Medicine Responds to Addiction II

Medicine Responds to Addiction II


June Sivilli: As we begin
our next session, A Model Approach to Addiction
Medicine Education, I’d now like to welcome to the
podium Dr. Kevin Kunz, who serves as the Executive
Vice-President of the Addiction Medicine
Foundation. Through Dr. Kunz’s
leadership, the Addiction Medicine Foundation has
greatly helped advance the addiction medicine in
medical schools through the establishment of addiction
medicine fellowships. Dr. Kunz, I turn
it over to you. Dr. Kevin Kunz:
Good morning. Thank you, Director Animoto,
and thank you Dr. Kup and Dr. Volkov and Director
Botticelli for your leadership in this field and
for your effective advocacy in translating addiction
science into practice. In 2009, as the campaign
for addiction medicine fellowships began, the
National Institute on Alcohol Abuse and Alcoholism
and the National Institute of Drug Abuse gave the very
first support grants for this endeavor, and they are
still supporting this work. Their investment has also
resulted in nearly $20 million of additional funds
into the development of new, sustainable fellowship
programs of which there are now 42. Dean David Stern and I
will be facilitating this session. Medicine is now formally
responding to the need for a workforce of qualified addiction medicine physicians. We will summarize three
expected next steps: the further expansion of
Addiction Medicine Fellowships, the modern
approach to building the physician workforce through
educational change, and the emergence of centers of
excellence in addiction medicine. I will start with an
overview of the need and strategy for expanding
Addiction Medicine Fellowships. Whoops. So this will wake up
your basal ganglia. You’ve seen this before. This is the topic of the
day, the drug of the decade, or the couple of decades,
and I’m going to actually start by focusing on death. Death is a crude measure of
health, yet death reflects the natural history
of a disease. In the case of addiction, it
is also reflective of the substantial secondary
medical public health and social problems, which
addition drives. These are the death rates
from opioids by state. Is there anyone in this room
from a state where opioids are not a problem of great significance today? Opioids. Whoops. This – here are the combined
death rates by state from opioids plus alcohol
plus nicotine. How is your state doing? How are you as a medical
meter or educator doing? There are states where one
out of three deaths today are caused by alcohol,
nicotine, and opioids, and as a nation, we have a poor
record of addressing this, and it is not just a state
crisis and a local crisis. This is a national crisis
that involves all drug use. Here’s another way
of looking at this. There are 2.6 million deaths
in the United States each year. One percent are attributable
directly to opioid overdoses. One out of every 100
deaths in America. 3.5 percent are
attributable to alcohol. Nineteen percent
more to nicotine. And about one percent more
from other illicit and licit drugs including non-opioids
prescriptions written by physicians. One of every four deaths
in America today are attributable to
these substances. What these numbers indicate
is not the real story. The real story is that these
deaths are very personal. Personal for parents,
siblings, our children, our nieces and nephews, our
friends, neighbors, colleagues, our
children’s friends. Personal for me,
personal for you. Most of us and most of
society have come to realize that addiction is not a
statistical or purely scientific disease. It is a personal, painful,
disruptive, life-changing disease for all around it,
and that is why we are here today. We are here because we
deeply care about our patients’ families
and communities. We are here because we have
compassion for those who are ill or are in harm’s way. As physicians we have
devoted our lives to the care of those who seek or
who need care, who need our help. This is our work, and right
now for all of medicine, it is the most important
work we can do. How can we do it? This slide illustrates how
medicine, when it shines its lights on a problem,
addresses that problem and has results. What is the plan of attack? Within the medical world, we
couldn’t talk about this if we did not have recognition
by the American Board of Preventive Medicine, the
American Board of Medical Specialties, and the
Accreditation Council for Graduate Medical Education,
because that put us in the house of medicine, and now
we can be part of this. There’s a continuum of
competencies for medical school through
fellowship training. We see that in every field,
and I’ll pick on cardiology as well. Clinical experts, faculty,
and change agents coming from fellowships drive the
science, the practice, the teaching, and the education
through all of physician training. And now – well — so the
fellowships become the epicenters for successful
response to whatever that problem may be, and we do
need a successful and a new response to the addiction
epidemic that America has had for decades
upon decades. CME will never suffice. We are at a tipping point. Here are the 183 medical
schools in our nation. There are 42 addiction
medicine fellowships now established and another 4
expected by year’s end. In addition to being
sponsored through medical schools, fellowships can
also be sponsored by individual entities, such
as teaching hospitals, so there’s room for even more. Can those of you at a school
with an Addiction Medicine Fellowship in this room,
or an Addiction Medicine Fellowship, or planning one
at your institution, please raise your hand. Thank you for bringing
this work forward. We need you as clinical
experts, as faculty, as teachers, as change agents,
as persons who can come to meetings like this, and work
at every level of society to change the status quo. The addiction medicine is on
track, and with your help, we expect to see the
establishment of 125 Addiction Medicine
Fellowships by 2025. Some people say,
“That’s an awful lot. You sure we need that many?” I would remind you that
sports medicine has 123. (laughter) Medicine can do this. We can do this together. We must do it. It is why we are physicians. I would like now to
introduce Dr. George Thibault, President of
the Josiah Macy Junior Foundation. Dr. Thibault is a thought
and action leader in reinventing
medical education. In addition to the Macy
Foundation, he awarded a generous grant to the
Addiction Medicine Foundation to engage medical
schools in SMSA Region 3 states to explore the
possibility of Addiction Medicine Fellowships with
a new model of education. The success of this outreach
is now being extended to other states
across the nation. Thank you, Dr. Thibault for
your work and your support. Dr. George Thibault:
Here we go. Thank you, Kevin, and it’s
a pleasure to be here. I’m honored to be in this
distinguished room with this distinguished group of
people addressing one of the most important medical
issues and medical education issues facing us. For the moment, I want to
put this in context of broader changes in medical
education that we at the Macy Foundation have been
promoting for the last 8 or 9 years. And help see how these
broader changes in the education of health
professionals going forward fit into the goals of
improving education for substance use disorders
