Education and Training
Addiction research poses an exciting challenge for young scientists who wish to address one of the most important and persistent problems confronting society today (see Chapter 2). However, a number of factors may present obstacles to talented researchers considering a career in addiction research. One often-cited obstacle is the lack of the educational and training opportunities necessary to attract and support students and young professionals—and to encourage them to stay in the field during periods in which opportunities in other fields seem more attractive.
Based on the workshop and quantitative information collected during the study, the committee identified obstacles in both research and public arenas that may deter young investigators from entering addiction research. Obstacles within the research arena include lack of educational and training opportunities, lack of opportunities for integrative and collaborative research, and lack of adequate and stable funding (see Preface). This chapter focuses mainly on the educational and training opportunities in secondary schools, undergraduate institutions, and graduate and professional schools, as well as issues specific to research training and support during the early career years. Chapter 7 addresses the resource issues for new professionals in the field, and Chapter 8 addresses the obstacles presented in the public arena.
Career pathways for scientists and physician researchers are varied and present numerous points at which decisions can be made regarding career alternatives (NRC, 1994). As is the case for many careers that require graduate degrees, an interest in addiction research is likely to develop in college or graduate/medical school. However, the decision-making process starts much earlier; unless teenagers are already interested in scientific or medical careers, they are unlikely to take the undergraduate courses that could expose them to information about addiction or prepare them for graduate or professional school programs that train addiction researchers.
Some undergraduate students will seek particular graduate programs because they have already decided that they want to learn more about addiction or pursue a career in addiction research. Others will be interested in related research issues and come into contact with patients, faculty, course work, or research projects that encourage them to specialize in the field of drug abuse and addiction.
Until 15 years ago, most basic, clinical, and behavioral researchers in drug addiction received their doctoral training in pharmacology, experimental psychology, or a social science field. More recently, doctoral training programs in neuroscience have been established in many academic institutions; students in these programs have the kinds of interests and educational backgrounds that are particularly compatible with a career in addiction research. Recent addiction-related developments in the areas of biology and molecular genetics, cell and developmental biology, neurobiology, immunology, and behavioral pharmacology present compelling biological questions which are also attracting new investigators into the field of addiction research. M.D. and M.D./Ph.D. students also may become interested in treating addicted persons or be drawn to the theories and research on addiction. Several programs for such students, funded by the federal government, the private sector, or other institutions, provide integrated research and clinical experiences relevant to addiction.
Many students and young investigators, however, are not exposed to addiction research during their undergraduate, graduate, or medical school training because there are relatively few addiction-related courses offered at colleges, universities, and medical schools. Responses to the IOM survey from university and medical school administrators suggest that there is a lack of commitment on the part of many academic institutions to teach the subject area and formidable barriers to adopting new educational curricula which include more training and education about addictive disease.1 These include competition with other subjects, the perception by many faculty members that the area is not scientifically
important, and the limited number of adequately trained faculty to teach such courses.
SECONDARY SCHOOL AND UNDERGRADUATE EDUCATION
All secondary schools offer science courses and many offer classes in psychology, sociology, or health education. Scientific information about drug addiction should be integrated into all these courses in high schools, colleges, and vocational schools. In addition, any classes or programs aimed at discouraging drug use should include factual, scientific information on the nature of drug abuse and should communicate that scientists are engaged in ongoing research in preventing and treating addiction.
Strategies are needed to enhance the educational curricula in drug addiction so that students learn about the genetic and biological bases for addiction and how they interact with psychosocial and behavioral factors in the development of addiction, efforts to overcome it, and relapse. There is also the complementary need to improve the expertise of faculty, so that well-qualified professionals who are capable of developing the necessary curricula are available to teach students about addicted individuals and addiction research.
Organizations such as the American Association for the Advancement of Science (AAAS) and the Faculty for Undergraduate Neuroscience (FUN) are attempting to broaden scientific knowledge at the K–12 and undergraduate levels, respectively (see Boxes 6.1 and 6.2). Such programs should include addiction research in their curricula.
