Held in conjunction with the Demand Treatment Conference in Houston, Texas

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Testimony Presented February 3, 2003 by:

John T. Pichot, MD of the American Academy of Addiction Psychiatry: Member of the Board of Directors; Head, Public Policy Section; and Member, PGY-V Residency Committee

Thank you for inviting us to participate in these hearings. The American Academy of Addiction Psychiatry (AAAP) is a professional membership organization with approximately 1,000 members in the United States and around the world. It was founded to:

• Promote accessibility to highest quality treatment for all who need it
• Promote excellence in clinical practice in addiction psychiatry
• Educate the public and influence public policy regarding addictive illness
• Provide continuing education for addiction professionals
• Disseminate new information in the field of addiction psychiatry, and
• Encourage research on the etiology, prevention, identification and treatment of the addictions.

The AAAP greatly appreciates and supports the leadership of this Quality Treatment Policy Panel in seeking ways to help people understand and overcome severe alcohol and drug use problems. We are here to provide testimony to this panel not only out of respect for your leadership efforts, but also with our hope we will be of some assistance in helping you achieve your goals, as we too are committed to improving the availability of quality treatment and long term outcomes for people who suffer with addictive disorders.

I would also like to express my personnel appreciation to David Rosenbloom and Janice Ford Griffin. My now five-year collaboration with them and the various organizations they lead, beginning with my Join Together Fellowship, has motivated me to move beyond my familiar clinical world as a physician trained in addiction psychiatry, to serve the AAAP in its efforts to develop polices that will help improve the lives of people with addiction related disorders.

Toward that end this brief oral testimony, supplemented by our 2 ½ page written testimony, will serve to highlight some of the key areas of focus and activity for AAAP in Public Policy and Physician Training, which are consistent with this Quality Treatment Policy Panel’s stated mission for quality substance disorder treatment and the training of treatment providers.

ADDICTION RELATED PUBLIC POLICY

1) AAAP has an active Public Policy Committee with over fifty physicians members, specializing in addiction psychiatry, that have accelerated policy development over the last two years. As of 2002 the AAAP Board of Directors, has approved 15 policy statements including policies on the following selected topics:

2) The AAAP is also seeking strategies to increase our collaboration and national profile as an addiction policy organization and these efforts have included:

• Providing AAAP funding for a part time consultant position of Director of Public Policy and Governmental Relations to assist the work of the Public Policy Committee and Board of Directors
• AAAP testimony at important panels, commissions, and committees on addiction topics. In addition to today’s testimony, within the last thirty-days the President of the AAAP provided testimony to the President’s New Freedom Commission On Mental Health focusing on the inclusion of treatment for people with co-occurring substance use and psychiatric disorders in their planning and recommendations. Two days from now the Secretary of the AAAP will again testify on co-occurring disorders and on parity of coverage to the President’s New Freedom Commission On Mental Health.
• Representation on the National Coalition to Increase Access and Parity for Addiction Treatment Committee and identification of AAAP members in 22 states interested in working on state level collaborations on parity efforts.
• AAAP support of selected Amicus Briefs an addiction related issues.

3) Primary short goals for the AAAP in the area of Addiction Public Policy include:

• Development of new policy statements on the following proposed topics:
• Advancing addiction education for all healthcare providers
  (In collaboration with the American Society of Addiction Medicine)
• Co-occurring hepatitis C and substance use disorder treatment
• Co-occurring pain and substance use disorder treatment
• Drug courts
• Secondhand smoke and banning public smoking
• Develop new strategies to make AAAP policy documents serve as a catalyst for member action
• All newly developed polices will have a succinct, more readable one page format
• Twice a year an AAAP Public Policy Update is sent all members (See Attachment 1)
• Develop specific policy action packets, modeled after the Join Together Online "Hot Topics", that can be download from the AAAP website
• Customizable op-ed letters for local papers, letters to local legislators, a focused talking points list, expanded key reference reading list to support the brief one page policy document, tips for editorial letter writing
• Expanded AAAP Annual Meeting Public Policy Workshops
• Experiential training in interviewing skills for video interviews; for pitching legislators and business leaders on policy topics; tips for staying on focus during interviews