and addiction. We started with a thesis,
eight and a half years ago when I became President of
the Macy Foundation, that the size, composition, and
distribution of skills in the healthcare workforce
will determine the success of healthcare reform, and
therefore, innovations in health profession education
are needed to prepare the workforce for tomorrow. We need to align health
professions education with the changing needs of
society and the changing delivery systems and,
of course, the issue of substance use disorders and
addiction fit very much with that premise: aligning
education with the need to the public. We’ve chosen six areas of
innovation, and I’m going to go through them
very briefly. Each one of them could be a
lecture in itself, and I’m not going to do that. But I’m going to make a
comment about each and how it may be relevant to
improving education for substance use disorders
and addiction. First and very important
on our list — and it’s probably been our
principle area focus, is interprofessional education. We now have an increasing
body of evidence that healthcare delivered by
highly functioning teams improves health outcomes,
improves the efficiency of care, and importantly,
improves patient satisfaction and
professional satisfaction. Yet, we historically
have educated our health professionals separately,
kept them apart until they’re fully developed,
fully licensed, fully accredited, and then are
surprised when they don’t work together as teams. They haven’t learned
the same language. They haven’t learned
respect for each other. They haven’t learned to work
in teams, and they haven’t learned what each of the
health professions have to offer. So, we’ve had a major
initiative on changing that paradigm so that all health
professions will spend some part of their educational
experience learning about, from, and with other
health professionals. Now, the treatment of
substance use disorders and addiction lends itself
perfectly to this. In fact, one could say that
cannot be done effectively without an interprofessional
team combining the skills and insights that are
brought by medicine, psychiatry, social work,
nursing, public health. We can go down the list. This lends itself perfectly
to an interprofessional approach, so by preparing
all health professionals to work in teams, we will
prepare them also for improved care of substance
use disorders and addiction. Second, we need new models
for clinical education. Our predominant models for
clinical education still are oriented towards acute care,
episodic care, hospital rotations of various length
rather than where most illnesses today and will be
in the future, and that is chronic disease care for
largely outside of a hospital setting, so we
need new models of clinical education that actually
prepare the next generation of health professionals to
deal with chronic illness in a longitudinal fashion, to
work in teams to do that, to work in communities to do
that, to work with patients and families over time, and
also to ward with mentors and teachers over time to
acquire the skills to manage product disease. And you all know the
substance use disorders and addiction are chronic
diseases and that one needs the skills and the
understanding of learning medicine in that way to
be able to treat chronic diseases. Third, we need new content
to complement the biological sciences, which have been
the underpinning for all of health professions education
since the time of the FLEXA report in 1910. Those biological sciences
are still absolutely necessary underpinning,
but they’re not sufficient today. We need to understand
principles in population health, the social
determinants of health. In other new skills, like
quality improvement, patient safety, pain control, it had
previously not been a focus of our educational efforts,
so introducing these new contents lend them self,
again, perfectly to understanding the full
spectrum of substance use disorders and addiction. We need new educational
models based on competency rather than time, and I
think you’re going to hear more about that
from a later talk. I’m not going to emphasize
that too much, but rather than just this certified,
the adequacy of our education by time and place
actually develop the tools to assess competency in the
various skills that we want our health professionals to
have including understanding substance use disorders
and addiction. We need to use new
educational technologies such as simulation and
online learning that will both facilitate the
efficiency of our education process, will facilitate the
interprofessional approach to it, and will also enable
us to teach at a distance, particularly thinking about
the needs to teach and delivery care and why do we
distribute it, parts of our country, particularly rural
and underserved areas, which are particularly susceptible
to substance use disorders and addiction. And finally, we need to pay
more attention to develop the faculty, to develop the
faculty to teach new kind of tents, to teach in
new ways, and teach interprofessionally. Since our faculty have all
been taught in the old way, we can’t expect our learners
to learn new skills, new attitudes, new approaches if
the faculty don’t know them, and we pay too little
attention to that, so if we are going to develop new
programs, which we must, to treat substance use
disorders and addiction, understand them. We are going to have to
bring our faculty along because by and large, they
weren’t taught those things when they were learners. And to do all of those
things we’re also going to need to bring about a
culture change in our educational institutions in
our healthcare delivery. We need to break down the
professional silos that have separated the disciplines
within medicine, for instances, medicine and
psychiatry — for instance, is a good example. And even more importantly,
the silos across the professions, medicine,
nursing, pharmacy, so that we really do get a true
team approach not only to education but to the
delivery of care. We need to develop closer
ties between education and the healthcare delivery
system that often run in parallel but don’t
talk to each other. So, that the educational
process is informed by the needs and changes in the
delivery system, and the delivery system as it
reforms, incorporates the educational mission. So, our learners are
learning in the settings that are most attune to
dealing with today’s and tomorrow’s problems. And finally, we need, in all
aspects of our education and delivery system, to be much
more outgoing focused. Much more focused on the
needs of the patient community, which should
drive our educational process and drive our
delivery system so that as new problems emerge in the
patient population, the education system and
delivery system are responsive to those, so
there’s a constant feedback loop. I want to cite one example
that change is taking place. An article published just
last month in Academic Medicine, Developing Core
Competencies for the Prevention and Management of
Prescription Drug Misuse and Medical Collaboration
in Massachusetts. The four medical schools
of Massachusetts — UMass, Boston University, Tufts,
and Harvard, in an unprecedented way I can say,
because that’s where I spent a good part of my career,
have gotten together and have developed together