Teenagers are exposed to a wide range of role models in various careers, but they are unlikely to know any addiction researchers, or even to read about them or see them on television. However, if there were more addiction researchers at colleges and universities, undergraduate students would be more likely to be inspired by their work and consider careers in the field. In addition and consistent with goals to increase the number of minorities and women in science and medicine, special attention should be paid to identifying women and minorities as role models.
To enhance interest in drug abuse research and foster a more complete understanding of the causes and consequences of drug abuse in secondary and undergraduate programs, the committee recommends:
The U.S. Department of Education should provide incentives for schools to increase emphasis on the physiological and psychosocial aspects of drug abuse and addiction in science and health education classes at elementary, middle school, and high school levels; and
BOX 6.1American Association for the Advancement of Science
The American Association for the Advancement of Science (AAAS) is a nonprofit professional society dedicated to the advancement of scientific and technological excellence across all disciplines and to the public's understanding of science and technology. AAAS pursues a number of activities with implications for raising the profile of substance abuse research, a few of which are listed below.
Project 2061. A long-term initiative to reform K–12 education so that all high school graduates are science literate. The project produced Science for All Americans in 1989, which outlines what all students should be able to do in science, mathematics, and technology areas by the end of the K–12 period. In 1993, Benchmarks for Science Literacy, a curriculum design tool, was published. The report set knowledge goals for students completing grades 2, 5, 8, and 12. An upcoming computer resource called Designs for Science Literacy will help educators analyze their own science literacy and analyze curriculum elements to determine which elements help to achieve science literacy goals. Ultimately, the project will produce a comprehensive computer-based design for construction of a K–12 curriculum.
Science + Literacy for Health. This project, supported by the National Institute on Drug Abuse (NIDA), combines adult literacy efforts with science literacy and health information. The effort will target low-reading-level adults in literacy programs and community-based substance abuse and mental health education programs. The project has produced two books relevant to raising the profile of drug abuse: The Brain Book which covers brain function and injury, tumors, strokes, and Alzheimer's and Parkinson's diseases; and Brain and Behavior, which covers how the brain and behavior can be affected by mental disorders and drug abuse. Finally, AAAS recently received funding from NIDA to develop a drug education curriculum to be used by adult literacy and family literacy educators through a three-year project called the Science + Literacy for Health Drug Education Partnership.
SOURCE: AAAS (1996).
Professional societies should facilitate expanding coverage of a science-based approach to understanding drug abuse and addiction at the university undergraduate level, especially in general psychology, sociology, and biology courses. Additional reviews should also be undertaken of related curricula in departments of social work, rehabilitation, and health education.
Box 6.2 Faculty for Undergraduate Neuroscience
The Faculty for Undergraduate Neuroscience (FUN) was established in 1991 to represent the concerns of neuroscientists teaching at undergraduate colleges and universities. FUN is an offshoot of the Society of Neuroscience and maintains close links with the parent organization. The group seeks to broaden knowledge and training in science, particularly the critical exposure to original research undertakings that may be absent from the traditional ''prepackaged" curriculum experience. According to its 1993 mission statement, FUN is pursuing five goals:
SOURCE: FUN (1996).
GRADUATE AND PROFESSIONAL EDUCATION
Graduate School Programs
Graduate schools offer relatively few courses in substance abuse, a situation that has not changed over the last two decades. For example, in 1978–1979, Selin and Svanum (1981) conducted a survey of clinical psychology programs that were approved by the American Psychological Association (APA) and found that students received only minimal training in drug use and abuse. Lubin and his colleagues replicated the study in 1984, including APA-approved counseling psychology programs as well as clinical psychology programs, and found that there were no discernible differences in the quantity or quality of courses compared to the 1978–1979 results (Lubin et al., 1986). The study was again replicated in 1991–1992, adding APA-approved professional psychology (PsyD) programs in clinical psychology to the PhD clinical programs, but excluding counseling programs (Chiert et al., 1994). Once again, the authors found no differences compared to the earlier studies.
