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

2. 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

3. 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

4. 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

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

6. 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

7. All Other Causes

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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, , 2001.

14. 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, , 2002. 1
Pre
During
During
During
Post
Stage of Treatment

15. 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

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

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

18. 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?”

19. 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.”

20. 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.

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

22. 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)

23. 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.

24. Addiction Medicine: A New Subspecialty!
Obama next.

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

26. Addiction Medicine

27. 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….

28. 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

29. Key Elements: Clinical Rotations

30. 183 Medical Schools: 46 ADM Fellowships
KEY
Medical School
ADM Fellowship

31. 125 ADM Fellowships by 2025
KEY
Medical School
ADM Fellowship

32. Kamsahamnida!
감사합니다