A dire need in addiction medicine wral.com

Chris McQ is a fictional case study created by Wlasiuk, brought to life for this class by Ric Mauré, a keyboard player who also works as a standardized patient — trained to represent a real patient, to help medical students practice diagnostic and communication skills. The assignment today: grappling with the delicate art and science of managing a chronic pain patient who might be tipping into a substance use disorder.

Addressing these quandaries might seem fundamental in medical training — such patients appear in just about every field, from internal medicine to orthopedics to cardiology. The need for front-line intervention is dire: primary care providers like Wlasiuk, who practices family medicine in a Boston community clinic, routinely encounter these patients but often lack the expertise to prevent, diagnose and treat addiction.

Now, a decadelong push by doctors, medical students and patients to legitimize addiction medicine is resulting in blips of change around the country. A handful of students has begun to specialize in the nascent field, which concentrates on prevention and treatment of addictions and the effect of addictive substances on other medical conditions. In June, the House of Representatives authorized a bill to reimburse education costs for providers who work in areas particularly afflicted by addiction.

There are only 52 addiction medicine fellowships (addiction psychiatry is a separate discipline), minuscule compared to other subspecialties. In August, the first dozen finally received gold-standard board certification status from the Accreditation Council for Graduate Medical Education (by contrast, there are at least 235 accredited programs in sports medicine).

While most medical schools now offer some education about opioids, only about 15 of 180 U.S. programs teach addiction as including alcohol, tobacco and other drugs, according to Dr. Kevin Kunz, executive vice president of the Addiction Medicine Foundation, which presses for professionalization of the subspecialty. And the content in all schools varies, he noted, ranging from one pharmacology lecture to several weeks during a third-year clinical rotation, usually in psychiatry or family medicine.

When you are a 20-something medical student, fists clenching nervously in the pockets of your white medical coat, learning to get gruff, grizzled Chris McQ to disclose uncomfortable truths is not readily gleaned from a textbook. McQ is crusty and defensive. As students resorted to the same chirpy rejoinder — “Awesome!"— he tried not to flinch. The man just wanted pain meds.

Despite the urgent need for addiction medicine education, there are considerable barriers to establishing it. Hours of training have already been meted out to conditions deemed critical. Making time in a jammed schedule can mean another subject has to be shrunk. Because addiction medicine is young, most medical schools can’t rely for expertise on fellows — postgraduate students who steep themselves in a subspecialty. Fellows would typically consult on addiction-related cases in hospitals and clinics, educate medical students and supervise residents in primary care fields where these patients first appear: family medicine, emergency medicine, obstetrics.

“I really enjoy working with these patients,” Buchheit told the students. “They have often been kicked to the curb by the formal medical system. They don’t trust us. So for them to walk into a room and have a doctor say, ‘It’s great to see you, thank you for coming in,’ is very powerful. And then you can see them get better with treatment. It can be very rewarding work.” The students tried out approaches on McQ. “You called our office and wanted an early refill on your Percocet,” said one. “But it’s important that you come in. I’m glad you’re here and we can maintain our relationship.”

The first patient, Brooke Anglin, 28, had had a rough ride. During a turbulent relationship when she was sagged down by depression and severe anxiety, she soothed herself with opioids. After the birth of her second child, she lost both her job as a supermarket cake decorator and custody of her two children. Under Wlasiuk’s care, she gradually weaned herself off the opioids. As Wlasiuk looked on, Anyikwa began careful questioning. “How have things been going?” she asked the patient.