These surveys, which were completed by between 79 and 82 programs each time, indicated that very few faculty had expertise in substance abuse, and most schools did not offer any courses in the subject. For example, the estimated number of faculty with interests in "alcoholism/substance abuse" ranged from 7 percent in 1978–1979 to 10 percent in 1991–1992. The number of schools offering at least one graduate-level course ranged from 42 percent in 1978–1979 to 38 percent in 1991–1992, but all but one of these courses were elective.
The 1991–1992 survey asked questions about specialization that had not been asked in the earlier surveys. Interestingly, it found that 52 percent of the schools offered practicum placements in institutions dealing primarily with substance abuse, and 76 percent indicated at least one current research project in the area (Chiert et al., 1994).
No data are available on the number of sociology departments with courses on addiction, although the American Sociological Association (ASA) reports that eight graduate programs offer specialty concentrations in substance abuse (ASA, 1996).
Graduate programs in pharmacy also have shortcomings, but efforts are underway to improve their curricula in the area of addiction. In the late 1980s, a survey of pharmacy faculty found that two-thirds believe their curriculum is inadequate in the area of drug and alcohol abuse. In 1988, the board of directors of the American Association of Colleges of Pharmacy adopted guidelines for curriculum development in drug and alcohol abuse (Baldwin et al., 1991).
It appears that there are more opportunities for training in drug abuse counseling than in research-oriented programs, and these opportunities are primarily at a less advanced educational level. The National Association of Alcoholism and Drug Abuse Counselors (NAADAC) lists 44 programs that offer graduate or postgraduate degrees, 38 that offer bachelor's degrees, and 77 that offer associate degrees (NAADAC, 1996).
These examples indicate that courses in addiction are not widely available on most university campuses. The lack of drug addiction research curricula at the undergraduate and graduate school level may discourage students who are interested in the field.
Medical School Programs
The lack of rigorous instruction on drug abuse and addiction is a particular problem in medical schools. Less than 1 percent of curriculum time is spent on drug addiction studies in U.S. medical schools (Durfee et al., 1994); few programs devote more than a few hours of class time to the topic within required or elective courses. Furthermore, only four of 121 medical schools reported requiring a separate course on alcohol and drug abuse (AAMC, 1997), and specific curricula have not been widely adopted (Durfee et al., 1994), as they have by many specialties (e.g., pharmacology) (Baldwin et al., 1991), psychiatry (Halikas, 1992), primary care and family medicine (Davis et al., 1992, 1993),
and pediatrics (Kokotailo et al., 1995). In addition, courses on addiction may be offered in several different departments (IOM, 1995) and their overlapping or inconsistent content may discourage students from taking more than one.
A concerted effort to stimulate medical school education in addiction medicine began in 1972 with the Career Teacher program sponsored by NIAAA and NIDA. The program, which is no longer funded, originally trained faculty to develop and implement curricula; it was funded in 59 U.S. medical schools. Currently, the U.S. Center for Substance Abuse Prevention (CSAP) sponsors a faculty development program, begun in 1989, which funds programs in 34 schools of medicine, nursing, social work, and psychology (IOM, 1995).
Only two medical schools have curricula and programs on drug addiction that are cited by those in the field as models: Harvard Medical School and the University of Pennsylvania School of Medicine (see Boxes 6.3 and 6.4). Harvard's four-year-old program includes required courses and course elements in the first two years and then various elective rotations, basic science seminars, and senior clinical electives. The program includes 60–70 faculty members whose primary focus is drug abuse issues. The University of Pennsylvania School of Medicine drug abuse curriculum, established in 1990, provides a basic introduction to addiction issues through lectures and elective rotations. Most of the course work is in the psychiatry department, and there are 10–15 faculty members involved.
