Charting the Way: Advancing the Field of Addiction Medicine

The addiction workforce faces many challenges, from limited capacity to meet the growing demand for treatment services to inadequate financial and professional incentives to enter and remain in the workforce. As a result of these challenges, individuals with substance use disorder experience disparities in care compared to those with a physical ailment. In this third and final episode of the Charting the Way podcast miniseries, Abt’s Leigh Fischer and Mt. Sinai’s Tim Brennan discuss opportunities to advance the field of addiction medicine, integrate approaches across physical and behavioral health, and unify the workforce to better prevent and address substance use disorders.

Sign up for monthly podcast e-mail notifications here. Listen to episode 2 here and episode 1 here.

Read the Transcript

Eric Tischler: Behavioral health challenges, notably substance use and mental health are more prevalent than ever, but the workforce is shrinking even as the need for equitable services grows. How did we get here? How can we turn the tide and how can we incorporate social justice into those efforts? We're taking one more to look at these issues in this last episode of the Charting the Way podcast mini series.

I'm Eric Tischler from Abt Associates. And joining me today are my colleague Leigh Fischer and our guest Tim Brennan, M.D. Tim is Vice President for Medical and Academic Affairs at the American College of Academic Addiction Medicine. He's also the Director of the Addiction Institute at Mount Sinai West and Mount Sinai St. Luke's Hospitals, and the Program Director of the Fellowship in Addiction Medicine Program at the Icahn School of Medicine, Mount Sinai in New York City.

Leigh is a Senior Associate at Abt where she works with clients such as SAMHSA and the Hilton Foundation to address social determinants of health, promote mental and physical wellbeing and integration of services and systems to improve outcomes for children, youth, and families. Her work focuses on mental health and substance use policy, research and implementation.

Welcome.

Leigh Fischer: Thanks Eric. It's great to be here.

Tim Brennan: My pleasure. Good to be on with you. And thanks for this opportunity.

Eric: Today, we're going to discuss the state of addiction medicine treatment so, Tim, can you explain how you differentiate addiction treatment from care for other health challenges?

Tim: Sure. Thanks, Eric. And thanks Leigh, for this opportunity to join you. I oftentimes like to compare addiction treatment to the care of a heart attack. Right now, right this very moment, if any of us on this podcast were to walk into an American emergency room, whether that be in Los Angeles, New Orleans, or here in New York City, and we were to complain of crushing chest pain that was radiating over to our left shoulder, we would all get essentially the exact same workup. We would get the exact same types of medications. And to be clear, we would see a board-certified cardiologist, no matter what emergency room we went into. The care has been honed through decades of peer review journals. It's been discussed at medical conferences and it's very homogeneous and algorithmic.

At the same time, if any of us, this afternoon, were to go into an emergency room in Los Angeles, New Orleans, or here in New York and complain of opioid withdrawal or alcohol withdrawal, the sad reality is that we would get very different care depending on where we went into the hospital. In some emergency rooms, there might not even be an addiction medicine doctor like myself that's available for consultation. Some emergency rooms may call a social worker, and that's not to say something's wrong with social workers, but we very much consider addiction to be a medical illness that should be treated by physicians. And so I say that because, when I think of the disease of addiction, I'm very comfortable defining it as a medical illness, but I very much want patients to have access to the same evidence-based medicine that they have when they go to the emergency room and are complaining of chest pain. So that's our goal. It's a lofty one, but I think we're headed in the right direction.

Eric: So Tim, you just mentioned a variety of responses. Now, obviously substance use is not a new issue, so why has developing a stronger workforce to tackle substance use and related concerns been so challenging?

Tim: I think it's helpful if we go back 50 or 60 years in American organized medicine, to be honest. If you grew up in the ‘50s and ‘60s, there was definitely addiction. There were many people that were suffering from alcohol addiction, but they didn't tell their doctors about it. It was talked about in hushed tones and people were not comfortable thinking of addiction as a medical disease. And for that reason, physicians didn't treat addiction. There were a few of them, but for the most part, it was considered a moral failing. And we, of course, know that that's not the case, but that's what it was considered. And so we did not have any workforce of trained physicians who were specializing in treating the disease of addiction. And because of that, addiction treatment took place outside of the traditional walls of organized medicine. I mean, outside the hospital, it was treated in mostly community level self-help groups, things like Alcoholics Anonymous and others. And the only qualifying credential one needed to treat somebody with addiction was perhaps having overcome their own addiction. And there's a really wonderful and rich tradition of that type of self-help in our field, but it was not part and parcel of organized medicine.

