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6
Training and Education
Pharmaceutical investment in new medications, from discovery to marketing,
is expensive and risky (OTA, 1993; Chapter 7), and it depends on a strong
infrastructure to support a return on investment. The infrastructure for research
and development of a new medication has many components: strong federal
leadership and private sector commitment, federal and industry support of
research, basic scientists dedicated to elucidating the mechanisms of disease,
clinical investigators designing and conducting clinical research and identifying
potential leads for new treatments, clinicians specifically trained in the diagnosis
and treatment of the disease, health care professionals knowledgeable about
recent research findings, adequate reimbursement for treatment, and an educated
public that supports effective treatments. In the area of anti-addiction medications
development, however, many of those components are scarce or nonexistent.
This chapter explores three paths towards strengthening the clinical research
and treatment components of the infrastructure for anti-addiction medications
development: increasing the number of clinicians and clinical researchers in the
field of addiction research and treatment; providing all physicians with training
in the diagnosis and treatment of drug dependence; and expanding the capabilities
and coordination of federal drug abuse research centers for all aspects of
research, training, treatment, and education.
Drug abuse is a major public health problem in the United States (Chapter
1~. The economic consequences of drug abuse are staggerin~the United States
spends more than $66 billion annually on drug-abuse related health care costs
and on the indirect costs of crime, incarceration, and drug supply control (D.
Rice, University of California at San Francisco, personal communication). Yet,
134
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TRAINING AND EDUCATION
135
the federal government has not provided sustained support or innovative
programs to increase the number of clinical researchers and clinicians in the field
of drug addiction-a critical component of the infrastructure. There are too few
clinicians trained in diagnosis and treatment, and there are limited numbers of
clinical investigators interested in pursuing careers in drug addiction research.
While the biomedical sciences in general are having difficulty in attracting and
funding young researchers, especially clinical investigators (IOM, 1988, 1990;
NRC, 1994), the numbers being attracted to the field of drug addiction research
are particularly sparse. That fact has led addiction medicine to be identified as
an orphan field of medicine (IOM Workshop, June 1994~.
It is possible, however for the federal government to stimulate the discovery
of anti-addiction medications. Historically, there have been other types of
medications for which research and development were not initially embraced by
the pharmaceutical companies. Comparable to the early history of acquired
immune deficiency syndrome (AIDS) research and drug development, for
example, the field of addiction treatment is faced with obstacles that include a
stigmatized patient population, a lack of specialized clinicians and researchers,
and limited scientific knowledge regarding the disease mechanism. Despite those
difficulties, federal investment and support in AIDS research has led to an
increase in researchers and clinicians and to the development of several
medications. During the past 10 years, four medications have been developed and
approved for the treatment of AIDS, as compared to three anti-addiction
medications in the past 30 years. Given the enormous burden of drug abuse on
society, drug abuse research and treatment deserve a similar level of attention
and resources from the federal government.
EXPANDING THE CORE OF RESEARCHERS AND CLINICIANS
The critical need for scientists, clinical investigators, and clinicians to
specialize in drug addiction research and treatment has been recognized by
Congress and the executive branch (ONDCP, 1994; U.S. Congress, 1994~.
However, there are numerous disincentives to entering this field, such as the
perceived low prestige of the field of addiction medicine, low-paying positions,
difficulties in conducting clinical research, personal health risks of working with
patients who often have serious illnesses (e.g., HIV infection and tuberculosis),
uncertain treatment reimbursement, a stigmatized patient population, and the
involvement of many patients with crime and the criminal justice system.
Although the limited availability of scientists and clinicians specializing in
drug abuse research and treatment has direct consequences for the delivery of
health care services and research on new treatments, it has a less obvious, but
equally important, effect on pharmaceutical R&D investment. Pharmaceutical
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136
DEVELOPMENT OF MEDICATIONS
companies traditionally market their products to health care professionals and
promote their products through personal visits by sales representatives, through
journal and mail advertising, and through support of scientific symposia and
continuing medical education. Pharmaceutical companies distribute their products
through hospital and community pharmacies, pharmacy chains, and distributors.
To the extent that the treatment of drug dependence is often delivered outside
that system by specialized clinics (e.g., narcotic treatment programs, typically
with part-time physicians and limited marketing opportunities for pharmaceutical
companies), and to the extent that drug abuse treatment involves many fields of
medicine (e.g., family practice, internal medicine, psychiatry), pharmaceutical
companies see greater difficulty in marketing anti-addiction medications than in
marketing other products. Pharmaceutical firms also rely on academic clinical
investigators and practicing clinicians to advise them on drug development issues
such as current therapeutic trends, the role of drugs in the overall treatment
strategy, unmet medical needs, indications to be evaluated, clinical trial design
and appropriate therapeutic endpoints. Therefore, increasing the number of
trained specialists is critical to anti-addiction medication development.
