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The unhooked.com science section contains selected educational readings from the scientific and popular literature about alcoholism, addiction, and recovery. The views expressed in the articles are those of their authors and not necessarily those of the science pagemaster or the webmaster or of the person who suggested the article to the list. This material is made available solely for the nonprofit educational use of unhooked.com readers as an aid in their personal recovery, and no other use is authorized or intended. Click here for the current Science Section reading list.
Authors: John T. Pichot, MD, Luz Starck, MD, John T. Harris, MD, Texas Health Science Center at San Antonio; Jeffrey M. Benzick, MD, US Air Force Wilford Hall Medical Center
Abstract: Addiction psychiatry physician residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) began training the initial group of residents in July 1996. We review addiction psychiatry subspecialty issues, primary goals of addiction psychiatry training programs, and requirements and examination schedules from the American Board of Psychiatry and Neurology for Added Qualifications in Addiction Psychiatry. Included is a list of Internet links to the 13 US medical schools that are affiliated with ACGME-credentialed Addiction Psychiatry Residency programs and to addictions-related World Wide Web sites to assist clinicians, patients, and families. [Medscape Mental Health 2(7), 1997. © 1997 Medscape, Inc.]
The field of addiction medicine has become an increasingly complex area. This fact is reflected by the National Institutes of Health having 2 major divisions--the National Institute of Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse--that focus on research related to basic sciences, clinical sciences, and health care policy issues regarding substance use in this country. Addictive behaviors occur at an extremely high cost to our society due to medical, legal, and work-related expenses. Arguably, when you combine all cases of trauma, cancer, infectious disease, and other medical disorders that are either directly or indirectly associated with the use of drugs and alcohol, substance use is the nation's number one health problem. Furthermore, this high rate of substance-use-disorder comorbidity with other psychiatric and medical disorders makes addiction psychiatry a particularly complex field. A great deal of knowledge is required to provide adequate treatment for people with substance-related disorders.
Several organizations laid the foundation for the recognition of addiction medicine in general, and addiction psychiatry in particular, as clinical subspecialty areas. These include the American Academy of Addiction Psychiatry; the American Society of Addiction Medicine; and the Association for Medical Education and Research in Substance Abuse.
The final steps for formal certification status required the support of the American Psychiatric Association (APA) and the American Board of Psychiatry and Neurology (ABPN). The ABPN created the new certification category of "Added Qualifications" to recognize psychiatrists with expertise in this subspecialty. Addiction psychiatry was granted this status in 1993. However, the process of obtaining subspecialty status was not without controversy, and several areas of conflict remain.
Many have expressed concern about the implications of increasing the number of subspecialty areas within psychiatry. This topic was the focus of a recent panel discussion among current and former members of the ABPN at the APA's 1996 Institute on Psychiatric Services.[1]
The arguments against subspecialization within psychiatry focus on potential harm to the role of the general psychiatrist. Kenneth Altshuler, MD, immediate past President and former Director of the ABPN, stated that the core of general psychiatry is being diluted by subspecialties and by managed care, and therefore, the APA should refrain from advocating the recognition of new subspecialties. He suggested that if general psychiatry loses psychotherapy, medication visits, geriatrics, addictions, forensics, and consultation-liaison psychiatry, what remains will be too narrow a specialty to practice.[1]
In regard to addiction psychiatry, Altshuler also argued that the 5-year deadline to meet the ABPN's requirements of 25 accredited programs and 20 graduating candidates per year will arrive in 1998. He also noted that addiction psychiatry in 1996 had 9 accredited programs and 14 graduating candidates for June 1997. Since the 1996 meeting, 4 additional programs have been accredited, making a total of 13 programs that have achieved Accreditation Council for Graduate Medical Education (ACGME) status as of March 1997. Dr. Altshuler also commented that a lack of funding for residency positions, including the reduced federal funding for subspecialty training, with the exception of geriatrics, has been a primary problem for the development of addiction psychiatry programs.[1]
Dr. Sheldon Miller, an ABPN Director and Chair of the Residency Review Committee for Psychiatry and consultant to the APA's Committee on Training and Education in Addiction Psychiatry, took a position in support of addiction psychiatry. Although he agreed that additional subspecialty categories should not be developed beyond addiction, consultation, forensics, and geriatrics, Dr. Miller disagreed with Dr. Altshuler's explanation of why addiction psychiatry had not yet reached its goal of 25 accredited programs as of 1997. He stated that although funding is an issue, it is also a fact that general psychiatry department chairs and program directors have not been aware of many of the developments in the area of addictions.
According to the report, Dr. Miller attributed this lack of awareness about psychiatrists working in addictions to their being considered "outsiders" in their departments. He further indicated that this isolation from general psychiatry is one of the reasons that addiction psychiatry is needed and will continue to be needed as a subspecialty. Addiction psychiatrists are not immune from the same stigma that has tracked addiction problems in patients and those who have been working in the addiction field. Miller further argued that the subspecialty of addiction psychiatry was not a threat to the core of psychiatry because the goal is to develop a cadre of teachers and experts to help general psychiatrists take care of these difficult-to-treat patients. He also added that about 1000 psychiatrists have been certified with Added Qualifications in Addiction Psychiatry through the initial period of practice pathway (ie, grandfathering of experienced clinicians without formal training) and successful completion of the written ABPN Added Qualifications Examination. However, Miller also noted that based on the fact that 14% of the general population has problems with addiction, more specialists will be needed to address this major clinical area in the future.[1]
One additional point is that other specialties are looking to develop advanced training programs to achieve formal specialty status as discussed below.[2] What are the implications for psychiatry if other medical specialties succeed in developing training programs and board certification status to treat patients with addictions?