And then thankfully in the ‘90s and early 2000s, physicians started to organize around this idea of becoming a medical specialty. And thanks to some pioneering physicians in the American Board of Addiction Medicine, we were finally able to become a member of the American Board of Medical Specialties, which has allowed us to describe the work we do and has allowed us to treat addiction here in the hospital with the same evidence-based medicine that we use for other conditions.

And so now we have a workforce that needs to be filled. We've created this specialty, we're recognized by the ABMS. We have fellowships that are accredited by the ACGME, but we have to figure out a way to convince physician trainees to come into this wonderful specialty. So that's the task before us.

The question really is who should be treating addiction? And I feel very strongly that physicians of all backgrounds should be treating addiction, whether it be pediatricians, internists, family medicine doctors, and so on. But with these fellowships, we now have one-year training opportunities for all of those physicians to come and receive subspecialty fellowship level training in addiction medicine so that they can augment their own practices and be able to treat addiction in all of their patients.

Eric: But Lee you want to talk about some of the challenges you've been seeing in building this workforce?

Leigh: Tim mentioned for so long, I think, individuals with a substance use concern or disorder were considered to have a moral, it was a moral issue or it's a criminal justice problem, and that's how we treated it. And so we, I think, as a general field, we've come a long way in recent years to recognize that addiction is a medical condition. It is treatable. We have evidence-based interventions. We have recovery support. We have integrated systems of care now where we have highly trained behavioral health providers and medical providers working hand in hand to help individuals who have substance use disorder. And yet in my work, I've traveled a lot around the State of Colorado, I am a Coloradan and I live and work from Colorado. And I have spent a lot of time working with hospitals and primary care offices and community health centers doing training and providing technical assistance around, “How do you screen for substance use concerns? How do you have conversations with patients around reducing their risk related to substances? How do you make effective referrals to evidence-based care treatment?” And we still hear that, "Oh, we don't have that problem here. Our patients don't have that problem. It's not our job to address those issues."

So, while we've come a long way, I just wanted to recognize that the stigma still exists. And we have a lot further to go in order to train up the workforce and help professionals across the board understand the key role that they can play in addressing this issue. So, Tim, I know we've talked about this before and in past conversations that the workforce really has been relatively siloed and there are different groups of providers. And there's also a lot of, I think, question and concern around who owns what part of the treatment field I would say, and whose role is it to provide that care. And I think we could move forward together if we start to have conversations together and say, “We need to tackle this as a community of providers and take a more multi-disciplinary approach to work together, to help individuals and families.”

Tim: Leigh, that's a really good point and I'm glad you raised it. There's an often-utilized concept in addiction medicine, which is a sad one, and that's of the patient essentially becoming a bit of a hot potato. And what I mean by that is it's somebody who's interacting with different types of healthcare providers, different parts of the healthcare system, and no one provider, no one center is willing to really take ownership of that patient. And when you think, for example of the disease of opioid use disorder, these folks frequently find themselves in pain management offices or emergency departments, or God forbid, the back of a police car. And so you can imagine that, as they pass through the health system, they're not necessarily doing so in a manner that we would want them to. And because of that, that perpetuates the stigma about who actually is treating these patients and who's taking ownership for their coordination of care.

So I'm sure all medical specialties consider themselves interdisciplinary. I think that's uniquely true in addiction medicine--physicians are just one part of the addiction care team. I'm proud to say that on our team here in the hospital, there are social workers, substance abuse counselors, licensed mental health counselors, nurses, of course. And then folks with lived experience, “peers” as they're known, which are really an invaluable member of our team.

Leigh: I think there's been more of an effort over the last 15 years or so to train a variety of health professionals in how to identify and address substance use issues. I know that SAMHSA had a very large initiative under their SBIRT portfolio, SBIRT is Screening, Brief Intervention, and Referral to Treatment for substance use. It's been a long-standing program at SAMHSA, and SAMHSA invested funding into health professional training programs so that a variety of health professionals, including medical students and residency programs, psychology students, school of nursing and social work all would have the opportunity to integrate curriculum around identification and treatment for substance use disorder into their programs for students. So these types of opportunities have existed now for a while. But again, I don't know that there is to this day anything that's more systematic.

I've heard time and time again that the average medical student only receives about three hours worth of education around substance use prevention and intervention while in medical school. And it's just not enough considering that substance use is one of the leading causes of preventable death in the United States. So there's a lot more that we need to do to educate the workforce across the board.