Many organizations are involved in efforts to strengthen the infrastructure
(Box 6. 1), and although some progress has been made, addiction medicine is still
a relative unknown to many in the health professions and continues to be
neglected by the pharmaceutical industry. Drug abuse treatment is intrinsically
interdisciplinary and involves a variety of health care professionals, including
counselors, social workers, therapists, psychologists, nurses, and physicians. The
committee supports increased training opportunities for all health care profession-
als involved in drug abuse treatment, but the focus here is on increasing the
numbers of clinical investigators and clinicians working in drug addiction
research and treatment.
The following section examines current efforts to increase the numbers of
physicians and scientists specializing in drug addiction research and treatment,
through the National Institute on Drug Abuse (NIDA) training programs,
fellowships offered by private institutions and the government, and certification
programs.
Training Programs
The committee heard throughout its work and at its June workshop that there
is a severe shortage in the number of clinical investigators in the field of
addiction medicine. Physician-researchers are needed to take the lead in
developing and implementing clinical research programs on new pharmacological
and behavioral treatments. NIDA offers research career development awards to
support mentored research by scientists and clinicians interested in pursuing
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TRAINING AND EDUCATION
137
careers as independent investigators. However, there is difficulty in attracting
physicians to these programs. The Scientist Development Award for Clinicians
(K20) provides drug abuse or mental health research experience for clinically
trained individuals, especially physicians; the Scientist Development Award
(K21) provides experience for biological or behavioral scientists (NIH, 19931.
Stipends for those awards are based on institutional base salaries and range up
to $75,000. NIDA funding of research career development awards has increased
annually from $507,000 in fiscal year (FY) 1991 (funding five awards) to an FY
1994 estimate of $3.9 million (38 awards) (NIDA, 1994a). However, those
programs are not filling the critical shortage of clinical investigators. Only two
of the 18 recent applicants for K20 and K21 grants were physicians.
NIDA's $7.9 million training budget for FY 1994 was 2.4 percent of its FY
1994 total extramural research funding. Since FY 1986 NIDA's training budget
has averaged 2.0 percent of its extramural research funding (Table 6.1~. In
contrast, other institutes of the National Institutes of Health (NIH:and the
organization as a whole have larger proportional training budgets. Since FY
1986 the training budget for the National Institute of Neurological Disorders and
Stroke averaged 3.1 percent of total extramural research (2.7 percent in FY
1993), the National Institute on Mental Health averaged 7.7 percent (6.4 percent
in FY 1993), and NIH as a whole averaged 4.8 percent (4.3 percent in FY 1993)
(NIDA, 1994a). In the FY 1994 bypass budget, NIDA requested an increase in
the number of trainees to 440 fill-time positions, but only modest increases were
funded. For FY 1995 NIDA has requested $17.4 million for research training,
which would more than double its training budget (NIDA, 1994b). Actual
funding increases are expected to be modest. Funding for the National Research
Service Awards (NRSA), the majority of training funding, is appropriated by
Congress to NIH as a whole. Once the final appropriation is made, NIDA
competes with other NIH institutes for a share of the funds.
Fellowships
Another mechanism for developing expert practitioners, researchers, and
teaching faculty is through postresidency fellowships, primarily sponsored by
~NRSAs fund training opportunities that include predoctoral and postdoctoral research
and mentored research for career development. In 1994, NIDA awarded 68 NRSA
fellowships (36 predoctoral and 32 postdoctoral) to support individuals working with
experienced researchers and 245 NRSA training awards (105 predoctoral and 140
postdoctoral) to support drug abuse research training at public or nonprofit institutions
(NIDA, 1994a).
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DEVELOPMENT OF MEDICATIONS
BOX 6.1
Some Organizations Involved in Training and Education
Federal Government
.
National Institute on Drug Abuse (NIDA) supports biomedical and
behavioral research, health services research, and research training on drug abuse,
including prevention end treatment. NIDA's training opportunities include individ-
ual and institutional awards to train predoctoral and postdoctoral clinicians and
researchers and support of the Minority Access to Research Careers (MARC)
program for minority undergraduate research training. Additionally, NIDA offers
mentored research career development programs for scientists and clinicians.
.