In other medical schools, the number of required and elective courses has increased in recent years, but the number of faculty with expertise in addiction who are available to teach these courses or serve as mentors is low compared to those with expertise in other chronic diseases (Durfee et al., 1994; Kokotailo et al., 1995). A rigorous, systematic evaluation of those curricula and the specific educational needs of medical students and of health professions in other specialties has not been conducted, nor has there been any systematic evaluation of training programs. Because such evaluations can be quite expensive consideration needs to be given to a variety of less costly strategies to improve coverage of these topics in medical schools.
Reflecting the lack of attention to addiction as part of medical school curricula, many educational institutions and even accreditation boards tend to ignore the issues of addiction completely. For example, there are few questions on drug addiction on the national medical and board specialty examinations (Chappel and Lewis, 1992; Schnoll et al., 1993). The lack of emphasis on this health and social issue is likely to convey a message to young professionals that is not important.
BOX 6.3 Case Study: Harvard Medical School, Division on Addictions
This 4-year-old program for addiction medicine focuses on required courses and course elements in years one and two, and various elective rotations, basic science seminars, and senior clinical electives in years three and four.
Faculty: Approximately 360 affiliated faculty members (60–70 with a primary focus on substance abuse issues).
Educational Task Force: Approximately 20 faculty from the 7 teaching hospitals affiliated with Harvard University. The group is charged with evaluation of course content ensuring sufficient depth and breadth.
Program Evaluation: A recent evaluation found several problems. These included findings that medical students (1) do not view successes; (2) are not taught to recognize substance abuse in an inpatient setting; (3) do not learn to make appropriate referrals; and (4) do not have good role models.
Barriers: Several barriers to improving the situation were identified: (1) lack of knowledge; (2) stigma and prejudice; (3) social acceptance of some drugs (i.e., alcohol and nicotine); (4) physician addiction; (5) denial (by physician and/or patient); and (6) enabling by the physician (e.g., overprescribing).
Potential Solutions: Several improvements were suggested: (1) expose students to patients with successful outcomes; (2) address physician addiction; (3) faculty development (better mentors); (4) increase patient exposure during first two years of curriculum.
Student Feedback: In the fall of 1993, two medical students who saw gaps in their substance abuse training proposed a project to correct the problem. The result was a collaboration by 38 medical students and 16 faculty on the Source Book on Substance Abuse and Addiction (Friedman et al., 1995).
Community Involvement Project: The medical school's Division on Addictions is developing, in cooperation with the community of Billerica, Massachusetts and the Merrimack Valley Educational Collaborative, an addiction science curriculum. The goal is to improve basic science education in grades 6–12 by using the scientific method and focusing on substance abuse and addiction science as examples.
SOURCE: Thurmond (1995–1996
Finally, clinical experiences are an essential part of the medical school curriculum, and exposure to addiction issues in clinical settings could be an important influence on medical students' career decisions. However, intentional exposure to addicts and addiction issues does not happen often during graduate training or medical residency. As one young investigator stated, "Perhaps if more residents had mandatory training in addiction treatment, the field would be more likely to be considered important and interesting" (IOM, 1996).
BOX 6.4 Case Study: University of Pennsylvania, School of Medicine
The substance abuse curriculum at the University of Pennsylvania School of Medicine and Veterans Affairs Medical Center was established in 1990 as a result of the periodic curriculum review process, including a student-faculty retreat. The program provides a basic introduction to substance abuse through selected lectures and elective rotations. The bulk of the course work is in the psychiatry department.
Faculty: Approximately 10–15 affiliated faculty members (most with psychiatry training and an added qualification in addiction medicine).
Barriers to Improving Curriculum: The major barriers are (1) competition for time in an already crowded curriculum; (2) ambivalence about the study of substance abuse or belief held by some faculty that it is less important; and (3) a persistent perception problem—is addiction a disease or simply bad behavior?
