Despite the high media profile of street drugs, medical marijuana and the ice “epidemic”, addiction medicine is a specialty in desperate need of new recruits with a strong streak of altruism
Recreational drugs are all over the mainstream news — ice epidemics, medicinal marijuana, growing concerns about Australia’s drinking culture — and yet the specialty best placed to exert a positive influence, addiction medicine, is struggling to meet the demand.
The Royal Australasian College of Physicians’ Australasian Chapter of Addiction Medicine (AChAM) came into existence in August 2002, with most of its founding Fellows regarded as pioneers and, frankly, legends in the field.
Today there are 230 Fellows across Australia and New Zealand, but two statistics tell the story of a looming problem.
The average age of Fellows of the AChAM is 58 years, and there are just 23 trainees across the two countries. Victoria, for example, with a population of some 5 million, has two trainees.
Dr Ingrid van Beek AM, the first director of Sydney’s Medically Supervised Injecting Centre and currently the director of 25 years’ standing of the Kirketon Road Centre in King’s Cross, has a blunt assessment of the situation.
“We’re a very ageing cohort”, she tells the MJA. “A whole bunch of us are poised to walk off into the sunset.”
When they do, with them will go decades of experience dating back to the HIV/AIDS crisis of the 1980s and the flood of pure, cheap heroin which washed the streets in the 1990s.
Clinical Associate Professor Adrian Reynolds, president-elect of AChAM, policy lead for the RACP in drug and alcohol matters and clinical director of Tasmania’s Department of Health and Human Services’ Alcohol and Drug Service, described it as “a dire situation”.
“We are an incredibly scarce resource”, he tells the MJA.
Three factors seem to be at play in discouraging doctors-in-training from hanging their hats on the addiction medicine peg.
“There is very little incentive”, Dr van Beek says.
“When you’re lining up against more lucrative and prestigious specialties like cardiology and surgery it’s a hard sell.
“People have to work hard to get into medicine; then to qualify as a doctor. Then it’s more years of study to gain specialist recognition. So it’s understandable that they may like to enjoy some social status when they finally get there.”
Most addiction physicians work in the cash-strapped public sector, so financially there are more attractive specialties on offer.
Currently there are 16 proposed new addiction medicine Medicare items which are due for Cabinet consideration, having been recommended by the Medical Services Advisory Committee.
But with rumours of a freeze on all new Pharmaceutical Benefits Scheme items floating around, Professor Reynolds’ colleagues are not overly optimistic about the chances of the 16 new ones being approved any time soon.
“I am optimistic that government will act when it realizes that the new item numbers would actually be a cost-saver for the government, not only in terms of direct health care expenditure but most importantly, health outcomes. At the moment psychiatrists are filling the gap, which is good, but psychiatrists are more expensive.”
Second, addiction medicine has an image problem — or at least its patients do.
“It’s a tough area, no question”, Professor Reynolds says.
“Colleagues often say to me, ‘how do you work in that tough area?’. But all specialties have their joys and their sadnesses, their difficulties and complexities.
“The tough part of my job is watching governments continuing to ignore the evidence and responding in largely ineffectual ways.”
Dr van Beek is not sure addiction medicine has an image at all.
“I’m not convinced people are even aware of the specialty’s existence”, she says. “People ask me all the time if I’m a GP or a social worker or a counsellor.”
Looked at from the outside, addiction patients are perceived as “criminals with self-inflicted problems, undeserving of health care”,
Dr van Beek says. “There are even some in the community who think that those of who work to keep such people alive are actually adding to society’s drug problem, which can be quite demoralising.
“I remember talking about my work at a local Rotary club once and the president, whose son was an orthopaedic surgeon, came up to me afterwards and said: ‘Why on earth did you choose to do this?’ Someone else upon hearing that I was the medical director of the injecting centre exclaimed: ‘Gosh, I’ve often thought that must be the worst job in Australia!’ Another conceded: ‘Well, I suppose someone has to do it.’”
Dr Matthew Frei, president of the AChAM, agrees that the patients addiction specialists treat are surrounded by a stigma.
“The first contact undergraduates and doctors-in-training might have had with drug users might have been in a setting where they would have been considered a pest or in which they weren’t managed confidently”, Dr Frei says.
“In fact, the people who access our treatment are from very broad backgrounds, from professionals through to those who are marginalised.
“We are using interventions that are often [producing better outcomes] than some chronic disease outcomes. But you often don’t get that sense in the emergency department when you are seeing drug users at their worst.”
The third barrier to recruitment is the length of training addiction specialists must undertake.
They must already be Fellows before undertaking addiction medicine training, and then follows a minimum of 18 months of core training and 18 months of non-core training, all while being paid as a junior.
“It’s a very long pathway”, Dr Frei acknowledges. “It is an issue for us, no question. We’re a very small chapter and we need to grow.
“We’re trying to balance what the Australian Medical Council and the RACP want in term of rigorousness, but not by making it so much of a mountain to climb that we can’t recruit.”
In the works are plans to make it easier for psychiatry graduates and other physicians to gain their addiction medicine qualifications.
Every physician spoken to for this story was clear on one thing — addiction medicine specialists are an altruistic bunch — and therein lies the key to recruiting the next generation.
Dr van Beek stands in front of medical students regularly and makes it clear to them the benefits of entering into one of the profession’s more misunderstood specialties.
“I tell them that they are privileged in that they have a leadership role to play and they really can make a difference”, she says.
Dr van Beek was on a surgical path before realising that public health and addiction medicine particularly were her passions.
“I knew that I wasn’t going to make much of a difference as a surgeon”, she says. “I enjoyed surgery a lot but I didn’t feel there was a demand for one more surgeon like me, as compared to addiction medicine where there was a screaming demand.
“This area is so heavily politicised. Medical people have credibility and we can cut through the emotion with a more objective, evidence-based approach.”
Dr Frei, like many of his colleagues, came to addiction medicine via general practice and has found the work “extraordinarily rewarding”.
“I tell medical students that they will be really valued and in demand”, he says.
“They’ll be asked to do all sorts of work — public health, advocacy, policy — it’s a broad specialty. They will find themselves being asked by quite senior people ‘what do I do here?’”
“Yes you need empathy and a streak of altruism, but when you see a patient stabilise or enter sustained remission, it’s incredibly rewarding.”
While the mainstream media ramps up talk of ice epidemics, it is alcohol, tobacco and prescription medications which light the activist fire under Professor Reynolds.
“Ice is a small component of the problem”, he says.
“We have really comprehensive evidence of what we could do to reduce harms from alcohol and tobacco, but the three levels of government have declined to meet their duty of care obligations over many decades.”
Professor Reynolds passionately believes addiction specialists have a key role to play in shaping future policy.
“I’m more vocal than most”, he says, “but I need more of my colleagues to do more. With health expenditure increasing to unmanageable levels, we just can’t afford to ignore the preventive agenda any longer.
“We have 40 to 50 years of evidence on what we could do to address alcohol and tobacco-related health harm and it’s time for the medical profession to stand tall, explain very carefully and clearly to the community and to our political decisionmakers what is required in public policy reform and intervention, and continue to press home the tragedy that we are treating every day, until governments take action.
“Let’s get serious about this now.”
A podcast with Dr Alex Wodak, former director and now emeritus consultant with the Alcohol and Drug Service at St Vincent’s Hospital in Sydney, president of the Australian Drug Law Reform Foundation and co-founder of Australia’s first needle syringe program, is available at https://www.mja.com.au/multimedia/podcasts
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