Integrating Addiction into Medical Education Margaret M. Murray, PhD National Institute on Alcohol Abuse and Alcoholism U.S. National Institutes of Health 2016 20th International Conference of the Korean Academy of Addiction Psychiatry

Dissemination Science is Part of the NIH Mission Dissemination is the targeted distribution of information to a specific public health or clinical practice audience. The intent is to spread knowledge and the associated evidence-based intervention Research on dissemination addresses how information about health promotion and care interventions are created, packaged, transmitted, and interpreted among a variety of important stakeholder groups. Office of Behavioral and Social Science Research, NIH

Medical Education is part of NIAAA’s Mission NIAAA Mission Statement NIAAA provides leadership in the national effort to reduce alcohol- related problems by: Conducting and supporting research in a wide range of scientific areas including genetics, neuroscience, epidemiology, health risks and benefits of alcohol consumption, prevention, and treatment Coordinating and collaborating with other research institutes and Federal Programs on alcohol-related issues Collaborating with international, national, state, and local institutions, organizations, agencies, and programs engaged in alcohol-related work ***Translating and disseminating research findings to health care providers, researchers, policymakers, and the public   Medical Education is part of NIAAA’s Mission

NIAAA has supported Training of medical school Faculty in fields other than Psychiatry Primary Care Medical School curriculum development Funding of Dissemination Science Grants Funding of Addiction Medicine Fellowships Support of two White House Meetings: Medicine Responds to Addiction

Medical students demand better training to tackle opioid crisis Harvard Medical School students hold out naloxone, that they bought from pharmacies. Courtesy Michael Dykstra

Director, U.S. Office of National Drug Control Policy The nation has seen “no huge change in prescribing behavior” around addictive opioid painkillers, Botticelli said, partly because “there is little to no education within medical education curriculums around addiction and safe prescribing.” Meanwhile, he said, the number of people who die of overdoses in each state is closely linked to how widely doctors are prescribing opioids. Director, U.S. Office of National Drug Control Policy

All Other Causes

Cost and Scope of Addiction Related Problems Alcohol cost changed to $249B to reflect CDC paper published in 2015 that estimated costs for 2010. Per NSDUH (SAMHSA survey): AUD prevalence in 2014 was 16.3M for age 18 and older, and 17.0 for age 12 and older. NCI: The number of people living beyond a cancer diagnosis reached nearly 14.5 million in 2014 and is expected to rise to almost 19 million by 2024. NCI: National expenditures for cancer care in the United States totaled nearly $125 billion in 2010 and could reach $156 billion in 2020. Sources: Prevalence – NSDUH (2014), NCI (2014), CDC (2012); Cost – CDC (2015), National Drug Intelligence Center - National Drug Threat Assessment (2011), 2014 Surgeon General’s Report, NHLBI (2012), Hutchinson et. al. 2006.

Key Findings Addiction is a chronic, relapsing brain disorder with potential for recurrence and recovery Addiction involves a three-stage cycle that becomes more severe with continued substance use: binge/intoxication stage withdrawal/negative affect stage preoccupation/anticipation stage The cycle is associated with dramatic and persistent changes in three principal brain regions: basal ganglia extended amygdala prefrontal cortex

Primary Brain Regions Involved in SUDs Basal ganglia: controls the rewarding, or pleasurable, effects of substance use (nucleus accumbens); responsible for the formation of habitual substance taking (striatum) Extended amygdala: involved in stress and the feelings of unease, anxiety, and irritability that accompany withdrawal Prefrontal cortex: involved in executive function—the ability to organize thoughts and activities, prioritize tasks, and make decisions—including exerting control over substance use

Key Findings Disruptions in these brain regions: enable substance-associated cues to trigger substance seeking (i.e., they increase incentive salience) reduce sensitivity of brain reward systems and heighten activation of brain stress systems reduce functioning of brain executive control systems, which are involved decision-making and regulating actions, emotions, and impulses Brain changes persist long after substance use stops; it is not known how much these changes may be reversed or how long it takes Adolescence is a critical “at-risk period” for substance use and addiction All addictive drugs have especially harmful effects on the adolescent brain, which is still undergoing significant development

Addiction Involves Multiple Factors DEVELOPMENT/Genes John Smith James Smith Ann Jones John Jones Mary Hill Walter Jones James Hill Susan Adams Alice Price Thomas Jones William Price Richard Hill Steven Adams Allison Fields Mary Walters Alice Benson Rebecca Wilson ThomasSmith EdwardSmith AnneCook JaneWalker John Walker JaneJones Susan Edwards JamesCook Beth Bryson JonathanCook Edward Bryson Amy Mason Beth Carter ENVIRONMENT Addiction DRUG Brain Mechanisms