Clinical Research Fellowship in Substance Abuse: A highlight of the substance abuse program is the clinical research fellowship program, run by the Department of Psychiatry and Veterans Affairs Medical Center's Treatment Research Center. The two-year fellowship program provides mostly clinical and some basic research training for physicians and postdoctoral fellows in the treatment of substance abusers. All fellows participate in clinical rotations, but focus their research in one of several laboratories affiliated with the program.
Training Program: All program participants are assigned a mentor with whom they meet weekly. The first year of the program consists mostly of clinical rotations supplemented by course work focusing on research methodology and ethics and biostatistics, particularly in the substance abuse field. During the second year, fellows engage in full-time research and publicly present the findings. Participants are also guided through the process of writing a NIDA/NIH-style grant application before the end of the program.
SOURCE: Cancro (1996); O'Brien (1996); Woody (1996).
Increasing course work and clinical experience in addictive disorders would have benefits beyond the recruitment of new physician-scientists into the field. For one thing, approximately half of all medical students and residents will become primary care providers. Thus, improving the curricula and enhancing exposure to addiction during clinical training would increase medical students'
knowledge and awareness and positive attitudes and beliefs and help them better identify drug abuse and addiction problems (Gopalan et al., 1992).
Multidisciplinary teaching addressing medical, epidemiological, public health, behavioral, and social science perspectives on drug addiction should be incorporated into mainstream educational curricula for all medical students and many other health professionals. In addition, specialty board examinations should include questions on drug addiction. Finally, because students need to be properly prepared to work in a clinical environment and have an understanding of the clinical needs of this field and the approaches to treatment, opportunities to work in clinical settings should be incorporated into medical training.
An innovative program to improve physicians' ability to diagnose and treat addiction has been established by the North Carolina Governor's Institute on Alcohol and Substance Abuse, Inc. In 1992, the Kate B. Reynolds Charitable Trust Fund provided $887,479 to the Governor's Institute to help promote curricula changes in the state's medical schools. The goal of the changes was to better equip medical students with the necessary skills and knowledge to prevent addiction and identify, intervene with, and manage addicted individuals. Evaluation of the institute's modification of curricula at four medical schools (Duke University, University of North Carolina, Bowman Gray at Wake Forest University, and East Carolina University) related to alcohol and drug abuse found that the amount of alcohol and drug abuse education increased, educational materials and activities related to alcohol and drugs were developed, greater interaction occurred in teaching and research across disciplines and departments, familiarity with the curriculum development process increased, and faculty development programs were initiated and enhanced (North Carolina Governor's Institute, 1996a). The Governor's Institute also works closely with universities to provide seed money for young investigators in addiction research (see Box 6.5). The committee believes that strategies similar to the North Carolina program should be encouraged.
Although there are many opportunities in educational and training programs for addiction researchers, serious gaps remain that can reduce the knowledge, ability, and potential impact of those treating addictive disorders. An effective educational and training system must be responsive to the different needs associated with individuals at various stages of their careers and in different disciplines. Continuity and early exposure are integral elements in such a system (see Appendix I).
BOX 6.5 North Carolina Governor's Institute on Alcohol and Substance Abuse, Inc.
Goals: The institute seeks to bring about concerted action to strengthen curricula and pioneer new training methods for both students and professionals through interaction with drug abuse research and treatment programs. A related and mutually supportive goal is to aid communication among all health professionals, especially those working in primary care settings and drug abuse treatment programs.
Structure and Role: The institute is a private, nonprofit organization created in 1990 to address the special needs of health professionals for better education and more information about the complex social and medical problems of substance use, misuse, abuse, and dependency. The institute works with university medical centers; community hospitals and treatment facilities; Area Health Education Centers (AHEC); state and local public health and mental health agencies; federal agencies, such as the Center for Substance Abuse Treatment, NIDA, and NIAAA; and professional organizations including medical, dental, nursing, social work, clinical psychology, pharmacy, and drug abuse professionals. The institute acts as a catalyst and broker to promote cooperative action.