across four medical schools a curriculum for dealing
with substance use disorders. This is a breaking down
of silos across medical schools, a breaking down of
silos between medicine and public health since the
leaders of public health were involved in
this initiative. And also, breaking down
silos, because this calls for an interprofessional
approach. It’s identified ten
competencies I think familiar with those who
are working in this area focusing on prevention,
focusing on secondary prevention, and is
identifying subject at risk — patients at risk —
because of misuse before addiction, and then
identifying the competencies to treat addiction
as a chronic disease. So this is a sign that
progress can be made if we focus attention on it, and
if we look broadly across the needs of reforming
health professions education to meet the needs of the
public, we will better address the needs of those
patients with substance use disorders and addiction. So, thank you for the honor
of speaking to you, and I congratulate you all
on this important work. (applause) Dr. Dave Stern: Thank
you very much, George. Let’s see if I can advance this. Yes. I’m Dave Stern from the
University of Tennessee. I’m the Executive Dean and
the Vice Chancellor for Health Affairs. I can say that before I
moved to Tennessee, I had the New Yorker — or the
Yankee view of Tennessee’s, well, you can look pretty
far, but you don’t see Tennessee. You kind of look right
toward the Pacific. Tennessee is actually a
state that actually has two time zones, on the one hand,
but more importantly, it has very diverse populations
from the Appalachian population in the eastern
part of the state towards Knoxville. We all know what
happens in Nashville. There’s lots of country
music, and there’s a large, underserved African-American
population in Memphis. And if you consider that
diversity, one thing that’s a common denominator is, of
course, the problem that you studied, the problem of
substance use disorders. The other kind of diversity
there is is there’s rural and urban populations. And as was just stated, the
rural populations really have a very severe problem
with regard to substances disorders. The basic hypothesis of my
talk actually comes from something that was embedded
in George Cube’s earliest slides where if you looked
at it, you saw that if you put together alcoholism,
substance use disorders, be it prescription drugs or
illicit drugs, it’s actually a much bigger problem than
even the cancer problem. What I’d like to suggest to
you is that if you consider the cancer centers at the
major institutions or your institutions the approach
to cancer clinically multi-disciplinary involving
teams of people looking at the issue from the
standpoint of research, it’s research that cuts across
clinical and basic science to put together the elements
that have to go with forming targeted therapies and
finding the patients that can benefit most from those
targeted therapies, and educationally, it spans
everything from screening programs in the community
to training people in community-oriented
approaches as well as basic science. What I’d like to suggest to
you is that those of you who represent academic medical
centers, that’s what we can contribute to this field. We can contribute a
multi-disciplinary, conclusive approach that
really embraces the population that, in the end,
we would like to impact. So, what I’m going to
introduce to you is our Center for Addiction Science
at the University of Tennessee. This first slide is Kevin
Kunz’s slide of how the Addiction Medicine
Fellowship — and I certainly agree, fits in in
an integral way into this, but our point is that an
integrated approach to this is really, again, what the
academic centers have to contribute. And if one is talking about
each of the missions that we all are concerned with —
clinical, again, multi and interdisciplinary surfaces
across all substances, and again, across the life
cycle, because everyone in this room deals with
everything from neonatal abstinence syndrome to an
infant mortality to problems that occur later in age. Educational, it’s training
the fellows, as we’ll talk about as, as cultural
change agents. And I know that’s a basic
theme of this meeting. Research, multidimensional. And, finally, leveraging
each of these missions for the community
outreach mission. If one takes a look at the
multidisciplinary care, there are multiple
modalities I’ve indicated on top, but the key is
to get these different constituencies to really
talk to each other and work together. One advantage that I have as
the Executive Dean is, since they all work for me, when
I ask them to get together, they do. But at least once. (laughter) After that, one can’t really
always predict if they’ll cooperate, but there’s
almost no one that shouldn’t — that couldn’t
be on this slide. If one takes the orthopedics
that gives an elderly patient 60 days’ worth of an
addictive narcotic, we know that they should be just
as involved in this. The other thing that
comes up in this are care transitions. That’s, again, that
something in cancer that’s been the key. We call then navigators. We call them all different
kind of things for coordinating care. You don’t really have that
in addiction medicine. In Tennessee, when a mother
that is insured by TenCare that has a substance use
disorder delivers, she’s no longer insured, the baby is. The mother isn’t as
soon as she delivers. So, in other words,
transitions in care from acute detoxification, to
more chronic from inpatient to outpatient, from a
pregnant mom to a then becoming — Female Speaker: Talk
into the microphone. Dave Stern: Oh. Could you hear me? I hope so. So there’s just multiple
things in transitions of care that I think a
multidisciplinary approach will have an
important effect on. The same thing applies to
the research in our field. One of the things that we
focused on is the neonatal abstinence syndrome, and
in particular, on genetic determinance of the neonatal
abstinence syndrome, looking at the two distinct
populations I mentioned to you, namely the Appalachian
population, which has in our state about 200 cases of
severe neonatal abstinence syndrome in the eastern part
of the state, and in the western part of the state
the African-American population in Memphis. We have a group, that you
can see, of geneticists as well as pharmacologists and
neuroscientists that are working on this on the one
hand, but we need all the clinical folks on this as
well, the maternal fetal medicine docs, the
neonatologist, the addiction medicine specialists,
behavioral health and social work. I would say with regard to
the wonderful work we’ve heard about before from
Dr. Scube and Volkov, for sure the gene environment
interactions that were referred to and the
relationship to genomics and personalized medicine, is
going to be the future, and it’s for all of us to that,
and it’s going to apply to everything from the
vulnerability to substance abuse disorders to the
susceptibility to the complications and the pace
and the completeness of the recovery. And, again, I suggest that
an integrated approach that brings together people that
can define the phenotypes that can join them with the
people that can understand the genotypes, that’s the
way in which we’ll be able to move the field forward. Finally, I’d like to talk
about the Addiction Medicine Fellows, and we started
