medical physicians or psychiatrists.
An addiction medicine specialist is a medically licensed physician who may have various duties and responsibilities. Some of the duties may include the following (Doctorly, 2017):
Detoxification procedures to help patients eliminate the substance from their bodies and begin treatment
Rehabilitation including physical and mental therapies designed to improve lifestyle choices and deal with causes of addition
Harm reduction for the patient including elimination of substance and risk factors and abstinence training
Treatment both physically and mentally with an effort to prevent relapse
Individual and Group Therapy sessions that can focus on understanding the effect substance abuse has on the body as well as processing the causes of addiction and abuse in a group setting
Oversight of Halfway Houses to ensure residents maintain their sobriety plans and medical services are offered when needed for residents
Treatment of Withdrawal Symptoms which can include cardiac or respiratory arrest, seizures and other physical reactions to the removal of the substance
Acute Intervention including in the cases of overdose, cardiac arrest, seizure and self-harm
Long term treatment and therapy to reduce the chance of relapse and increase the length of time patients are sober by offering support and accountability during transition and after
Treatment of infectious disease associated with addiction like HIV, and hepatitis which can be acquired during addiction
The Definition of Addiction
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry (ASAM, 2011). People suffering from addiction are unable to consistently abstain from their negative habits, have impaired behavioral control, cravings and a diminished recognition of the severe consequences of their behaviors not only to their health but to their relationships as well. As with many chronic diseases, those suffering from addiction tend to have cycles of recovery and relapse. If addiction goes untreated, it can lead to permanent disability or death.
Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors (ASAM, 2011). It also affects brain memory and biological and behavioral responses, which can trigger cravings or the desire to continue with the addictive behavior.
The frontal cortex of the brain is responsible for impulse control, judgement and the pursuit of rewards. The function of the frontal cortex is significantly altered in people suffering from addiction. Functions such as delaying gratification are affected as well. Because this part of the brain is still developing during adolescence, substance use by tweens and teens can permanently damage certain brain functions related to the frontal cortex.
According to ASAM (2011), genetic factors significantly contribute to the probability an individual will develop an addiction. Environmental factors effect certain genetic factors and influence gene expression. There is still much to be discovered about genetic pre-disposition to addiction and other diseases, although great strides have been made.
Addiction is characterized by the following (ASAM, 2011): the inability to consistently abstain, impairment in behavioral control, cravings or increased hunger for drugs or other substances or addictive behaviors, diminished recognition of significant problems, and a dysfunctional emotional response.
The History of Addiction Medicine
Addiction medicine is more widely accepted today than it was in the late 1700s, when the first addiction, alcoholism, was described as a disease by Dr. Benjamin Rush. Dr. Rush was not only a doctor during this time, but he also signed the Declaration of Independence. Alcoholism was not readily accepted by the public as a disease, and it wasn’t until the late 1930s that alcoholism as a disease was widely accepted. Alcoholics Anonymous was found in the 1930s, although during this time, a doctor by the name of William Duncan Silkworth claimed alcoholism was due to an allergic reaction of the body and compulsion of the mind (Smith, 2011).
The modern addiction medicine movement began with the formation of the New York City Medical Society on Alcoholism in 1954 and its recognition of alcoholism as a disease (Ruth Fox, one of its organizers, is considered the founder of the American Society of Addiction Medicine) (Smith, 2011). Narcotics Anonymous was formed in California in the 1950s, because Alcoholics Anonymous specifically excluded those addicted to other substances.
During the 1960s, the drug revolution peaked in the Haight-Ashbury district of San Francisco, near the University of California San Francisco. Dr. David Smith, due to the lack of the City’s planning for the large number of youth arriving, opened the Haight Ashbury Free Medical Clinic, based on principles that health care is a right, not a privilege and that addicts have a right to medical treatment (Smith, 2011). This represented one of the beginnings of addiction medicine and the view that addiction is a chronic disease, just as diabetes or other accepted chronic disease. Addiction is a disease of the brain, just as diabetes is a disease of the pancreas.
The Organization of Addiction Medicine
Dr. Smith’s practice of treating addicts in an outpatient medical center was illegal at the time in the state of California. The California Society for the Treatment of Alcoholism and Other Drug Dependencies was formed in 1972 to advocate for medical specialties in addiction. The following year, in 1973, the California Society of Addiction Medicine was established and incorporated.
During this same time, in part due to the increase soldiers returning from Vietnam with addiction issues, President Richard Nixon formed the Special Action Office of Drug Abuse Prevention (SAODAP) and the National Institute of Drug Abuse (NIDA), as well as the National Institute of Alcoholism and Alcohol Abuse (NIAAA). These organizations provided funding for treating addicts; however, minimal funding went toward enforcing illegal drug laws. This is reversed today, with more funding going to enforcement and less going toward treatment. In 1976, the American Academy of Addictionology was formed by Dr. Doug Talbott. This organization certified physicians who specialized in treating alcoholism.