Scholarship Programs: The Young Investigator Award Program in Biomedical/Substance Abuse Research. The program, established in 1993, is a statewide, peer-reviewed award funded by the Burroughs Wellcome Fund. Its goal is to identify and promote the development of scientists who will perform research into the causes and effects of drug abuse with the goal of improving treatment modalities. The program provides one year of start-up funding of $5,000 to $12,000 for projects that can later be supported by outside sources. Each young investigator presents his or her findings at the following year's institute annual statewide conference. Applicants must be in an accredited postdoctoral educational program or in the first 48 months of a faculty appointment at a university in North Carolina. In its first three years, the program funded 12 of 37 applicants.
Public Policy Scholars Program. This program, established in 1992, is funded by the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. The program seeks to stimulate graduate students' and health professionals' interest in drug abuse and to produce information that will lead to a better understanding of drug abuse. The program awards support short-term research studies on drug abuse issues and their health and public policy implications. In 1995–1996 10 awardees will receive $2,500 each; they must present their findings in a televised public forum. Applicants must be graduate or medical students, postdoctoral fellows, or medical residents in North Carolina academic health sciences programs. In its first three years, the program funded 33 of 65 applicants.
The committee recommends that:
Accreditation and certifying entities [e.g., Liaison Committee on Medical Education (LCME), American Psychological Association (APA)] should review curricula in medical schools and in psychology, social work, and nursing departments for the adequacy of drug addiction courses and should require basic competence in these areas for certification and recertification on medical specialty board examinations and in other relevant disciplines;
Deans, administrators, and professional societies should undertake systematic evaluation of existing curricula to assess how they encourage or discourage training in addiction research and develop curricula tailored to different levels of schooling and specialty. Incentives should be provided to recruit and train faculty to teach courses in addiction research and to serve as role models.
THE IMPORTANCE OF MENTORS
Exposure to course work and clinical experiences in the area of addiction is a potentially important way to generate students' interest in addiction research careers. In addition, as in all areas of medicine, some investigators are motivated by personal reasons, such as having family members or friends with drug abuse or addiction problems. However, most of the new investigators who attended the committee's workshop highlighted the importance of their mentors and role models in their career decisions.
The lack of courses in addiction starts a cycle of shortages at every stage of the pipeline for professionals in the field of addiction research: fewer undergraduates
are exposed to scientific information about addiction, so that fewer graduate students and medical students express interest in the field; thus administrators do not seek faculty who are experts in the field, resulting in fewer young professionals on the faculty, and, ultimately, fewer senior faculty. A cause and an effect of these shortages is a lack of mentors at many institutions.
Undergraduates are influenced by the role models they meet in college and in their communities during a trial-and-error learning process which occurs early in their formative university years. A mentor, by contrast, is more actively engaged with a student but unlikely to be an important influence until graduate or professional school. Given the apparent importance of mentors for young investigators currently in the field, the shortage of faculty who have expertise in drug addiction and can serve as mentors is a serious problem (Chappel, 1991). At the March 1996 IOM workshop, several new investigators reported that good mentors were difficult or impossible to find in the schools (IOM, 1996). In addition, they noted the lack of female and minority role models. Several young investigators expressed the belief that research and treatment in the field tend to be dominated by males and that female students would benefit from female role models especially in dealing with patients who are difficult or threatening.
It is well known that clinical supervision provides the most effective means for improving clinical skills (Chappel and Lewis, 1992). Clinical researchers depend upon experienced role models and mentors to build a solid foundation in understanding and treating patients. However, the committee found that the lack of mentors was a particular problem for clinical addiction researchers. There was also some evidence of an insufficient number of qualified researchers in the behavioral and social sciences to serve as role models for graduate students interested in pursuing addiction research, particularly in combination with the M.D. degree. For example, the behavioral and social sciences are excluded from the Medical Sciences Training Program (MSTP), which provides federal funding to pursue M.D./Ph.D. degrees jointly.