The Hilton Foundation for the past six years has been investing in health professional training around identifying youth substance use. It's often said that addiction is a pediatric disease. And so there's more that we need to be doing to identify risk earlier on in young people's lives and to intervene with youth in order to prevent addiction in adulthood. And so the Hilton Foundation has funded training programs, including with the American College of Academic Addiction Medicine, that NORC has had funding to provide training and education to nursing schools, social work programs. And Abt Associates has served as the cross-grantee evaluation and learning partner with the Hilton Foundation on this effort. So we've had the opportunity to work closely with these grantees and to understand the progress that's been made in training countless residents and nursing students, social work students over the past six years.

Eric: That's great, because I think the next question would be then, we're making progress, what can we do to further advance this workforce? “This is what we're doing, we're starting to turn the ship ...” I'll say, how do we turn the afterburners? But I'm mixing my vehicle metaphors. What more can we be doing? How do we accelerate in the future?

Tim: Yeah. If I could maybe take a stab at that, Eric. I mean, as Leigh mentioned, getting time in front of medical students is really challenging. Most medical schools do this, spend the first half of the medical school experience, the first two years doing classroom-based didactic instruction. And then the second two years, of course, on the wards, learning about how to actually practice medicine, practice surgery. It turns out those two years are, as you would imagine, pretty packed at the, and I'm talking about the front two years. And so when you want to add in curriculum at the undergraduate medical education level, it stands to reason that something has to go in order to add on some lecture material. And so Leigh's right, the reality is that most medical students get three or four hours of addiction training throughout their medical education.

The problem is that when you look at the types of diseases encountered by people, once they're done with their medical education, it's totally different than what they may have learned about in medical school. That is, they may have spent hours and hours learning about syndromes and conditions that they may never see. We now know that substance use disorders account for an incredible amount of routine primary care visits. When you look at the sequella of substance use disorders, and just how many organ systems are impaired by things like alcohol use disorder or tobacco use disorder, it stands to reason that the medical schools should be spending a lot more time in training physicians about treating, about first screening for addiction, recognizing it, and then treating it. So it is something that we're working on. I would say the good news is that the medical schools want to change, the challenge before us is how we tweak those curriculums so as to make sure people aren't losing valuable material because of the increase in addiction time that they might be getting.

Eric: Lee, how about you? What are you seeing as things we can do to accelerate the growth of this workforce?

Leigh: I think there's a lot that we could be doing. One thing I just want to mention, again, it's the more we can do to normalize conversations around substance use and to talk about substance use disorder as a preventable illness that you can intervene, you can treat, people do recover. I think that goes a long way to say, okay, this is not something that needs to be hidden. We don't need to be secretive about this. We can have conversations and that you, as a patient of primary care practice or walking into a hospital, expect to be asked about your substance use. You expect that that is a part of your full health and wellbeing picture. So that's just one piece I wanted to mention, that I think that's an important step. And that health providers start to understand that they can do something about it, they can help individuals cut back, reduce their use, treat their disorder.

I think we also need to do a lot to help incentivize individuals to do this, to want to join the behavioral health workforce and to help them to stay in the workforce. We all know that reimbursement rates are typically quite low for doing this work. And so I think we need to, as a systemic level, think about increasing reimbursement rates and finding other ways to incentivize providers, to provide evidence-based treatment. And in thinking about building the incentives, also building a pipeline for students from diverse backgrounds to, again, want to enter this workforce and stay within this workforce. We know that typically this, traditionally this field has not been very diverse and that we have a long ways to go to bring in individuals from communities of color to provide substance use disorder care.

And then the other point I wanted to hit upon a lot of the work that Abt Associates does with our federal agencies, including the CDC, HRSA, the Agency for Healthcare Research and Quality is around quality improvement. And so, if we provide trainings to the workforce, it needs to be in an ongoing way. And we need to be able to have measures in place to monitor progress, to monitor patient outcomes. And I think the more that health professionals see improvements in their patients, and they can actually see the data and they hear the stories and they share the stories, improvements, the more likely it is that their peers or more providers around them will also want to be addressing substance use concerns.

Tim: Lee, I'm really glad you brought that up. And if I could make a follow-up point, there's almost a financial, some perverse financial incentives to patients, sick patients remaining sick in a fee for service model. And if you conceive of a patient with lung cancer, you can imagine just how high the reimbursements are for treating somebody with lung cancer. You oftentimes perform surgery upon them, all sorts of radiologic bills related to CAT scans and MRIs and PET scans and so on, chemotherapy, radiation, et cetera. It's a very expensive endeavor to care for somebody with lung cancer. But when you unpack the reason why that person perhaps developed lung cancer, and you talk about tobacco use disorder, there's really no incentive for the primary care physician 20 years earlier to have screened for tobacco use disorder, intervened upon it, and prevented all of that healthcare spend later on in that patient's life.