The other major area of controversy related to practice in addiction medicine is the current inability of physicians who are not psychiatrists to obtain an official certificate of added qualifications from specialty medical associations. There has been a written certification examination available through the American Society of Addiction Medicine (ASAM) since 1986; recertification is required every 10 years. However, ASAM certification does not confer board certification because ASAM is not a member of the American Board of Medical Specialties.[2] In 1996, 148 physicians passed their initial ASAM certification exam and 134 physicians passed their recertification exam.[3]
A recent American Medical Association (AMA) resolution requested national medical specialty societies of emergency medicine, family practice, internal medicine, pediatrics, preventive medicine, and others to determine the desirability and feasibility of having training available that would lead to the development of certificates of special qualifications in addiction medicine.[4] The AMA Board of Trustees was asked to report on the response to this resolution from the specialty societies at the 1997 Interim Meeting of the AMA House of Delegates.
Despite these controversies, the process of physician education and certification in addiction psychiatry is ongoing. One of the major concerns noted above was a lack of information regarding the status of addiction psychiatry training among general psychiatrists; we believe this overview will help address this problem.
The ACGME Residency Programs in Addiction Psychiatry are 1-year programs (post-general psychiatry training) that focus on clinical care. Resident physicians are taught not only the diagnosis and treatment of a wide range of substance-use disorders, but also how to treat dually diagnosed individuals with complicated coexisting psychiatric disorders.
Goals of addiction residency training programs. The 1-year clinical training programs are designed to follow the specific ACGME Program requirements for Addiction Psychiatry.[5]
The following summarizes the clinical work, skills, and education required during the 12-month residency:
Additional information relevant to addiction psychiatry addressed during the residency should include the following:
Specific departments of general psychiatry that have developed ACGME-approved addiction psychiatry residency programs include the 13 programs listed in Table I.
A new issue in the residency training program is the potential use of the Internet as a resident recruitment tool.[6] Review of the links listed in Table I showed that individual addiction psychiatry residency training programs have much work to do in building Web sites that support recruitment; nevertheless, the infrastructure to produce Web sites is available at all 13 of the affiliated medical schools on the list. Although currently there is limited information at these linked Web sites that is specific to addiction psychiatry training programs, there is substantial available information about the medical schools, and in some cases the departments of psychiatry, with which these programs are integrated.
Additional information about ACGME Addiction Psychiatry Residency Programs is available through the AMA's Fellowship and Residency Electronic Interactive Database Access (FREIDA) System.[7]
The ABPN published a memorandum and schedule in October 1996 providing information about board-certification testing through the year 2000.[8,9] The last written examination that may be taken without completing any formal addictions training, either a non-ACGME or an ACGME program (ie, the practice pathway), is scheduled for April 7, 1998. The regular application deadline for the April 1998 examination is September 1, 1997 and a second "late" application deadline, which will require an extra fee, is October 1, 1997.
After that examination, the next scheduled examination will be on April 4, 2000. The application deadline is September 1, 1999, and the "late" application deadline is October 1, 1999. Proof of successful completion of formal addictions training (either a non-ACGME or an ACGME program) will be required to take the examination. All examinations given after the year 2000 will require proof of completion of an ACGME-accredited addiction psychiatry residency.
In addition to the aforementioned practice or training program requirements, the physician must attain ABPN General Psychiatry Board Certification prior to taking the Added Qualifications in Addiction Psychiatry examination. Further information about the certification process can be obtained from the ABPN at: 500 Lake Cook Rd., Suite 335, Deerfield, IL 60015, 847-945-7900.
The Added Qualifications in Addiction Psychiatry status is valid for 10 years. After the 10-year period, the physician must successfully complete a recertification examination to maintain board-certified status.
In addition to these new developments in certification and training in the field of addiction psychiatry, the Internet is a rapidly developing and valuable clinical and educational resource. Table II provides some excellent Web sites that are related to addiction psychiatry, which will assist practicing clinicians, patients, and their families.
The field of addiction psychiatry is quickly evolving in terms of continuing developments in board certification for physicians interested in practicing in the field, new training programs, and information resources available via the Internet. We have attempted to provide an overview of some of these new developments and, more importantly, information links that will allow readers to keep up-to-date.
Dr. Pichot is Director and Dr. Starck and Dr. Harris are Addiction Psychiatry Residents at the University of Texas Health Science Center at San Antonio. Dr. Benzick is a Resident at the US Air Force Wilford Hall Medical Center General Psychiatry Residency Program, Lackland Air Force Base, Tex. The views expressed are those of the authors and are not US Air Force policy or the policy of any other Department of the Federal Government.
Table II Internet Sites Related to Addiction Psychiatry