Although there is empirical literature concerning the importance of mentoring on shaping careers, relatively little of this research has been conducted in the fields of medicine or addiction research. A study of psychiatry faculty at 116 medical schools found that M.D.s listed faculty and other mentors as most influential in their decision to obtain research training; those trained in Ph.D. and M.D./Ph.D. programs cited faculty and other mentors as the second most influential factors in their decisions to become trained as researchers (Pincus et al., 1995). The central role of mentors is further underscored by the finding that time spent with a mentor was seen as an integral part of a research training program and provided guidance into specified areas of research and career development (Pincus et al., 1995).
Strategies to Enhance the Role of Mentors
Mentors are needed at all stages of research training as well as for different groups of students, such as women and minorities. There is no single strategy for increasing and sustaining the number and quality of mentors; several different efforts are needed.
One strategy would be to make more attractive existing programs provide mentorship opportunities for students. The Senior Scientist Award (K05) and the Academic Career Award (K07), offered to both the junior and senior researcher levels,2 could include mentoring qualifications to support this development. These and other awards should be further encouraged and reviewed to ensure that they are attracting the most capable mentors and that the awards are closely coupled with the mentored career development awards for biomedical and behavioral scientists. For example, NIDA and NIAAA in the past jointly sponsored a Career Teacher Training Program—which was cut from the budget during the Reagan years—and placed career teachers in nearly 60 medical schools (Pokorny and Solomon, 1983). These and other programs would be particularly useful if available at the research centers that offer the best training environments in terms of breadth and depth for emerging scientists.
The committee believes there is a critical need for mentors trained in interdisciplinary approaches. The committee supports the development of new pre-and postdoctoral fellowships that provide comprehensive and intensive training in sound research methods and practical research experience in drug addiction, using mentoring by an interdisciplinary group (two or more) of experienced investigators.
Another strategy would be to develop a network of mentors to provide opportunities for co-mentoring when the available mentors at the young investigator's department or institution lack critical expertise in areas required to conduct a particular research project. In those instances, the young investigator would have a mentor on-site but would obtain additional technical assistance from another person who might be located at a different institution. To facilitate geographically remote mentoring relationships, satellite mentoring programs could be established through the network of mentors. To gain a better understanding
of the role of mentors in various research career pathways (i.e., neurological, clinical, and behavioral), it would help to assess systematically the effects of various aspects of mentoring experiences on subsequent research involvement.
Strategies aimed at providing staggered intervals of mentoring at various stages of training might also be useful, for example, short-term internships to expose researchers in addiction to the clinical setting or educational materials that yield an accurate picture of the clinical experience. Incentives for such exposure could be provided through joint programs with industry, foundations, universities, and government.
Ways to overcome the unique difficulties in designing and conducting addiction research are best learned from good mentoring relationships, where students learn by example how to work with, manage, test, and treat some extremely difficult patients. Mentors in a clinical setting can help develop suitable and testable hypotheses, critique papers, assure that adequate research time is available for collecting pilot data, and assist with grant applications. Clinical mentors are also important to help address some of the problems, such as lack of time, competing demands, and financial support, that lead to the high attrition rates in addiction research by health professionals.
To promote appropriate mentoring, the committee recommends that:
Ph.D. programs in the behavioral and social sciences should be included among the degrees eligible for M.D./Ph.D. (MSTP) support;
NIDA and NIAAA should increase the number of mentors by promoting interdisciplinary research through the establishment of funding mechanisms for mentoring teams composed of investigators from different disciplines in the Academic Centers of Excellence programs;
NIDA and NIAAA should emphasize innovative mentoring programs through the K05, K07, and other K award mechanisms; and
NIDA and NIAAA should consider reviving the Career Teacher Training Program.