an Addiction Medicine Fellowship program this July
1, and we have two fellows that are in it. The emphasis is on
interprofessional education. I didn’t know Dr. Thibalt
was going to emphasize that in his remarks — but he
doesn’t remember for sure, but he was one of the people
that rained me as a Harvard medical student many years
ago, and so maybe I did learn something,
Dr. Thibalt. (laughter) The addiction clinics that
we run are really the perfect place for
interdisciplinary education, because although as he
pointed out, in the learning in the formalized sense, we
often separate the students in these kinds of
extracurricular activities in clinics such as that
there’s no reason to not put together nursing, dentistry,
medicine, pharmacy, and health professions,
and we do. But perhaps the most
important place where this plays out is within the
health system where there are lots of inpatient and
outpatient facilities. And I’m very fortunate
enough to have a wonderful partner that I’ve worked
with for several years, Dr. Jeff Liebman, that’s now
going to come up and make some remarks in regards to
the health system and the integration of these fellows
and how he’s trying to use this to change the culture
and the institute. Jeff is the CEO of the
Methodist University Hospital, which is the
largest hospital in Memphis, and is Senior Vice President
of Methodist Le Bonheur Healthcare. Jeff. Dr. Jeff Liebman:
Thank you, Dr. Stern. Good morning. Dr. Thiebalt doesn’t
remember, but I actually was in the partner system for
years, and he had some pointed comments for me too,
which I took bend at of the time. I want to thank you for
letting me be there. Let me first describe what
the Methodist Le Bonheur system is. This is the dominant
healthcare system for the greater Memphis area
in Shelby County. We are the largest Medicaid
provider in the state. We do 350,000 emergency
visits a year, and any time within Shelby County, for
the 1.2 million people we serve, 45 percent of the
adult patients, inpatients, are in a Methodist bed. We have a predominant,
pretty much exclusive children’s hospital called
Le Bonheur Healthcare — Le Bonheur Hospital. And, again, we are sort of
the safety net hospital, because we provide the
largest amount of Medicaid in the state as well as the
largest amount of pre-care, if you will. We also have an open medical
staff, and the reason I mention that is because when
these patients come into the hospital, an open medical
staff provides some additional challenges,
because the bedside nurse traditionally for any other
provider, falls back to the doctor who takes
care of that patient. So, my encouragement to you
is train the doctors of the future, but do not forget
that in those immediate settings, it is the general
population and medical community that most of
the nurses, respiratory therapists, pharmacists,
etc., will look for towards advice and counsel
as they move forward. Our need honestly is more
infrastructure, and with this fellowship, we are
hoping that we can start to train our inpatient
providers, doctors, nurses, pharmacists, etcetera, in
better ways to deal with these patients. There is a void in our
market in particular, and our hospital is
very interesting. You go ten blocks in one
direction, you could be in a million dollar home. If you go ten blocks in
another direction, you would be in third poorest district
in the United States. So, we truly get both ends
of the spectrum and both many types of abuse. So, with the partnership
with the University of Tennessee, we’re looking
forward to using these fellows to train and set a
new bar and standard for the way we’re going to deal
with these problems. Thank you, Dr. Stern. Dr. Dave Stern: I’d like to
just conclude by saying I think it’s important in this
field that we really define the metrics and talk about
what will success look like. One of the things that I
deal with in dealing with deans and hospital CEOs all
the time, they want to know what are the metrics. What’s going to work. What’s not going to work. I’d like to suggest to you
that you have a number of very firm metrics, whether
they’re medical or economical, but they
really make a difference. I haven’t put numbers on
these, but clearly, in every setting, one could. But there are multiple,
important impact measures with regard to the incidents
and the prevalence of substance use disorders: the
medical complications, the cost — which in our state,
are very often very much borne by TenCare or our
Medicaid equivalent in Tennessee, the social
consequences, and of course, the acrogenic harm. And I’d like to just suggest
to you again, if you take the analogy of the cancer
center at your institution, that that multidisciplinary
model with respect to care and research and transitions
in care, that’s the model that I think very
productively could be applied here to a disease
which is really of the same, or of an even larger scope. And I think that in way,
we’ll have benefits to all stakeholders. So, I thank you for your
attention, and I think we want to move on to the panel
responders, and I’d like to welcome first Dr. Sara
Wakeman, Director of Substance Use Disorder
Initiatives from Bass General and Harvard
Medical School. And apparently, Sara, you
should speak from where you’re sitting. We look forward
to your remarks. Dr. Sara Wakeman: Thank you. Good morning. It’s an incredible honor
to be here with all of you today. As we’ve heard this morning,
it’s no longer news that the opioid epidemic — Male Speaker: Sara, can you
turn your microphone on? Dr. Sara Wakeman: It’s on,
but I can bring it closer. How’s that? There we go. I’ll hold it. (laughs). All right. Let’s try that again. Good morning. It’s an incredible honor
to be here with all of you today. As we’ve heard this morning,
it’s no longer news that the opioid epidemic is a
public health crisis. As we heard, by the end of
today another 78 Americans will die from an
opioid overdose. Since 2000, half a million
lives have been lost to the opioid crisis alone, which
puts the carnage really on par with HIV in the number
of American lives lost to the HIV epidemic. Substance use including all
addictive drugs, not just opioids is truly the
epidemic of our times. Yet unlike the early years
of other epidemics, such as HIV, when we needed to wait
for science to catch up and for new treatments to be
discovered, as we heard this morning, we already know
what works for addiction. We heard about the
incredible breadth and depth of science and the
understanding about both the disease and the treatments,
and that fact is almost as devastating as the deaths
themselves, because truly no one, no one should ever die
from an opioid overdoes. We have an effective
antidote with Naloxone. We have proven public health
strategies to keep people who are at risk safe. And, most importantly
as we’ve heard, we have effective treatment that can
transition what was once a fatal illness into a
chronic disease that can be successfully managed just
like hypertension or diabetes. When society and medicine
have partnered to tackle other deadly diseases, we’ve
had tremendous success. We’ve done so for infectious
diseases, for stroke, for heart disease and cancer,
and yet for addiction, the toll keeps rising. It’s long past time for
medicine and society to join together to meet