Substance Abuse and Mental Health Services Administration
(SAMHSA) supports prevention and treatment services for mental health and
addictive problems and disorders. The three major components of SAMHSA are
the Center for Substance Abuse Treatment (CSAT), the Center for Substance
Abuse Prevention (CSAP), and the Center for Mental Health Services (CMHS).
· CSAT currently funds l 1 addiction training centers that focus on
increasing the number and knowledge of health professionals of all disciplines
involvedinsubstanceabusetreatment. Additionally, CSATsponsorsaddiction
counselor training programs and develops and disseminates the National
HIV/AIDS Training Curriculum.
· CSAP has four components in its training system: curriculum
development, community prevention training, volunteer training in prevention
activities, and the Faculty Development Program, which provides part-time
support for faculty in health professional schools to implement or strengthen
drug abuse education at their institutions.
.
CMHS training programs include institutional grants to enhance
clinical training of mental health professionals from many disciplines, regional
grants for in-service training of practicing mental health professionals, and
HIV/AIDS education programs for mental health care providers.
· Health Resources and Services Administration (HRSA) Bureau of
Health Professions has established the Physician Consortium on Substance Abuse
Education, which brings together representatives from academia, government
agencies, medical professional organizations, and accrediting agencies to focus on
drug abuse education for all levels of medical training. Additionally, HRSA has
funded faculty development programs in this area.
· Department of Veterans Affairs (VA) medical centers offer chemical
dependency fellowship programs.
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TRAINING AND EDUCATION
Academic Institutions
Individual academic medical centers vary widely in medical school and residency
education on drug abuse. Fellowships in addiction medicine are offered at more
than 35 institutions, primarily in departments of psychiatry. Health education
schools of many disciplines also offer training.
Foundations
Many foundations provide support for drug abuse curriculum development and
sponsor educational activities on drug abuse which have included conferences of
medical educators, scholarship programs for medical student training on substance
abuse, and continuing medical education programs.
Associations and Professional Societies
.
American Academy of Psychiatrists in Alcoholism and Addiction
(AAPAA) has 1,300 members who are board-certified psychiatrists or residents of
psychiatry interested in furthering education, research, and treatment of addicted
patients. AAPAA offers continuing education review courses and sponsors the
publication of The American Journal on Addictions.
.
.
American Society of Addiction Medicine (ASAM) has a membership
of more than 3,000 physicians involved in education, treatment, research and
prevention of drug abuse. This organization offers continuing education courses for
practicing physicians, administers the independent (non-ABMS) certification in
addiction medicine, and sponsors the Journal of Addictive Diseases.
· Association for Medical Education and Research in Substance Abuse
(AMERSA) has a current membership of more than 400 health professional
educators. It works to expand drug abuse education and to support faculty and
curriculum development. AMERSA was formed in 1976 by many of those
involved in the Career Teacher Program. The journal, Substance Abuse, is
sponsored by AMERSA.
.
College on Problems of Drug Dependence (CPDD) is an interdisci-
plinary research society focusing on the problems of drug dependence. Its annual
scientific meeting brings together basic scientists and clinical investigators from
industry, academia, and government. CPDD sponsors the journal, Drug and
Alcohol Dependence, which reports scientific research.
.
Professional medical societies including the Society of Teachers of
Family Medicine and the Society of General Internal Medicine offer continuing
education courses, develop drug abuse curricula for residency training, and support
faculty development efforts.
139
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140
DEVELOPMENT OF MEDICATIONS
academic institutions. A 1992-1993 survey conducted by the Center for Medical
Fellowships in Alcoholism and Drug Abuse reported 46 fellowship programs
inthe addiction field providing 88 fellowship positions, however, only 61 ofthose
positions were filled (Center for Medical Fellowships, 1993~. The total number
of fellows for 1992-1993, including all training years, was 170. The fellows
spent an average of one-third of their time in research, and almost half of their
time in patient care. Typically, the fellowship programs are affiliated with
psychiatry departments, either solely (85 percent) or jointly with other depart-
ments including internal medicine and family practice; few of the programs were
affiliated solely with family practice programs or departments.
TABLE 6.1 NIDA Research Training Funding as a Percentage of Total
Extramural Research Funding ($ millions)
Research Training
Individual Institutional Total
No. Amount No.
Amount No.