SPECIALIZATION AND CREDENTIALING ISSUES
Although the focus of this report is on addiction research, the issues of treatment and research are often intertwined. Faculty with expertise in treating drug-addicted individuals can stimulate faculty who have expertise in conducting basic or applied research on addiction. Likewise, the availability and quality of treatment are dependent on innovative research findings. Furthermore, many graduate students, medical students, postdoctoral students, and medical residents
will be exposed to the field of addiction research while being supervised in treatment settings.
Professionals who deal with the public concerning mental health and drug addiction need to be familiar with the scientific research regarding addiction (Chapters 3, 4, and 5). Currently, many professionals do not possess the information they need to inform others. If the goal is to ensure appropriate and effective treatment and research, drug addiction must be taught as part of the educational credentialing process of all health care providers, and there should be rigorous standards for specialization as well. One way to achieve this would be better translation of research into treatment, particularly community-based treatment programs and providers, and better use of clinical experience in the design of research studies. This topic is the concern of another IOM committee, the Committee on Community-Based Drug Treatment, whose report is expected in 1998.
Overall, the committee found limited opportunities for credentialing, specialization, and accreditation for the practice of drug abuse treatment. Strategies are needed to encourage wider adoption of a credentialing process for addiction across the range of medical and health care specialties.
Board certification has become an important postdoctoral licensing mechanism for physicians in the United States (Moore and Lang, 1981). Many hospitals and managed care organizations require board certification in a physician's field of specialty (IOM, 1995). In the addiction field, there has been some pressure for physician certification from third-party insurance carriers and regulatory agencies to establish the qualifications of physicians responsible for drug treatment (Chappel and Lewis, 1992).
In some specialty areas there has been positive movement toward certification opportunities. In 1991, the American Board of Psychiatry and Neurology (ABPN), in concurrence with the American Board of Medical Specialties, officially established the field of addiction psychiatry as an area of subspecialization. Board certification of psychiatrists involved in addiction treatment provides a means of identifying properly trained and experienced addiction psychiatrists. Similarly, APA recently established a College of Professional Psychology to certify licensed psychologists in proficiency areas of practice; the first program established criteria for a certification program in alcohol and drug abuse. Although other professional associations have not followed suit, the American Society of Addiction Medicine (ASAM) has established certification examinations for its members and continues to request the American Medical Association (AMA) to ask each of the primary care specialties' certifying boards to study the desirability and feasibility of offering subspecialty examinations in addiction medicine (ASAM, 1997).
Although addiction medicine may not become a board-certified specialty, most professional associations and organizations provide and recommend continuing medical education (CME) courses in drug addiction. For example, the Association for Medical Education and Research in Substance Abuse
(AMERSA) promotes postgraduate medical education on drug addiction through curriculum development and national meetings.
The committee recommends that:
All treatment professionals should have some knowledge of basic neuroscience and how alcohol, nicotine, and other drugs work on brain pathways, influence behavior, and interact with diverse conditions. Treatment professionals should include physicians, nurses, clinical psychologists, social workers, drug abuse peer counselors, and other health care providers who work in conjunction with one another in treating patients with an addictive disease;
Continuing education courses to update treatment professionals' knowledge base on addiction should be instituted systematically and widely; and
Competence-based documentation of treatment professionals' knowledge base on addiction should be sought in licensing and recertification examinations.
A number of strategies are necessary to attract talented students into the field of addiction research. Incorporation of additional information about the process of addiction in precollege and undergraduate science classes, for example, may not only interest young people planning a research or medical career but it can also increase public understanding of addiction. The challenge in graduate and medical school programs is to increase the amount of information presented in a variety of ways, including course work, clinical experiences, research fellowship opportunities, and other mechanisms. Throughout the educational experience, however, mentors and role models provide often critical input in the career decisions of talented young people. Thus, ways to develop and enhance teachers and mentors with expertise in addiction research would be very useful long-term strategies. Finally, increased attention to addiction in medical specialty board examinations and other professional certification programs is needed to foster a greater understanding of addiction by professionals leading eventually to integration of the diagnosis and treatment of addiction into general medical and primary health care settings.
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