In 1983, representatives of the American Medical Association (AMA) agreed to organize an addiction medicine organization, which would be called American Society of Alcoholism and Other Drug Dependencies to include all addictive drugs and not just alcohol. This group would eventually be named the American Society of Addiction Medicine (ASAM).
The American Medical Association (AMA), in 1988, granted the American Society of Addiction Medicine a seat, with a vote, in the AMA House of Delegates. In 1990, the AMA recognized addiction medicine as a "self-designated specialty," and has designated a specific code ("ADM') that physicians can select as their specialty, and that will be listed as such in the AMA Physician Masterfile (ASAM, 2011). The first edition of Principles of Addiction Medicine was published in 1994, with updates to follow in 1998, 2003, and 2009.
The U.S. Drug Addiction Treatment Act (DATA) signed into law in 2000 recognizes certification in addiction medicine as a credential that allows physicians to prescribe "narcotic drugs in Schedule III, IV, or V or combinations of such drugs to patients for maintenance or detoxification treatment" (ASAM, 2011). The DATA 2000 act authorizes the use of Schedule III drugs such as Subutex (buprenorphine) and Suboxone (buprenorphine and naloxone, to be used in the treatment of narcotics addiction by qualified physicians in a medical setting (Wesson and Smith, 2010).
A Final Rule issued by the Department of Health and Human Services (HHS) in 2016 increases the number of patients that certain physicians can treat, and board-certified addiction medicine physicians qualify by nature of their board certification to treat the maximum number of 275 patients (ASAM, 2011). In 2008, the Mental Health Parity and Addiction Equity Act was passed, allowing for mental health services in addition to addiction medicine.
In 2009, the American Board of Addiction Medicine awarded its first board certification.
Modern Day Addiction Medicine
In 2011, the ABAM established accreditation for ten residency programs focused on addiction medicine. During this time, the ASAM and NIDA launched a free, nationwide service to help primary care physicians identify and advise their patients who are at risk for substance abuse disorder (Smith, 2011). These organizations established an advisory board comprised of specialists in family medicine, internal medicine and emergency medicine. This board developed peer-to-peer mentorship for early intervention on substance disorders in a primary care setting will be available (Smith, 2011).
Also in 2011, the ASAM released a comprehensive, updated version of the definition of addiction. It was defined as follows (ASAM, 2011):
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
The American Board of Medical Specialties (ABMS), in 2016, officially recognized Addiction Medicine as a medical subspecialty.
The Disease Model of Addiction
Addiction was initially recognized as a strictly criminal condition. Throughout over 40 years, it has gradually become to be recognized as a disease of the brain and its neurochemistry. From Dr. Smith’s first illegal medical center treating addicts in Haight-Ashbury, treatment of addiction has evolved to trained physicians legally administering anti-addiction pharmaceuticals in their offices or in hospitals. Psychosocial therapy is now involved in the treatment of addiction, as is monitoring and long-term patient relationships. The establishment of drug courts and diversion programs acknowledges that the costs of addiction treatment are far less than those of incarceration (Smith, 2011).
The recognition of addiction as a disease has also destigmatized addicts’ perception of themselves as criminal or weak and has made it more acceptable for them to seek treatment at earlier stages of their disease (Smith, 2011). Addition is unique in that those with the disease are encouraged to take responsibility for their actions and with the consequences of their addiction. Established medical care of addicts has improved the identification, early intervention and appropriate referrals for treatment.
The incidence rate for addiction peaks between the ages of 15 and 21. The growing and developing adolescent brain is susceptible to substance abuse disorder, and early use leads to a significantly higher chance the abuse or addiction will continue throughout adulthood. An early addict’s brain does not respond appropriately to emotional, cognitive and social environmental cues, or even to basic survival mechanisms (such as the need for food or water).
Practitioners in the field of addiction medicine have also championed support for physician health programs (PHPs) for the treatment of chemical-dependency, psychiatric, and other well-being issues (Smith, 2011). Although some of these programs have been eliminated recently, there remains the awareness of the effectiveness of these health programs.
American Board of Addiction Medicine
The American Board of Addiction Medicine (ABAM) sets standards and certification requirements for physician education, knowledge and skills. The ABA was established in 2007 to promote the training and certification of physicians in the diagnosis, treatment and prevention of substance abuse or substance-related disorders. Certification by the American Board of Addiction Medicine Stands for the highest standard in Addiction Medicine, and has meant that ABAM-certified physicians have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care (ABAM, 2017).
An ABAM certification demonstrates that a physician has met the clinical and educational requirements to become eligible for such a title, in addition to successfully passing the certification examination.