Percent of
Total
Extramural
Amount Research
1986 24 0.40 48 1.03 72 1.43 2.2
1987 36 0.67 66 1.58 102 1.25 2.0
1988 31 0.57 67 1.73 98 2.30 1.9
1989 35 0.64 52 1.73 87 2.37 1.5
1990 42 0.83 1 13 2.98 155 3.81 1.4
1991 73 1.26 217 5.55 290 6.81 2.1
1992 61 1.11 224 6.01 285 7.12 2.1
1993 65 1.26 237 6.1 1 302 7.37 2.2
1994 68 1.38 245 6.52 313 7.90 2.4
Estimate.
SOURCE: NIDA, 1994a.
Fellowships are also offered by NIDA's Addiction Research Center and
through the Department of Veterans Affairs. Additionally, NIDA and the Food
and Drug Administration (FDA) offer a joint fellowship program aimed at
training physicians in drug-abuse treatment research, specifically focused on
clinical trials to aid in the development of new anti-addiction medications. That
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TRAINING AND EDUCATION
141
program provides stipends for three clinicians per year to receive 3 years of
training through rotations at NIDA's Medications Development Division, the
FDA Center for Drug Evaluation and Research, and the NIDA Addiction
Research Center. There has been, however, limited applicant response to that
program (IOM Workshop, June 1994~.
Certification
Board certification has become a"de facto postdoctoral licensing mecha-
nism" for physicians in the United States (Moore and Lang, 19819. Hospitals and
managed care companies often require that physicians become board certified in
their fields of specialization. In the addiction field, the push for physician
certification has resulted in part from third-party insurance carriers' and
regulatory agencies' attempts to ascertain the qualifications of physicians
responsible for chemical dependency units (Chappel and Lewis, 19924.
The American Board of Medical Specialties (ABMS), a nationally
recognized organization with oversight for medical specialty board certification,
includes 24 member boards that give annual examinations in core specialties
(e.g., internal medicine or psychiatry). Many of these core specialty boards offer
certification examinations in subspecialty areas, such as geriatric medicine or
addiction psychiatry. In 1991, the American Board of Psychiatry and Neurology
(ABPN), an ABMS member board, established the field of addiction psychiatry
as a subspecialty. Certification for added qualifications in addiction psychiatry
requires ARMS board certification in psychiatry, completion of a fellowship in
addiction psychiatry (required after 1998) or extensive clinical practice time with
addicted patients, and successful completion of the added qualifications
examination (ABPN, 1993~.
The American Society of Addiction Medicine offers independent (non-
ABMS) certification in addiction medicine for physicians of all specialties.
Qualifications for certification include completion of a residency training
program, at least one additional year of work in the field of alcohol and drug
dependency, and successful completion of the multi-disciplinary certification
examination.
The move toward certification is strongly supported by the committee. It
increases the number of physicians with a subspecialty in addiction medicine and
it increases the knowledge and skills of those physicians who choose certification
in addiction medicine.
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142
DEVELOPMENT OF MEDICATIONS
Conclusions and Recommendations
The committee applauds current efforts aimed at increasing the number of
researchers and clinicians in the field of addiction research and medicine, but it
recognizes that those efforts have had only limited success. Given the paucity of
trained professionals in this area, coupled with other disincentives to the
pharmaceutical industry, it is clear that additional measures must be taken to
overcome this obstacle.
The committee recommends that the federal government increase
its efforts to attract researchers and clinicians to the field of drug
addiction treatment. That may be accomplished by implementing
one or all of the following options:
· NIDA's training budget could be increased, but not at the
expense of their research programs. Requests from NIDA for large
increases in its training budget have not been filled in FY 1993 or
FY 1994, and NIDA has received a lower percentage of training
funds than several other institutes. Increasing NIDA's training
budget such that it will enable NIDA to offer fellowships that are
competitive with private sector salaries, and therefore, more
attractive to potential candidates would "jump-start" the expansion
of the field of drug addiction treatment and research; it could have
nationwide impact by increasing the numbers of scientists and
physicians recruited, trained, and working in the field of drug
addiction.
· An educational loan repayment program in return for work
in drug abus~related clinical research could attract young physi-
cians with substantial educational debt into careers as clinical
investigators.
There is a precedent: the NIH Loan Repayment Program (LRP) for AIDS
Research (P.L. 100~07 and P.L. 103~3) allows NIH to repay education loans
for NIH scientists, physicians, and registered nurses who spend at least 80
percent of their time involved in AIDS research. Applicants for the LRP program
must have qualified educational debt in excess of 20 percent of their annual NIH
basic pay or stipend and must be employed under a mechanism that allows for
their NIH employment to last a minimum of 2 years (Health Policy and
Biomedical Research News of the Week, 1994~. To achieve greater national
impact, loan repayment for work in the drug addiction field could be extended
beyond NIH employees to encompass NIDA trainees and others working in the
field.