this great need. There is a paradox; however,
in addressing the addiction crisis. Unlike other diseases, as I
mentioned, the issue with addiction is not the need
for new discovery, nor is it for a continuation of a
whack mole approach where we chase one drug only to have
the problem to reappear with another substance; rather
what is required is true ownership of the crisis and
implementation of known strategizes and treatments. For a hundred years as a
country, we’ve chosen to marginalize addiction as a
social problem or a criminal justice issue. And, thankfully, we’re now
hearing our leaders say that we can’t incarcerate our
way out of a public health crisis, and nor can we
punish or shame people into wanting to get well. But undoing that historic
legacy requires educating not only our population but
also our policy makers and our health care providers
about the nature of this complex brain disease, and
it requires relentless advocacy to change policy
and practice and serious accountable involvement
of the house of medicine. As with HIV, we need
physician specialists in addiction with increased
training for all doctors to prevent, screen, diagnose,
treat, and manage addiction. Addiction medicine
Fellowships offer the necessary training to create
leaders, expert clinicians, faculty, and teachers. Addiction medicine
physicians serve patients, but they also serve
their colleagues. They serve as role
models and mentors. They serve as a source
for consultation and for guidance. Imagine for a moment if your
loved one was diagnosed with a serious, life-threatening
cancer diagnosis, wouldn’t you want her to receive
care from a board certified oncologists, and wouldn’t
you want the cancer identified and prevented
as soon as possible? The same option should exist
for any patient or family member with a
disease of addiction. Academic medicine in our
health systems must also be involved. Formal education, training,
research, and practice in this field are as important,
if not more important, as in the over hundred other
medical sub-specialties. I thank AVMS for recognizing
our new field and ACGME for opening the pathway
to accreditation. At Massachusetts General
Hospital — I’m also a Harvard Medical School and
Partners Person where I work as an internist in the
Medical Director of our Substance Abuse
Disorder Initiative. We will be seeking ACGME
certification for our Addition Medicine Fellowship
as soon as it becomes available next year. And as soon as the American
Board of Preventative Medicine sponsors the
first AVMS level addiction medicine certification, all
of our addiction medicine physicians will become
credentialed and certified. We can turn the tide on
the addiction epidemic. We can create a future where
no one has to die from this disease. Thanks for coming together
today, and thanks so much for the opportunity
to say a few words. Dr. Kevin Kunz:
Thank you, Sara. A special thanks to — (applause) –a special thanks to you
and your colleagues for the startup of that fellowship at Mass General. Terrific. Our next speaker is
Dr. Allison Whelan, the Chief Medical Officer at
AAMC, which is the most heavily involved group with
medical education in the United States. Dr. Allison Whelan: Good
morning and thank you. I’ve been the Chief Medical
Education Officer at the AAMC since October 3
— yeah, October 3. Three weeks and two days. (laughter) Before that, I spent the
last 20 years as a faculty member in both the
Departments of Medicine and Pediatrics at Washington in
St. Louis and continued to do inpatient medicine
attending, so firsthand experience with much of what
has been talked about today. I want to congratulate
the Addiction Medicine Foundation, ONDCP, and all
the others who helped to organize this
important discussion. Both bring us here today and
for their work in raising the national consciousness
on this incredibly important problem. So what is the AAMC? We represent all
145 accredited U.S. medical schools, nearly 400
major teaching hospitals and health systems including the
51 VA medical centers in more than 80
academic societies. Although AAMC membership is
institution-based, we really do our work with individuals
of those institutions, which includes 160,000 faculty
members, 83,000 medical students, and 115,000
resident physicians. It’s an incredibly exciting
time to join the AAMC, because it’s a time of both
change and challenge in medicine. Rapid advancements in
clinical and biomedical knowledge are transforming
patient care, and medical educators are exploring new
approaches to teaching and assessment to ensure that
our future physicians are equipped to adapt as
medicine advances and healthcare changes. An important paradigm shift
in medical education is a major emphasis on the
master for competencies, communication skills, and
professional teamwork that Dr. Thibalt talked about. And you’ll hear more about
these from Dr. Homeembau later today. These serve as a foundation
for physician in any discipline to provide
high quality work in any circumstance, and it’s
within this framework and within the framework of
accreditation, that medical education programs
design their curriculum. So, necessarily, they
vary from institution to institution. So, every medical school
does include content on substance use disorder in
both required and elective course in both didactic
and clinical work. It’s integrated and taught
in different ways in each medical school. The other thing that’s
important to recognize that I think that is important to
recognize is the continuum of education. Medical school is 4 years. In a few years, it’s been
shortened to three plus. Formal residency training
is three to six to seven to eight years, and the vast
majority of time that our physicians are in practice
is when they’re in the continuing education field. I’m a mid-career physician,
and of the three approved FDA drugs, only one was
approved at the time that I was finishing my formal
training, so the imperative to figure out a way to relay
make sure those physicians who are in the trenches, who
are doing the work every day as others have mentioned, is
critically important, and I think the CE world is an
area that all of us continue to expand in. So, we think about our role
in working with our academic health centers, the AMC’s
role is primarily as a convener and a forum for
members to share their best practices and to learn
from one another. We offer a variety of
resources to assist our members at work, Webinars,
and as you heard last year, my colleague described
MedEd Portal. It’s a web-based, open
access repository of peer review, teaching and
learning modules that we maintain. We’ve seen major efforts by
our members in expanding their content in addiction
medicine, and MedEd Portal is a natural resource to
find classroom tests and materials. We specifically welcome the
opportunity to work with those in this room to build
and highlight a more robust collection of submissions
focused on addiction medicine and to utilize
your expertise as potential contributors if you are
driven as an associate editor for this collection. As with any public health
crisis, challenges in prevention, identification,
and treatment of addiction have a number of drivers,
which all of you have talked about already today, and
many of them extend beyond what education
alone can address. So, I really appreciate that
