Yet, the addiction psychiatry programs currently produce only 20-40 subspecialists annually, and the addiction medicine fellowship adds another 20-30 per year, leading to a shortfall of 30-60 physicians, according to a 2011 analysis of addiction medicine programs by Dr. Blondell and his colleagues. (Substance Abuse 2011;32:84-92).
"There’s an enormous population and not enough doctors," said Dr. Stuart Gitlow, acting president of the American Society of Addiction Medicine, the professional organization for addiction medicine specialists, which established ABAM in 2007.
Applicants to addiction medicine programs come from a wide range of backgrounds. Some are fresh out of a residency; others are midcareer. Dr. Blondell estimated that roughly 40% of fellows come from psychiatry, 25% from family practice, 25% from internal medicine, and the rest from a wide range of backgrounds, including ob.gyn., pediatrics, and surgery.
Some of the addiction medicine programs run in close collaboration with the addiction psychiatry residencies, and some say that there are benefits to having the two groups of residents side by side.
Boston University’s addiction medicine residency modeled itself after the existing addiction psychiatry residency. "We have a good relationship with the university’s addiction psychiatry residency," said Dr. Alford. "It was really critical for us to sit down with addiction psychiatry and figure out how to put it all together."
There’s overlap, but there are also significant differences between addiction medicine and addiction psychiatry. While addiction medicine specialists focus more on the medical treatment of patients with medical and/or surgical comorbidities, addiction psychiatrists tend to focus on the treatment of coexisting mental illnesses.
"The whole subspecialty is so young that we don’t have much experience on how this will play out," said Dr. Petros Levounis, chief of the division of addiction psychiatry at St. Luke’s–Roosevelt Hospital Center in New York. "Eventually, it will be clear who the patient needs to go to," he said, adding that for starters having medical vs. psychiatric comorbidity could serve as a designating role.
Under the ABAM accreditation, the addiction medicine training should have four components: training in inpatient settings; training in outpatient settings such as residential programs; program-specific training depending on the region and nearby facilities; and electives, which are based on the physicians’ backgrounds. "So, at the end of the year, they all will have similar knowledge, although they come from all sorts of backgrounds," Dr. Blondell said.
Despite the obvious need for an addiction medicine subspecialty, Dr. Friedmann added a note of caution.
"I think we have to be mindful that creating a subspecialty is not a substitute for physicians and other providers developing greater knowledge and skill in the addiction field," he said. "There are too many patients. We’re not going to be able to train enough specialists to treat all those folks. The general medicine field needs to accept that these are legitimate medical conditions for which they should take responsibility."