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TRAINING AND EDUCATION
· Mid-career programs could be developed to encourage a
cadre of practicing physicians and scientists to enter the field of
drug addiction treatment and research.
143
Mid-career programs have been sponsored in the field of geriatric medicine
with success. The Bureau of Health Professionals and the John A. Hartford
Foundation have sponsored one-year training programs for physicians interested
in redirecting their careers toward geriatric medicine (IOM, 1993; Robbins,
1993~. Similar programs could fill the current needs for physicians in drug
addiction treatment and research, while new researchers and physicians are
receiving training. In addition, short-term, mid-career training programs should
be made available at NIDA's existing research centers and proposed comprehen
sive drug abuse centers.
INCREASING KNOWLEDGE AND SKILLS
AMONG PRIMARY CARE PHYSICIANS
Just as critical as infusing the addiction field with researchers and medical
specialists is expanding primary care physicians' knowledge and skills in the
diagnosis and treatment of drug abuse. Given the consequences of managed care,
health care reform efforts, and the potential for new medications to treat drug
addiction, primary care physicians must be able to diagnose drug addiction, and
they must be familiar with its treatment modalities. It has been shown that
physicians do not diagnose drug abuse disorders with the same accuracy as other
chronic diseases (Coulehan et al., 1987; Gopalan et al., 1992~. Although they are
often the first to see drug-dependent patients (Kamerow et al., 19861. Because
of their minimal training in drug abuse, many physicians lack confidence in their
diagnostic ability and they are ambivalent or pessimistic about the effectiveness
of treatment (Chappel et al., 1977; Cotter and Callahan, 1987~. This is not
surprising; the curriculum on drug abuse and its treatment varies greatly in
medical schools. Over the past 20 years, drug abuse education (most often
combining information about alcohol dependence and other addictions) has
evolved slowly and has only recently begun to make inroads into the medical
school curriculum, residency training programs, and the certification process.
A concerted effort to stimulate medical school education in addiction
medicine began in 1972 with the Career Teacher program sponsored by the
National Institute on Alcohol Abuse and Alcoholism (NIAAA) and NIDA.
Funded in 59 U.S. medical schools, the program trained faculty to develop and
implement curricula. That program provided two key elements for raising
awareness and expanding knowledge regarding the addiction field a dedicated
faculty member serving as a role model for students and a high profile in
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144
DEVELOPMENT OF MEDICATIONS
medical schools for drug abuse education. During its 10-year existence
(1972-1981) the program resulted in an increase in curriculum hours, although
the percentage of total time required for drug abuse education remained under
1 percent (Pokorny and Solomon, 1983~. Currently, the Center for Substance
Abuse Prevention (CSAP) sponsors the Faculty Development Program, begun in
1989, which funds grants to 34 schools of medicine, nursing, social work, and
psychology. Each grant provides part-time support for a program director, an
evaluator, and three to five faculty fellows with the goal of developing a cadre
of faculty to- provide leadership in expanding and improving clinical teaching
about drug abuse (CSAP, 1994; Fleming et al., 1994a). Faculty development in
drug abuse education also has interested medical professional organizations,
including the Society of General Internal Medicine and the Society of Teachers
of Family Medicine, which, with funding from the Health Resources and
Services Administration (HRSA) have developed and implemented faculty
development courses (Fleming et al., 1994a).
Additional efforts have been made to define and promote education for
primary care physicians. The 1985 Conference on Alcohol, Drugs, and Primary
Care Physician Education produced a consensus statement identifying core skills
and competencies for primary care physicians and set out educational strategies
for implementation (U.S. DHHS, 1985; Lewis et al., 19871. In 1989, under the
auspices of the HRSA Bureau of Health Professions, the Physician Consortium
on Substance Abuse Education was formed and subsequently drafted recommen-
dations for improving drug abuse education at all levels of medical education
(U.S. DHHS, 19911. Work is ongoing to implement those recommendations.
Through private and public funding, model undergraduate medical curricula
on alcohol and drug abuse have been developed at several universities. Project
ADEPT (Alcohol and Drug Education for Physician Training), a core curriculum,
was developed at Brown University, and is used in more than 75 percent of U.S.
medical schools (Chappel and Lewis, 1992~. Gains have been made in increasing
medical school and residency education on drug abuse issues, although it is often
fragmented between departments and frequently is not linked to adequate clinical
training (Cotter and Callahan, 1987; Lewis et al., 1987~. Little attention is being
given to cross-cultural and special-population issues in drug abuse education at
all levels (U.S. DHHS, 1991).