others have highlighted that we need to continue to work
on the science of addiction, which will better inform
the care that we provide. And as was said earlier by
Dr. Kiue, we need to learn about the most effective
strategies to actually integrate those
lessons into practice. I’m not going to test
everyone whether they knew the three drugs that can be
used in alcohol treatment, but as you know, they’re
highly underutilized. We really need to figure
out how to make the change happen. And, importantly, we can’t
overlook the deeply rooted societal and systemic
figures that go far beyond what medicine and medical
training can overcome alone. The treatment desert that
was mentioned is not something that academic
health centers can help with, and so the broad
approaches are critical, but medical schools and teaching
hospitals are a community doing our part to address
these challenges in partnership with all the
esteemed individuals in this room and the broader
stakeholder community. Thank you again for the
invitation, and I look forward to the
discussion today. Dr. David Stern: Thank
you for your remarks. (applause) I’d like to move on to
Dr. Mary Lich-Lai, Senior Vice-President for Medical
Accreditation from the ACGME. Dr. Mary Lich-Lai: Good
morning, everyone, and thanks for the honor
in joining this group. I’d like to tell you about
the accreditation counsel for graduate
medical education. This is a private
organization that sets standards for U.S. graduate medicine education
programs and institutions. Accreditation physicians are
based on compliance with the standards, and it provides
assurance that a sponsor institutions or program
meets the quantity standards for which it prepares its
graduates with our main goal of preparing physicians for
the future who can provide good patient care. We currently accredit close
to 10,000 programs in the United States, and this
includes almost 129,000 residents and
fellows and duty. There are actually three
sets of requirements that each specialty or
sub-specialty has to adhere to and that includes a
sponsoring institution requirement, the common
program requirements, which all the programs have to
adhere to, and the specialty and sub-specialty
specific requirements. Male Speaker: They want you
to use another microphone. Dr. Mary Lich-Lai: Oh. It’s not working? Is this better? Male Speaker: Closer. Dr. Mary Lich-Lai: I should
hold it to my mouth. Male Speaker: A
little closer, Mary. Dr. Mary Lich-Lai: Okay. Sorry about that. So each of these specialties
or sub-specialties are reviewed by a review
committee that is comprised by volunteer specialty
expert physicians, or their peers. We recently added public
members to these review committees. There’s always a resident
member, meaning a trainee, as a member of
this committee. And it’s run by
staff at the ACGME. There’s a very specific
process for applying to become a new specialty or
sub-specialty, and this follows approval of that
particular sub-specialty by the Member Board of American
Board of Specialties. Following this, a letter of
intent is sent to the CEO of the ACGME, and that
application is then reviewed by the Board of Directors,
and if approved, an adhoc committee is convened to
review the application. Following policies and
procedures, and there’s eight major components that
that application has to cover. Once approved, program
requirements are written in cooperation with a
sub-specialty expert and pertinent review committee
representatives. The Fellowship for the
Sub-Specialty of Addiction Medicine was approved by the
ACGME Board of Directors on June 11, 2016, so
just very recently. The Fellowship in Addiction
Medicine approval for accreditation is actually
unique, and since everyone this morning seems to be
using cardiology as an example, I’ll use
the same specialty. So, for example, if you
wanted to become an adult cardiologist, you actually
have to complete internal medicine residency training,
or if you wanted to be a pediatric endocrinologist,
you have to complete pediatrics training, or if
you wanted to do pediatric surgery, you have to
complete general surgery training. So, if you completed
neurology training, for example, you can’t just
go and undergo cardiology fellowship training. So, addiction medicine
approval for accreditation is unique in that sense
in that anyone who has completed successfully
specialty training can apply for a fellowship in
addiction medicine, and we approved it in that way with
a specific intention knowing that addiction medicine is
an important component of any practice, whether
internal medicine, family medicine, pediatrics,
anesthesiology, emergency medicine, neurosurgery,
or general surgery. Therefore, having addiction
medicine specialties in any specialty would increase
awareness of this wide-reaching problem
related to addiction that would result in better care
in this often neglected population. The process of putting
together program requirements generally
takes the most time. It takes a year. However, because of the much
appreciated preparation and hard work by the members
of the Addiction Medicine Fellowship Directors
Association, this process is probably being cut
in half at least. So, right now what we’re
doing is that the staff at the ACGME is reviewing the
program requirements that have already been put
together by the Association, and once that is finalized,
we’ll bring representatives from the review committees
and the addiction medicine community to review those
requirements, and when finalized, that would be
posted on our website for a 45-day review and
comment period. The end product will be then
sent to the committee and requirements, which is a
sub-committee of the ACGME Board of Directors, they
will review and discuss and present their findings and
decision to the Executive Committee and the full board
before it’s implemented. Just a very quick word about
what the components are of the program requirements. There’s a big introductory
section, which describes the residency and fellowship. A description of the
sub-specialty’s purpose, prior certification
required, and the duration of the training. Then there’s six general
sections, which comprises probably about
30 some pages. It addresses the first
component, the sponsoring institution and all the
participating sites. Then there’s a site on
program personnel and resources, which covers
the program director requirements, faculty
members, and other program personnel. Third section of
fellow appointments. Fourth one, which comprises
the educational program including the competencies
for the sub-specialty. Then the very important
component of evaluation, and that’s not just evaluation
of the fellows, but the fellows get to evaluate the
faculty, and the faculty and the fellows get to
evaluate the program. Last but not least, the
sixth section deals with fellow duty and the learning
and working environment, professionalism, and the
recently added section of personal responsibility
including wellness and patient safety. Thank you. (applause) Dr. Kevin Kunz: Thank you,
Mary, and thank you for your encouragement and
collaboration and your leadership of ACGME and
the addictions medicine community of the
last five years. When we teach competencies,
they have to be evaluated. There are several
ways to do that. One is through examination. Our next speaker is Dr.
