EDITORIAL: Addiction medicine: a new medical specialty in a new age of medicine

Abstract

It is doubtful that there exists any physician in Australia who did not at some stage in their training encounter an individual who abused alcohol or who smoked tobacco, whether it related to learning techniques of physical examination or how to formulate a comprehensive assessment and management plan in a ‘long case’. These individuals are not uncommon in the health system.1 As many as one-quarter of patients in general medical wards consume alcohol hazardously.2 However, with the widespread increase in the availability of alcohol as well as a range of other substances, the decrease in age of onset of substance use and changes in the psychosocial profile of today's society3 not only the prevalence, but also the complexity of presentations of substance use-related problems have substantially increased. Around 9% of the total global burden of disease is attributable to the use of psychoactive substances; alcohol and tobacco aside, prescription drugs are now reported as the second most commonly abused category of drugs after cannabis, and ahead of heroin, methamphetamine and cocaine.4 Alcohol and drug problems were originally the domain of Psychiatry.2 This was largely attributable to Psychiatry being the branch of Medicine most involved with facilitating change in human behaviour and to the strong relationship between substance use and comorbid mental health disorders. Today, however, many alcohol or drug problems present to health services with physical complications (e.g. alcohol or other drug withdrawal, recurrent seizures, cellulitis, bacterial endocarditis secondary to injecting drug use, liver failure, etc.), often interrelating with several other, often complex, medical problems (acquired brain injury, hepatitis C, cardiovascular disease, chronic liver disease, etc.) as well as mental health disorders. The approach to managing alcohol and drug presentations therefore fits neatly into the framework that physicians use when managing multiple, chronic and complex medical problems. The increased prevalence of alcohol and drug problems in the community is reflected in their presentation very commonly in medical and surgical patient populations and highlights the need for consultation liaison services in Addiction Medicine. Typical clinical scenarios include withdrawal from alcohol or other drugs, postoperative management of pain or drug interactions with pharmacotherapy for substance dependence. From an epidemiological perspective, the rise in alcohol-related problems with the increased availability of alcohol5 and the escalating rates of prescription drug abuse (opiates, tramadol, non-steroidal anti-inflammatory agents and benzodiazepines) in the community4, 6, 7 and substance use problems in indigenous populations draw attention to the importance of Public Health expertise to the development of prevention and intervention strategies. Addiction was originally attributable to single aetiologies, especially psychological dysfunction or personality traits and in the past, there was little available that the physician could offer to individuals experiencing problems with alcohol or other substances. However, the advancement in the understanding of the many processes underlying addiction (including physiological, neurobiological, behavioural and psychosocial) means that the physician can assess and advise on the optimal management of the acute complications of alcohol and drug use as well as formulate a management plan for the longer term. In addition, Addiction physicians have an important role in providing responses to the very real and significant issues of rising rates of chronic non-malignant pain, ‘drug seeking behaviour’ and problematic prescribing. These are important emerging issues in medical practice today that would benefit from the input of Addiction Medicine. Examples of such input include through involvement in medical training (both undergraduate and postgraduate), through contribution to changing regulatory processes and establishment of real-time reporting for prescribing of drugs of dependence. It is in this context that the Australasian Chapter of Addiction Medicine (AChAM) was established as part of the Royal Australasian College of Physicians (RACP). AChAM's aims include the advancement of knowledge, expertise and ethical standards in the clinical practice of Addiction Medicine. AChAM also aims to be an authoritative body for the purpose of consultation in matters of educational or public interest in connection with alcohol, tobacco and illicit drugs. To date, Fellows of AChAM have already been involved in several initiatives. Many individuals have for some years now collaborated with other areas of the RACP in the development of submissions to government and policies on alcohol,8 tobacco,9 drugs10 and prescription opioids.4 Fellows of AChAM have also made valuable contributions to the development of the Australian Alcohol Guidelines, Clinical Practice Guidelines for Opiate Dependence and Alcohol Dependence and been involved with many educational initiatives. Addiction Medicine was recognized as a new medical specialty in December 2009 by the Federal Health Minister Nicola Roxon, and included in the Australian Medical Council (AMC) List of Australian Recognised Medical Specialties. This was the result of considerable work commencing in 2004 and followed several steps that included making a case for Addiction Medicine being considered a medical specialty, establishment of a formal Training Program, review and accreditation by the Australian Medical Council and advice to the Federal Health Minister on formal recognition of the field. The RACP is, to the author's knowledge, the first College of Internal Medicine Physicians to offer formal Advanced Training in Addiction Medicine. The curriculum has been defined, piloted and refined, and offers trainees a wide scope of training in both hospital and community contexts. Training of Physicians in Addiction Medicine currently includes a much broader range of alcohol and drug problems than physicians were exposed to in the past. Training requirements include rotations that are hospital-based (including Consultation Liaison experience) as well as training in community-based settings in acute withdrawal (‘detox’) units and ambulatory contexts, such as Pain Management Clinics. Some examples of the broad range of clinical experience the Addiction Medicine trainee is exposed to include management of acute withdrawal from alcohol, tobacco or other drugs when abrupt cessation of the substance use occurs on admission to hospital, management of pain in the context of (often escalating) opiate or other analgesic dependence, addressing binge drinking in the context of unstable diabetes, liver disease in the context of alcohol abuse and hepatitis C infection or acquired brain injury secondary to longstanding alcohol or polysubstance abuse. These are the ‘bread and butter’ of Addiction Medicine. Clinical scenarios often less thought of in the context of addiction, but still common, include the management of withdrawal from longstanding benzodiazepine use for insomnia in the elderly individual with deteriorating respiratory function. More ‘generic’ training experience includes enhancing adherence to treatment, managing challenging behaviour, diagnosis and intervention for many mental health disorders comorbid with the presenting disease, ‘crisis’ management, transition in care from adolescent to adult healthcare services, communication skills and working in a multidisciplinary team. In addition to high-quality clinical management of individuals, another benefit of the establishment of Addiction Medicine is the development of physician-researchers to bridge the divide between the sciences underlying our knowledge about substance use disorders and the clinical application of the science in medical practice. This has long been recognized as an important objective of the RACP as highlighted recently in RACP News by Emeritus Professor Richard Larkins.11 The recent review of governance and education at the RACP reflects new expectations of physicians from government and community. These expectations have not just influenced the RACP but undergraduate and other postgraduate institutions are now incorporating Addiction Medicine into their curricula so that there can be appropriate responses to the needs of the community. The establishment and recognition of the AChAM is timely as its relevance to our colleagues in internal medicine grows and the broad multidisciplinary readership of the Internal Medicine Journal provides an ideal opportunity to share our knowledge and experience in this area.