ADDICTION RELATED PHYSICIAN EDUCATION

1) The AAAP and its members are a leading force in medical education regarding addiction related disorders in the United States

• The organization in large part was formed to lead the development, for the first time, of board certification in addiction as a specialty area by the American Board of Medical Specialties and to require formal supervised training in the clinical care of people with addiction related disorders as a requirement for board certification
• Both goals were accomplished in the mid-1990’s and there are now 47 addiction physician training programs located in academic centers across the country

• Nationally this is an investment of ~$19 million a year in training physicians in addiction medicine with a typical program having a minimum of 2 board certified faculty [2 x ~$150, 000] and average of two physician fellows in training per year per program [2 x $50,000 for salary & fringe].

• Leadership in training physicians to use buprenorphine as an office based treatment for opioid dependence disorders, sponsoring courses across the country.
• Key teaching positions for addiction topics for medical students, primary care and non-psychiatry specialty residents across the country, providing both didactic instruction and clinical supervision in treating addiction related disorders.
• Sponsors an AAAP Annual Meeting in December that is focused on the clinical care of people with addiction related disorders
• Sponsors a two day Review Course in Addiction Psychiatry every other year

2) Despite recent successes in developing educational programs there are substantial problems related to addiction education that must be addressed in a collaborative fashion.

• There still needs to be more physician addiction training programs developed for specialists

• For example the Houston area, which has one of the greatest concentrations of medical resources in any single metropolitan area, does not have single addiction physician training program between Baylor College of Medicine, University of Texas at Houston or University of Texas Medical Branch in Galveston

• Funds are needed for both faculty and physician trainee salaries to sustain and build addiction programs

• Currently the only formal federal support for these physician addiction-training programs is VA based funding for 6 of the 47 programs. The remaining resources are allocated out of research funding or some alternative source, such as unfilled general psychiatry resident positions.

• Funds need to be found to train primary care physicians, non-psychiatry specialty physicians, and other health care providers within these existing addiction physician training programs

• Only 10 of the 47 addiction programs have training positions for non-psychiatrist health care providers, primarily because there are no funds from any of the other services, either primary care or specialty care, to support physicians interested in addiction training.

• Stigma that strongly effects people with addiction related disorders is a major problem that also strongly impacts on the clinical providers who care for these people

• Recruiting physicians to enter training for addiction medicine, especially U.S. medical school graduates is increasingly difficult due to a combination of these stigma issues and the large debts residents have completing medical school

• The "Health Professionals Substance Abuse Act", which was introduced as SB 1996 by Sen. Biden and HR 3793 by Rep. P. Kennedy, proposes funding a multi-million dollar addiction education program for primary care physicians and other healthcare providers completely independent and specifically exclusionary of the existing addiction training programs

• Such a strategy would lead to a wasted opportunity to combine these new funds with the existing ~$19 million dollar a year investment in addiction physician training programs to build a comprehensive addiction education program network that would be open to many more health care providers

RECOMMENDATIONS FOR THE QUALITY IMPROVEMENT PANEL

• Collaborate with the AAAP to find creative new ways to support the expansion of addiction training for health care providers in the U.S. We have had far more success in this area then any other group over the last ten years and are very interested in continuing this past success.

• Consider sponsorship of a national meeting that would include both AAAP and the American Academy of Addiction Medicine, as will as other key organizations, to review the planning process and implementation strategies for a revised version of the Health Professionals Substance Abuse Act for the 108^th Congress. The goal would be a bill that is inclusive and collaborative with the existing funded addiction training programs.

• Look to the AAAP as a resource in your future efforts to develop and implement addiction clinical education projects and public policy efforts.

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