ADDICTION CAN BE TREATED Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence 3 ml/gm Normal Control METH Abuser (1 month detox) METH Abuser (14 months detox) Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

Pre - - Post During Pre - - - - - - - - - - - - Post Evaluation of A Hypothetical Treatment 10 HYPERTENSION 9 8 Pre - - Post During 7 6 Symptom Severity 5 4 3 2 Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care 1 Pre During During During Post 10 ADDICTION 9 Pre - - - - - - - - - - - - Post 8 7 6 Symptom Severity 5 4 3 2 Source: McLellan, AT, Addiction 97, 249-252, 2002. 1 Pre During During During Post Stage of Treatment

Medical Treatment for Addictions For Nicotine Addiction Nicotine Replacement Therapies (NRT) Bupropion Varenicline Currently 19,000 physicians are certified to prescribe bphine (Source: CSAT Buprenorphine Information Center) For Alcoholism Disulfiram Naltrexone Acamprosate Naltrexone ER Opioid Addiction Methadone Naltrexone ER Buprenorphine

Why does America Needs physicians who are trained and credentialed in Addiction Medicine?

Receipt of Specialty Treatment in Past Year Adults 18 or Older Who Needed Substance Use Treatment in the Past Year: 2015 NSDUH

President Barack Obama National Prescription Drug Abuse and Heroin Summit Atlanta Georgia -- March 29, 2016 “……we need to recognize that addiction is a disease.   If we treat addiction like a crime then we're doing something that’s …….ineffective. …. taking parity seriously so that mental health issues and addiction issues are treated as a disease in the same way that if somebody came in with a serious medical illness that it’s treated” “What are we doing to address the lack of effective, non-opioid treatment for chronic pain?”

Out of 183 U.S. Medical Schools, 61 schools signed the pledge that President Obama requested. The pledge asked that all general medical students be taught the guidelines developed by the U.S. CDC in using care to prescribe opiate pain medication. In refusing to sign, the Dean of Harvard said, ““We don’t agree with the idea of taking pledges with what to put in our curriculum,” Dean Dr. Jeffrey Flier said in an interview last week. If Harvard started doing that, “I don’t see what would limit the number of groups going through, telling us what to put in our curriculum,” he said, “which would be the death of higher education.”

Two Pathways to Addiction Medicine in the U.S. ABAM Certification open to all recognized medical specialties. Training Exam Addiction Psychiatry as a subspecialty certified by the American Board of Psychiatry and Neurology. Residency Exam Two Pathways to Addiction Medicine in the U.S.

Huge growth in physician interest and certification in the last 23 years (2015: applicants) 21

The American Board of AddictionAmeriMedicine (ABAM) Established as an “Independent” medical board in 2007, 1st exam in 2008 Primary Goal: ABMS recognition Multidisciplinary subspecialty & Board of Directors: Emergency medicine, family medicine, internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, surgery Current status: > 3900 ABAM diplomats 46 Addiction Medicine fellowship programs Plans for 65 programs for 2020, 125 by 2025 American Board of Addiction Medicine (ABAM)

The House of Medicine American Board of Medical Specialties - ABMS (certifies physicians as specialists) 24 ABMS Member Boards For example: Internal Medicine, Family Medicine, Pediatrics, Geriatrics, OB/GYN, etc. Accreditation Council for Graduate Medical Education -ACGME (accredits the training of physicians) With ABMS and ACGME taking on physicain certification and fellowship accreduitation, ADM passes into maturity and becomes part of physician training and health care practice nationally.

Addiction Medicine: A New Subspecialty! Obama next.

Accreditation Council for Graduate Medical Education ADM recognition June, 2016. Process for accreditation of ADM fellowships underway ADM Residency Review Committee Program Requirements, Milestones July, 2017: First ADM ACGME cohort

Addiction Medicine

Continuum of Medical Education and Training Maintenance of Certification Continuing Medical Education 25 Hours per Year -- 10 Years Exam Exam 8 Years 6 Years Exam 4 Years 2 Years This is how American medicine responds to a special problem. Cardiology example. Fellowships in cardiology drive teaching, research and practice. They also becopme centers of excellence. There are 85 subspecialties recognized for which ACGME accredited training and ABMS certification is available. And now ADM has joined….

Why are Addiction Medicine Fellowships Needed? Fellowships produce expert clinicians, change agents, and faculty and content experts for medical students and residents Health care teams, administrators and others need access to ADM expert physicians Expands acceptance of SUD prevention and treatment

Key Elements: Clinical Rotations

183 Medical Schools: 46 ADM Fellowships KEY Medical School ADM Fellowship

125 ADM Fellowships by 2025 KEY Medical School ADM Fellowship

Kamsahamnida! 감사합니다