Required Education in Medical Schools
A 1991-1992 survey of medical schools found that 93 percent of the 124
medical schools responding had at least one curriculum unit in drug abuse; at
least two-thirds of those units were required (Fleming et al., 1994b). That was
double the amount found in a similar 1986-1987 survey (Davis et al., 19881. The
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TRAINING AND EDUCATION
145
curriculum units ranged from single lectures to clinical experience. The number
of departments reporting drug abuse curriculum units ranged by specialty 95
percent of psychiatry, 87 percent of family medicine, 59 percent of pediatrics,
47 percent of internal medicine, 46 percent of emergency medicine, and 45
percent of obstetrics-gynecology departments had at least one unit (Fleming et
al., 1994b). The multifaceted nature of the consequences and treatment of drug
abuse suggests that medical school education in this field should be cross-
departmental and that the basic science and clinical aspects should be sequenced
appropriately throughout medical training (Cotter and Callahan, 1987; Burger and
Spickard, 19911.
Only eight medical schools surveyed by the Liaison Committee on Medical
Education in 1991-1992 had a separate required course on drug abuse (Fleming
et al., 1994b). Far more had separate required courses in other special multidis-
ciplinary topics. For example, 17 require a geriatrics course, 32 require a
community health course, and 40 require a nutrition course (Fleming et al.,
1994b). Few medical schools require clinical experience with drug-abuse patients,
and if it is available the clinical experience is often limited to hospital inpatient
settings where it is reported that the students are less likely to see the continuum
of problems or the range of treatments (Kamerow et al., 1986; Lewis et al.,
1987).
Residency Training
Residency education in addiction medicine is highly concentrated in
psychiatric programs. A 1991-1992 survey of residency programs in four
specialties found that 95 percent of psychiatry programs offered at least one
addiction medicine curriculum unit, followed by family medicine (85 percent),
pediatrics (59 percent), and internal medicine (47 percent) (Fleming et al.,
1994b). Most of the required units were lectures and seminars; the electives were
usually 2- to 8-week clinical rotations. Residency programs also rely on inpatient
treatment settings for clinical training although most offer clinical exposure to
two or more treatment settings (Davis et al., 1988~.
The Josiah Macy, Jr. Foundation targeted residency education on drug abuse
as the topic for its October 1994 conference. Leadership of the primary care
certifying boards and of the residency review committees in internal medicine,
family practice, pediatrics, and OBGYN along with business purchasers of health
care, state legislative leaders, and drug abuse experts met and reached consensus
on the urgency and necessity for primary care residency review committees to
require drug abuse education for all residents under their supervision. Additional-
ly, consensus was reached on the need for certifying boards to better reflect in
their evaluation process the clinical magnitude of the drug abuse problem (D.
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146
Lewis, Brown University, personal communication).
Continuing Education
DEVELOPMENT OF MEDICATIONS
Most currently practicing physicians had received minimal formal
training if any in the diagnosis or treatment of drug abuse while they were in
medical school or during their residencies. Continuing medical education (CME)
can fill the gap, and several organizations, including the American Society of
Addiction Medicine and the American Society for Medical Education an
Research in Substance Abuse conduct workshops and conferences that prepare
faculty for teaching continuing medical education courses. National professional
organizations and state medical societies are also key to CME efforts. For
example, the American Medical Association, the American College of Physicians,
the Society of Teachers of Family Medicine, the Ambulatory Pediatric
Association, and the American College of Obstetrics and Gynecology have al
prepared continuing education materials, workshops, and courses in this field.
The transfer of new research findings on treatment is especially critical as greater
numbers of primary care physicians become involved in diagnosing and treating
drug-dependent patients.
Conclusions and Recommendations
Increasing the depth and breadth of drug abuse education at all levels of
physician training will result in heightened awareness of the physiological,
psychological, and behavioral components of addiction and heightened
understanding of the effectiveness of and the need for a range of treatment
modalities. By understanding the spectrum and effectiveness of treatment
services, physicians will be able to recommend the most appropriate and cost-
effective intervention for the individual patient (Simek-Downing and Forman,
1987~.
The committee recommends an increased emphasis on drug abuse
education throughout medical school and primary care residency
programs. To accomplish this, the following could be implemented:
· Drug abuse education could follow a systematic, integrated
approach to coordinate the curriculum across specialty depart-
ments.
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TRAINING AND EDUCATION
· Training institutions could develop affiliations with commu-
nity-based treatment centers, where feasible, to provide student
access to multiple treatment settings.