Donald Melnick who is the President of the
National Board of Medical Examiners. Dr. Donald Melnick:
Good morning. The NBME is a 100 plus year
old organization, non-profit rooted and focused on the
assessment of physicians and other healthcare
professionals for the knowledge and skills that
support high quality and effective patient care. We’re best known as the
developer and co-owner of the United States Medical
Licensing Examination, USMLE, used by all licensing
authorities in the United States for the initial
license of MDs, including all internationally-qualified doctors. We also provide extensive
assessment tools in undergraduate and graduate
medical education, self-assessment for
students, and assessments for other medical
professionals as well as other healthcare
professionals like veterinary medicine,
physical therapy, clinical research, health and
wellness coaching, and many, many others both in the U.S. and internationally. We have co-administered
the addiction medicine certification exam with the
American Board of Addiction Medicine since its
first exam in 1986. Adding to the rigor of the
credentialing process — and we hope we’ve helped the
exam evolve and grow as this field has come of age. We want to congratulate all
of you who have advanced the filed, and thereby, advanced
the prevention and treatment of substance
abuse disorders. And particular thanks to the
young career physicians in the room. You are urgently needed to
address the preventable and largely untreated substance
use disorders through our medical schools, our
healthcare systems, and in society at large. With the recognition of
addiction medicine as a sub-specialty of the ABMS
Member Board in Preventive Medicine, our support
relationship with the American Board of Addiction
Medicine is coming to an end; however, we are eager
to assist wherever we can to encourage the momentum of
this new sub-specialty, and we hope to work with the
American Board of Preventive Medicine to provide
continued support for certification assessment
in addiction medicine. In addition to our support
for the certification program, MBNE has a history
of engaging with substance abuse and addiction
community activities for many years. During the 1980s we worked
with a task force funded by United to create assessments
for use in medical and other health profession schools. Unfortunately, at that time
interest and utilization in this field didn’t result
in adequate result for the support of the ongoing cost
of sustaining the program, and its availability ended
in 1988 after testing only 300 students. In 2010 we were invited by
ONDCP to work with others to identify ways to place
greater emphasis on substance abuse and
addictions in the USMLE program. While USMLE is primarily
about providing a credential for physicians to obtain
licensure, it has profound driving effects on both
teaching and learning. Volunteers from NIDA, HHS,
HRSA, SMSA, and the Indian Health Service reviewed
USMLE item pools and prepared recommendations
for improvement. The USMLE management
committee endorsed their implementation in May 2011. Central to the
recommendations was to shift the focus from acute issues
related to substance abuse to substance abuse
as a chronic disease. While I can’t publically
disclose the exact numbers of items currently in these
areas on USMLE, I can assure you that this process
resulted in a substantial increase in examination
content-related to substance abuse and addiction. These items now appear on
every form of the multiple choice components of Step 1,
Step 2CK, and Step 3, and in many patient management
simulations in Step 3 and patient interaction
simulations in Step2CS. USMLE standing test
committees routinely receive writing assignments each
year relevant to substance abuse and addiction. In May we engaged with the
Association of American Medical Colleges and
Dr. Stein from ONDCP to review how fully the U.S. Licensing Exam system is
vetting the knowledge and skills of new physicians. We shared in more detail
the information I’ve just outlined, and we asked
for further assistance in identifying context experts
to work with us in the development of test
content for USMLE. We look forward to
continuing our dedicated long engagement with our
community and to ensure that substance use disorders gain
the prominence they deserve in the preparation of
physicians to meet the needs of patients and society. If anybody here today is
interested in working with us to improve assessments in
this field, please just drop me an email at
[email protected], and the e-mail address is in
the attendee list. Thank you very much. (applause) Dr. Kevin Kunz: Thank
you, Dr. Melnick. I think, as much as anyone,
you’ve told us that we’re all on the same page in this
same room going in the same direction. Dr. David Stern: As a
medical school dean, we respond to that (laughs). What’s on the USMLE I think
that’s going to have a big effect on the culture and
the residency program and the medical
student programs. We’d like to move on to
Dr. Hugh Mighty, the Dean and Vice-President of
Clinical Affairs at Howard University College
of Medicine. Dr. Hugh Mighty: Thank you. My microphone works. (laughter) It is an honor to be here to
represent Howard University College of Medicine and
Howard University Hospital. We at Howard have had a
strong commitment in our support and research of
— and interventions in addiction medicine. Back in 1997 we developed
the Alcohol Research Center, funded from the NIAAA, which
at the time, its fundamental purpose was to stimulate
strength and facilitate multidisciplinary research
and collaboration that would lead to the reduction of
alcohol morbidity and mortality among minority
populations with emphasis on African Americans. We next developed other
projects such as — in 1998, we developed a medical
education model for the prevention and treatment of
alcohol use disorder alcohol intervention in an
inner-city emergency room in 2003 and using
implementation signs for community-based, expert
delivery in older adults in 2015, projects both funded
by the NIAAA as well as NIDA. We furthered our efforts and
formalized it a bit more by having an addiction
medicine, like I said before, residency program
in 2004; screening expert medical residency programs
we introduced residents to that in 2008. We then expanded into the
expert medical professional program in 2014, which
brought in nursing and counseling psychology
and expanded to nursing students. And in the same year, 2014,
we extended the program to our first-year
medical students. We have approximately 265
residents and fellows, 475 medical students, and over
200 nursing and allied health professionals, most
of whom come from all parts of the United States and are
predominantly from minority ethnic groups. I would consider this
the beginning of a force emulsifier in the making. Finally, we’re proud to
have progressed through our Addiction Medicine
Fellowship Program, which will be housed in the
Department of Community Health and Family Medicine
and will be strongly supported by experienced and
dedicated faculty within Howard University Hospital
College of Medicine and within the
university itself. Core and elective rotations
will be available across the spectrum in community
health and family medicine, psychiatry, pediatrics,
OBGYN, pharmacology, and the school of social work. This fellowship will
