Dear Dr. Duke:
Prompted by the release of a document entitled "Strategic Plan for
Interdisciplinary Faculty Development: Arming the Nation’s Health Professional
Workforce for a New Approach to Substance Use Disorders" that was primarily
supported by HRSA Cooperative Agreement #U78HP0001, we would like to take this
opportunity to share our views with you regarding some of the recommendations in
this report and to familiarize you with the American Academy of Addiction
Psychiatry. As a result, we hope that you and your staff will avail yourselves
of the resources and expertise of the Academy in future substance abuse related
activities.
We applaud the interest of the Health Resources and Services and
Administration in issues related to mental health including substance abuse. We
are aware that for more than twenty-five years, HRSA and its predecessor
organizations have recognized the valuable and crucial role of primary care
practitioners in identifying and referring patients for substance use disorders.
In the early 1980s, former Secretary of HHS, Joseph Califano was one of the
first prominent Federal officials to encourage attention to substance abuse
issues by requiring a funding preference for alcohol curriculum activities for
departments of family medicine under Section 780 of the Public Health Service
Act. We are pleased to see that trend continue.
The adverse consequences of substance use, abuse and addiction are widely
known and the prevalence of these disorders in the patient population of primary
care clinicians is also well established. However, as stated in the Executive
Summary of the report and documented in several credible research publications,
primary care physicians "do not identify and diagnose substance use
disorders with the same degree of accuracy as they do other preventable
diseases" and they do not feel confident or comfortable diagnosing these
disorders. There is, therefore, no doubt that critical needs exist to improve
the education of primary health care providers regarding mental health,
including substance abuse.
In that context, we would like to share our concerns about some of the
recommendations contained in the above referenced report that we believe would
be detrimental to improving access to substance abuse treatment services as well
as to the effectiveness of the interventions by primary care physicians. Because
we cannot comprehensively discuss all of our concerns, we are selecting two of
them that are of primary concern and request that you find a time in your very
busy schedule to meet
with the leadership of the Academy to more thoroughly discuss ways that we
can work together in the future for our mutual benefit and for those of our
patients.
Recommendation #5 calls for the creation of a HRSA interdisciplinary faculty
development fellowship specialist training program in substance use disorders.
Although the concept is indisputably an excellent one, the operationalization of
this recommendation appears to overlook existing manpower resources in the field
that could serve as the core of such a training program. As you may know,
psychiatry is the only medical specialty with an American Board of Medical
Specialties (ABMS) approved subspecialty in addictions, and there are PGY-5
addiction psychiatry residencies in 43 medical schools across the country. The
faculty and residents in these programs could serve as mentors and onsite
resources to substance abuse training programs in those institutions. Yet, this
is not recognized as a vehicle to accomplish our common goals. Instead,
according to the Strategic Plan, the "interdisciplinary specialist
educators in substance abuse" would be drawn primarily from alumni of
Project MAINSTREAM. This group of highly qualified individuals does not appear
to be broadly representative of the cadre of educators who are needed to make a
significant impact on the field. Again, specialists in addiction psychiatry are
notably absent. We believe that the involvement of addiction psychiatrists is
crucial to improving medical education in substance abuse.
Another example of our concern appears in Recommendation #9 that calls for
the convening of representatives of licensure, certification and accreditation
bodies to consider how certification requirements can better address SUDs.
Unfortunately, there is no reference in the document to the experience gained by
addiction psychiatry in achieving subspecialty status. The lengthy and intensive
route to achieving recognition of SUDs as a legitimate area of medicine or of
any other health profession, is likely to benefit greatly by the decade long
battles fought and won within psychiatry. The American Academy of Addiction
Psychiatry has, within its membership, many of the resources to provide advice
and consultation to others interested in increasing attention to SUDs within
their profession. This includes identifying core competencies, developing
criteria and questions for examinations and offering review courses to prepare
for the examinations.
We are aware that HRSA’s attention to SUDs is not a legislative requirement
and that changes in authorizing legislation may be required to comprehensively
address the substance abuse education and training needs of primary health care
practitioners. However, we believe that a good first step can be made without
legislative change by utilizing the expertise of members of the American Academy
of Addiction Psychiatry and other national professional substance abuse medical
organizations. Furthermore, collaboration with SAMHSA, as was done to some
extent in the above referenced cooperative agreement, could maximize the limited
resources of both agencies.
We would be pleased to discuss these issues with you in more depth if you are
able to offer us an appointment with you. We offer the resources of the Academy
to collaborate with you in improving the substance abuse education of health
professionals.
Sincerely,
Richard N. Rosenthal, MD
President
Enclosure