· The National Board of Medical Examiners2 and the
primary care specialty boards of the American Board of Medical
Specialties (ABMS) could pay increased attention to drug abuse
issues, skills, and knowledge on their examinations for certification.
· Faculty development programs could receive increased
federal support. CSAP's Faculty Development Program which
trains medical school faculty members to serve as role models,
educators, and mentors in the field of drug abuse research and
treatment, is a good model.
COMPREHENSIVE DRUG ABUSE CENTERS
147
The goal of a solid infrastructure needed to support anti-addiction medica-
tions development and comprised of specialists and primary care physicians who
are knowledgeable in the diagnosis and treatment of drug abuse, can be realized
in part through the implementation of comprehensive, multidisciplinary drug
abuse centers recommended by the committee (Chapter 2~. The centers of
excellence would focus on all aspects of research and treatment, and they would
offer the added benefit of serving as training sites for new investigators and mid-
career physicians entering the field. They also would be clinical training sites for
medical students and residents as they learn to diagnose and treat drug-dependent
patients. A characterization of the centers, as envisioned by the committee, is
provided below. Additionally, current NIDA and Substance and Mental Health
Services Administration (SAMHSA) centers are briefly described and options for
implementation of the centers are given.
Proposed Model
For optimal effectiveness the centers should have clinical research, treatment,
basic research, and training components. Built around a core clinical research
program with both inpatient and outpatient treatment capability, they could be
funded directly using the model of the National Cancer Institute's (NCI)
Comprehensive Cancer Centers (Box 6.2), as discussed in Chapter 2.
2The National Board of Medical Examiners prepares and administers to medical
students a two-part examination that is accepted by individual states as part of licensing.
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148
DEVELOPMENT OF MEDICATIONS
BOX 6.2
NCI Cancer Centers Program
Begun in the early 1960s, NCI currently supports 55 research centers with
diverse focus, structure, size, and funding.
.
research.
Basic science cancer centers are primarily engaged in basic laboratory
Clinical cancer centers focus on basic and clinical research.
Comprehensive cancer centers are multidisciplinary and are designated
as meeting NCI's criteria for strong basic and clinical research programs, state-of-
the-art patient care, strong participation in NCI-designated high-priority clinical
trials, significant prevention and control research, and community outreach
activities.
· Consortium centers focus on cancer control and prevention research and
work with state and local public health agencies.
The centers are funded through a variety of sources, including the cancer
center core grants (P-30 grants from NCI), which cover centralized administrative
and program costs including personnel, shared resources, and services (including
laboratory equipment), development, planning, and evaluation.
SOURCES: IOM, 1989; NCI, 1993.
The core clinical research program would not be linked to any given
research project but would be available to investigators for specific projects and
used as a site for training. Pilot projects could be reviewed by a local committee
that would decide which proposals could make use of the core treatment unit for
research. It would be expected that many of these pilot projects would result in
peer-reviewed research project grant (ROT) funding. The core treatment unit of
the comprehensive center would provide state-of-the-art patient care, serving as
a valuable community treatment resource treatment costs could be supported in
part by community or state block grant funding administered by the Center for
Substance Abuse Treatment (CSAT). Strong participation in NIDA- and NIH-
designated high-priority clinical trials and sponsorship of community outreach
activities would be additional priorities for the centers.
An equally essential component of the comprehensive center would be the
conduct of preclinical research and the timely transfer of basic research findings
to the clinical arena, which should result in the incorporation of pertinent
information into clinical protocols to improve their viability. Collaboration
between preclinical and clinical researchers is essential and at a minimum should
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149
involve regular interdisciplinary seminars that would be expected to lead to
collaborative projects.
The training component of the comprehensive centers should involve
undergraduates and graduate students, to train physicians and other health care
professionals including social workers, nurses, psychologists, and rehabilitation
counselors. The center training programs also should include a postdoctoral
training program primarily for research, but including training in treatment
techniques. Training programs should include funding for faculty and administra-
tive support of training. Competitive salaries for trainees are essential, given the
precarious financial situations of most recent medical graduates, and a loan
forgiveness program should be explored for trainees in the centers.
The comprehensive centers should be encouraged to develop collaborative
ties with the pharmaceutical industry. This would involve testing new medica-
tions in preclinical laboratories and conducting clinical trials in the core treatment
units. By supplying clinical trial site capability, the centers would provide
industry with an incentive to develop anti-addiction medications. The centers
would screen patients and obtain the necessary regulatory approvals- overcoming
many of the hurdles cited by industry as strong disincentives.