How to Become an Addiction Medicine Specialist
An addiction medicine specialist is a very demanding occupation, but it does have its rewards as well, when a patient overcomes their addiction and remains sober. An undergraduate degree, medical school and licensing are all required to become an addiction medicine specialist. A fellowship and certification are not required, but they are recommended by the ABAM and ASAM.
Undergraduate Degree
There is no specific major required for an undergraduate program, although medical school requirements should be considered throughout the bachelor’s program. Many aspiring addiction medicine specialists major in a science such as biology or chemistry, while others may choose to major in a social science such as sociology or psychology. Most students take the Medical College Admissions Test (MCAT) around the third year of their undergraduate program.
Medical school acceptance is extremely competitive, so students will want to focus on their academics while also volunteering at a hospital or other medical center, in addition to participating in multiple extra-curricular activities.
Medical School
An accredited medical school typically consists of two years of classroom study and two years of hands-on training. During the first two years of classroom study, students will take coursework in biology, chemistry, anatomy and physiology, among other classes. In addition, basic patient care procedures and reviewed.
The last two years involve performing patient care and hospital rotations under direct supervision of a licensed physician. Hospital rotations allow the medical student to be exposed to various medical specialties, such as internal medicine, pediatrics, cardiology, oncology and many other fields.
Residency Program
Most residency programs are three years in duration. During a residency, the aspiring addiction medicine specialist will begin to practice the skills and training they received during medical school. A residency can be extremely challenging, with demanding hours and various medical situations and patients, in addition to working within a team of licensed physicians. A resident must work a certain number of hours as well as in-service training, teaching conferences and meetings, leadership roles and more.
Most addiction medicine specialists complete their residency in a detoxification unit or a rehabilitation clinic, or some may work within a psychiatry department as well. Most residents work with a mentor in their specialty field of choice to help them navigate the challenges of a residency program.
Fellowship Program
Although a fellowship is optional and is not required for licensing, many future addiction medicine specialists choose a fellowship program to receive additional training and develop expertise in this medical field. A fellowship allows for further specialized knowledge in addiction medicine. This program may include patient care, research and laboratory analysis and other training opportunities.
The ABAM offers accreditation for fellowship programs, which can be found on their website. A physician does not need specialized knowledge of addiction medicine before applying for such a fellowship. All medical specialists may apply for an addiction medicine fellowship.
Licensing and Certification
Each state has their own licensing requirements for addition medicine specialists, although most involve a written examination. A certification may be achieved through the ASAM, and it does require an examination. The ASAM offers conferences and training materials for any physician seeking certification. The courses include substance abuse detection, prevention and treatment by highlighting topics such as neurobiology, identification and screening, treatment referral, medication and many more (Doctorly, 2017).
After certification courses are completed, the addiction medicine specialist has a deeper knowledge and understanding of how substance abuse affects the brain, performing screening and identification of patients, providing counseling, conducting and assessing levels of care and motivating behavioral changes. Addiction medicine specialists must also complete a minimum number of hours of direct patient care, focusing on the education, research, administration and clinical care of the prevention as well as the treatment of individuals who are at risk for or who currently have substance abuse disorders (ASAM, 2011).
Because of the DATA 2000 act, it is also recommended that addiction medicine specialists have a Drug Enforcement Administration (DEA) number (which registers them as an approved distributor of certain pharmaceuticals) and a Buprenorphine waiver in addition to board certification. Many states and certain medical facilities require DEA numbers and Buprenorphine waivers.
Divisions of addiction services in several state health departments (including Florida, Maryland, New Jersey, and North Carolina) require that medical directors of public treatment programs have American Society of Addictive Medicine (ASAM) Certification. Other states such as Wisconsin, recognize American Board of Addictive Medicine (ABAM) and ASAM certification as a measure of physician knowledge and skills to treat patients with addiction and hold clinical leadership positions in state-certified treatment agencies and programs (ASAM, 2011).
Job Prospects
There are more than 20 million Americans struggling with addiction and only approximately 4,400 specialists with the education and training to treat addiction. Addiction medical specialists may work in ambulatory care, acute care, long-term care facilities, psychiatric settings or residential facilities (Doctorly, 2017).
According to ASAM (2011), Some addiction medicine physicians limit their practice to patients with addiction or other patterns of unhealthy substance use. Others focus their practice on patients within their initial medical specialty who have substance-related health conditions.” This choice is up to the physician and how he or she desires to practice medicine – either with a focus on addiction or with a focus on medicine that has a deeper understanding of the issues associated with addictions.
Addiction medicine specialists have a median income around $96,000. Of course, addiction medicine counselors make a lower salary, while addiction medicine psychologists have a higher salary. A counselor does not need a medical degree to counsel patients suffering from addiction. Because of the large number of people suffering from addiction and a small number of addiction medicine specialists, there is much job growth expected for this medical specialty field through the year 2024.
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