And so I think one of the exciting things about a possible pivot to wide-scale value-based care is we could see some of those incentives start to move upstream, if you will. And we can start to incentivize physicians for keeping their patients healthier and doing perhaps what some might consider to be less glamorous work and simply sitting with somebody and counseling them about the dangers of tobacco use so that they never end up developing that cancer, which causes so much spend 20 years later.

Leigh: Tim, we spend a lot of time thinking about this at Abt Associates and talking about the point that you just made and would love any opportunity to evaluate this type of work. We do a lot of work around quality improvement, developing quality measures with health systems, helping systems move upstream and working with our federal government clients around value-based payments and alternative payment models. So yeah, we would love to do more to investigate that approach.

Tim: So, Lee, you mentioned diversity in our field and the reality is we have two challenges ahead of us in addiction medicine fellowships. Number one, we have now 83 ACG in the accredited addiction medicine fellowships across America. And they're in very diverse geographic settings and take care of diverse communities. One of our goals, of course, is to make sure that all of those fellowships are filled year in and year out. And so we're facing a challenge of making sure that physician trainees, who are in their residencies, be that in pediatrics medicine or family medicine, know that we exist as a field. And so getting exposure, trying to get the word out that these addiction medicine fellowships are available for physicians from any specialty is really important for us. These are one year fellowship programs that can really be a wonderful way for physicians from any background to differentiate themselves in the healthcare marketplace.

Just as important as filling our fellowships, though, is making sure that we're graduating a diverse workforce that represents America and represents American addiction patients. America has a rather sordid history when it comes to addiction treatment and certainly when it comes to the way that laws related to the horrible disease of addiction have been prosecuted. And so at Icahn, we are very committed to expanding our workforce and making sure that it better reflects the heterogeneity of America. And so, with that in mind, we're very much looking forward to partnering with historically Black colleges and universities across the country so as to help make them aware of our specialty. Likewise, with graduate medical education programs that have a specific focus on underrepresented minority patients, we look forward to partnering with them as well.

Leigh: And Tim, you probably know more about this because I'm sure you've been having internal discussions as an organization, but the American Rescue Plan that passed in March allocates $100 million in funding for behavioral health workforce education and training opportunities. And it's yet to be seen what will come of that money or what that will actually look like, but it's sounds like there might be great opportunity ahead to come up with a unified approach where we're developing standards and competencies and, again, multi-disciplinary approaches to address workforce needs.

Tim: I sure hope so Lee. I mean, I think when you look at the rescue plan, you do see this profound commitment to helping to support workforce training. Just like we educate physicians and nurses and physician assistants in other disease conditions, we should do the same in addiction medicine in that we are explaining the disease as a disease, and we're explaining the evidence-based medicine in a very heavily protocolized template. All graduates of medical schools know exactly what to do for a heart attack. We know what to do for an opioid overdose, we know what to do for alcohol use disorder, but we're not graduating trainees that know exactly how to treat those conditions. And so we need to collaborate across nursing schools, medical schools, social work schools, so that that entire workforce is actually learning the same material. And only then I think, can we really start to see improvements in the quality of care for the disease of addiction,

Leigh: Tim, I know that your organization, that Icahn has really been leading this charge in many ways over the past several years. You've had several meetings where you've brought together just healthcare decisionmakers, leaders from medical schools, the federal agencies to be having these discussions. So now seems like the time to advance a national plan, a strategy for actually creating change moving forward.

Tim: The spotlight has never been brighter upon the disease of addiction. Now, tragically, of course, it's the opioid crisis that has really brightened that spotlight. But the good news is that, as a country, we're finally talking about this condition that, of course, includes federal leaders and legislators. And so there's a lot of good intention out there, how we take the next step, how we come together collaboratively is before us now. And I think we're up for the challenge.

Eric: Great. Well, I think ending by talking about looking upstream seems like a pretty good place to bring this series to a close. Thank you both for joining me.

Tim: Thanks Eric.

Leigh: Oh, thanks so much, Eric. And thanks so much, Tim for joining us. It's always great to have these discussions with you.

Eric: And thank you for listening to this Abt podcast.