Existing Research and Training Centers
To expand on its recommendation (Chapter 2), the committee explored the
existing research and training centers sponsored by NIDA and SAMHSA.
CSAT Centers
The Center for Substance Abuse Treatment initiated its addiction training
center (ATC) program in FY 1993 to link publicly funded addiction treatment
and recovery programs with institutions that train health and allied health
practitioners. The centers serve as training sites for students, provide continuing
education to currently practicing treatment staff, and strengthen the drug abuse
curriculum within the participating institutions. All ATCs are multidisciplinary
and provide training opportunities for addiction counselors and other profession-
als, including social workers, marriage and family therapists, psychologists,
psychiatrists, and primary care physicians and nurses. ATC funds are used to
develop clinical training programs, support faculty, and conduct training needs
assessments.
Implementation of the program began in FY 1994, and 11 centers are now
funded through cooperative agreements three through state alcohol and other
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DEVELOPMENT OF MEDICATIONS
drug addiction agencies, and eight at academic institutions (including three
medical-school based-programs).
NIDA Research Centers
In FY 1993 NIDA funded 23 specialized research centers through the P50
Specialized Center extramural grant mechanism, at a cost of $24 million.
Specialized centers are multiple-investigator, long-term programs planned around
a major research objective or theme. Funded centers cover all aspects of NIDA's
mission. Additionally, NIDA has finned treatment research units (TRUs), which
conduct clinical studies examining multiple aspects of treatment. Initially funded
as research demonstration grants, TRUs now apply competitively for new center
grants as they come up for renewal. NIDA's intramural research center, the
Addiction Research Center in Baltimore, Maryland, is the site for clinical and
basic research on behavioral arid pharmacological treatments.
The FY 1995 Department of Health and Human Services appropriations bill
calls on NIDA to "support up to five multidisciplinary comprehensive substance
abuse centers that will undertake research, service, arid training activities to
demonstrate the effectiveness of such coordinated activities focused on women,
children, alla minorities" (U.S. Congress, Senate, 19941. The committee supports
the implementation of those centers and stresses the importance of a multidisci-
plinary effort.
Conclusions and Recommendations
Upon examination of the CSAT and NIDA centers, it appears that there is
ail opportunity for collaboration. Many of the individual components necessary
for the centers, as recommended by the committee, are currently in place. A
coordination of efforts between NIDA and SAMHSA could increase the number
of facilities available to patients, increase services, enhance research opportuni-
ties, and provide additional training opportunities without the need for a
concomitant increase in fimding. A possible NIDA/SAMHSA collaboration effort
could be the use of the ATCs as sites for treatment or prevention research. The
committee envisions the comprehensive centers as maximizing effective research
arid implementing innovative and effective drug abuse treatments.
The committee recommends that comprehensive drug abuse centers
be developed to engage in and coordinate all aspects of drug-abuse
research, treatment, and education. Further, the committee
recommends that NIDA and SAMHSA work together to coordinate
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TRAINING AND EDUCATION
the effective and efficient use of existing centers by adding, where
feasible, research, training, and/or treatment components.
151
The enormous public health and societal costs of drug abuse justify federal
funding of comprehensive centers that will train physicians and scientists, provide
state-of-the-art treatment, and expand basic research. The committee is aware of
federal budgetary constraints and has therefore recommended a mechanism of
cooperation between existing resources and capabilities, by expanding the mission
and goals of existing NIDA and SAMHSA centers.
SUMMARY
The current involvement of the research and medical communities in
research on arid treatment for drug abuse is limited. Few clinicians and clinical
researchers have been interested in pursuing careers in drug abuse research and
treatment, arid current efforts, through fellowships, traineeships, research
development awards, and certification, have not attracted sufficient interest in the
drug addiction field. This shortage of medical specialists has had a negative
effect on the pharmaceutical industry.
All physicians need to be educated in diagnosing and treating the chronic
nature of drug abuse. Current efforts must be strengthened to increase medical
school and primary care residency curricula, provide faculty development
programs, and expand continuing medical education.
Comprehensive drug abuse centers, as recommended by the committee, could
fulfill the multiple goals of providing sites for state-of-the-art drug abuse
treatment and research while serving as training facilities for generalists and
specialists.
As the societal costs of drug abuse increase, it is time to address the shortage
of specialists and the inadequacy of drug abuse education. Those efforts will
strengthen the infrastructure needed for research and treatment and will
encourage pharmaceutical investment in this field.
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Representative terms from entire chapter:
substance abuse
