Abstract
This special issue of Substance Abuse reviews postgraduate training programs for addiction medicine and their development in several model countries. It is an opportune time for this review, as a key step in the evolution of addiction medicine as a discrete medical specialty is the development of an appropriately trained workforce, and in turn, a training program for this purpose. Accreditation of a new specialty critically involves review of its training program, making it all the more important to establish these programs early on. At the same time, establishment of a defined training program plays a significant role in defining the scope of practice for the specialty. Until recently, there were few structured training programs for addiction medicine in any country so that clinicians gained skills in an ad hoc manner through experience, from reading the literature, and from senior colleagues. The scene is now changing rapidly. Structured training for specialists in addiction medicine is now established in several countries, and is under development in many others.
Development of a specialist training program requires careful consideration of a range of issues including admission criteria, content of training, particularly taking regional substance use problems and expectations regarding approaches to treatment, approaches to learning, assessment, and the nature of any ongoing learning or recredentialing. These must also match local requirements and expectations for a medical specialist training program.
The admission criteria to training vary enormously from those countries, the majority, that have no specific requirements beyond being a registered medical practitioner, to those with rather specific requirements. For example, the Australian program is auspiced by the Royal Australian College of Physicians and admission to addiction medicine training is regarded as advanced training that can only be undertaken after completing an approved basic training program, including an examination in general internal medicine or another comparable medical specialist examination (1). High entry standards may play a role in maintaining practice standards but potentially at the cost of discouraging some applicants from joining this program.
Various approaches to training in the management of substance use disorders have been developed. The Canadian model of adult professional development described in this issue (2) has been influential and has been adopted in other programs (3, 4). These focus on adult learning strategies as opposed to traditional didactic teaching methods. For clinical specialties, theoretical knowledge is important but clinical skills and appropriate attitudes to a marginalized patient population are often even more important. Thus, supervised and reflective clinical practice is important to develop these skills and implement them in daily practice. However, it is evident that there are limited clinical positions with the capacity to provide this type of training, as exemplified by the US experience (5).
The common comobidities are also uniformly included in the training, particularly mental health comorbidities. There is less clear agreement on other topics. The Canadian program includes training in behavioral addictions, including such compulsive behaviors as gambling and sex addiction (2). Other countries limit their focus to misuse of substances. In some settings, addiction medicine physicians become closely involved in the medical complications of substance use. These include drug overdose, end-organ damage, and related infections such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Thus, there is some difference between a more mental health versus a physical health orientation to training and practice in this specialty throughout the world. Not all forms of evidence-based treatment are available in every country or training program. In particular, opioid substitution treatment with methadone and or buprenorphine is not widely available throughout the world and some clinicians must undertake overseas training to gain this experience. In addition, some forms of substance abuse are confined to certain regions, which become the most appropriate place to gain treatment skills for disorders involving that substance. Thus, exposure to the international medical community is an important facet of a well-trained specialist in this field.
The structure of addiction medicine training must be consistent with other medical specialties in the same country. Each country has its own models for specialist training with which addiction medicine must comply. Perusal of the programs described in this issue will reveal the diverse structures that result. As discussed earlier, training does not yet lead to membership of a discrete specialty in most countries, but is the platform to establish the specialist status of addiction medicine.
Assessment of trainees varies from an exit examination to continuous assessment. A particularly interesting development is the international addiction medicine certification examination developed by the International Society of Addiction Medicine (ISAM) and described in this issue (6). This is likely to play an important role in development of this speciality given that many countries lack the resources to establish their own programs at this time. A validated international examination offers the advantage of an international “gold standard” but cannot readily include local considerations.
Continuing education and recredentialing is increasingly required for all generalist or specialist physicians, including those in addiction medicine. This is not described in this issue but must take part in continuing education according to their local craft group requirements.
It is hoped that this special issue will be of interest to those working in this field who are developing similar programs in other countries and that it will provide a point of reference as programs develop further into the future. The availability of approved training processes will play a key role in the evolution of addiction medicine as an approved medical specialty throughout the world.