leverage our university’s unique position in diverse
and underserved populations and particularly here in the
District of Columbia where we’ve seen that the
statistics themselves were very high in substance use. So this was a great pleasure
that we’ve progressed this far, and we look forward to
progressing even further. Thank you all. (applause) Dr. Kevin Kunz: Our next
speaker, who I know, so I’m so very happy to
introduce her. We visited her school in
Virginia, and it was a great visit. So Dean Jan Willcox, the
Dean of the Edward Via School of Osteopathic
Medicine at Virginia Campus. Jan Willcox: Thank you. It’s a pleasure to be here. VCOM is a private,
non-profit, osteopathic medical school with a
mission to create physicians for rural and underserved
Appalachia, and if you visit us in southwest Virginia,
it is Appalachia there. We’ve graduated 1800
physicians and 66 percent of those have returned to
southern Appalachian states. The issues of substance
abuse and addiction in these areas is well documented,
particularly the rural areas, as other speakers
have mentioned. The Virginia College is
the main campus for VCOM. We’re affiliated
with Virginia Tech. We also have branch campuses
in Spartanburg, South Carolina and Auburn, Alabama
associated with Auburn University. We’re three campuses
with one curriculum. We recruit from, train in,
and hopefully, return to these rural and
underserved areas. We’ve created teaching
hospitals, core teaching hospitals, in rural and
underserved areas, and that’s — we have core
clinical faculty that is part of our true faculty
that teach our students in these areas. We begin in the first
year within ethics and professionalism introducing
the students to opioids prescribing and including
the CDC guidelines. That introduces, at a very
first-level, 500 students across three campuses
to this each year. In our clinical skills and
standardized patient cases, we digitally archive and
view 20,000 standardized patient-student experiences
per year, so we have an opportunity to really study
this aspect and how students present with a patient, and
also we’re finding out some of the word that’s gotten
back to clinical preceptors because we notice that upper
level students, when they come back for standardized
patients particularly in the last year, absolutely
will not prescribe pain medication regardless
of the complaint. So we see an opportunity
here not only to see what’s going on in clinical
training, determine what needs to be done, what needs
to be handled as far as educating the students. We can also do faculty
development in these rural sites as a result of
what we find from this. Much of the charge of the
National Board of Examiners, Osteopathic Medical
Examiners, is to protect the public. We’re able to initiate this
process early on in the formative process of
formualtive being a physician. We, of course, have opioid
addiction as part of the behavioral sciences
in second year. We’re integrating
prescribing and substance abuse within core third-year
curriculum, and we’ve always provided a fourth-year
opportunity for an elective in addiction medicine since
our first class went on rotations in 2006. Our goal is to establish
an Addiction Medicine Fellowship. However, we do find some
struggles in finding a program director that is
interested in developing this in a rural and
underserved area, so we do have a little bit of chicken
or egg thing going on here, and I so appreciate everyone
in the room who is working so hard to create a
workforce for us to take into these areas of need. So, I really want to
acknowledge also Dr. Kunz and Dr. Bennet who visited
all of the medical schools in Virginia recently and
brought so much information to us in sharing, and as a
result of that recently all of the medical schools in
Virginia have recently met, planned more collaboration
to see how we can tackle these issues across the
state of Virginia, so thank you very much for
this opportunity. (applause)
Dr. Kevin Kunz: Thank you
for your remarks, Dean Willcox. I will add that of our first
50 Fellowship graduates, four of those are now
directors of other Fellowship programs. Three were new programs they
started, so help is on the way. (laughter) Dr. David Stern: Our next
speaker and last speaker but certainly for sure not meant
to be in that order is a medical student, Kristin
Johnson, President of the Student Medical Association. We’re delighted
to have you here. Where are you? Oh. There you are. Okay. Sorry. Your turn, Kristen. Kristin Johnson: So, thank
you all for inviting me here on behalf of the SNMA as
well as the Medical Students of America. I’d like to talk a little
bit about as what has been said as well as what’s going
on in addiction medicine education for
medical students. So we get a lot of what
has been said as far as preparing for step 1 and
step 2, making sure that we understand what we would see
if a patient was coming into the ED with some type of
substance that we were unable to identify by urine
or seeing what a patient would look like if they were
coming in withdrawing, but some of the problem is that
once we learn that, and we learn these skills, as
students first and second year, we’re then thrust into
the culture of medicine. The problem with that is
that a lot of physicians, especially our attending
physicians, don’t necessarily have the
experience with addiction medicine to be able to give
us the sensitivities that we need. This is especially seen
where hospitals that have underserved communities
coming in as patients are talked about as pill seeking
rather than actually looked at as a full patient, so
these things are extremely important to ensure that
we’re able to go forward and do these things in changing
the way that we treat our patients especially those
who have addiction problems. When you look at addiction
as a health issue or as a disease rather than it just
being something that we are kind of pillaging towards
the end of, I think it changes the way that we as
students are able to really expand our skills and
address as future physicians. As President of the SNMA,
one of the things that I really wanted to work on
this year was making sure that our students have the
opportunity to understand all of the doors that are
open to them in going into medicine, and so with that,
a couple of things that we’re specifically working
on this year include a plenary session at our
national conference that will address addiction
medicine but especially addiction medicine in
underserved communities as well as looking at bias in
medical education and ways that we can, as students,
start to learn to unpack these biases before we
become physicians, and ways that we can assist our
medical schools through research that we’re doing
nationally at the moment in curriculum that actually
targets bias and targets ways that we can teach our
students to fully look at patients as a whole. I feel like if we are able
to achieve these things in medical education, then
we’ll have medical students that are fully able to
take on this task and to potentially enter these
fellowships and become really socially conscious
and culturally competent physicians who will also
be clinically excellent in helping us deal
with this issue. Thank you. (applause) Dr. Kevin Kunz: Thank you,
Kristin, for those great remarks. There is a future here. Thank you.

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