The U.S. surgeon general's office estimates that more than 20 million people have a substance-use disorder. Meanwhile, the nation's drug overdose crisis shows no sign of slowing.
Yet, by all accounts, there aren't nearly enough physicians who specialize in treating addiction — doctors with extensive clinical training who are board certified in addiction medicine.
The opioid epidemic has made this doctor deficit painfully apparent. And it's spurring medical institutions across the United States to create fellowships for aspiring doctors who want to treat substance-use disorders with the same precision and science as other diseases.
Now numbering more than 60, these fellowship programs offer physicians a year or two of postgraduate training in clinics and hospitals where they learn evidence-based approaches for treating addiction.
Such programs are drawing a new talented generation of idealistic doctors — idealists like Dr. Hillary Tamar.
A drive to connect with patients in need
Tamar, now in the second year of a family medicine residency in Phoenix, wasn't thinking about addiction medicine when she started medical school in Chicago.
"As a medical student, honestly, you do your ER rotation, people label a patient as 'pain-seeking' and it's bad," Tamar says. "And that's all you do about it."
But in her fourth year of med school, she happened to be assigned to a rotation at a rehab facility in southern Arizona.
"I was able to connect with people in a way that I haven't been able to connect with them in another specialty," the 28-year-old recalls.
Working with patients there transformed Tamar's understanding of addiction, she says, and showed her the potential for doctors to change lives.
"They can go from spending all their time pursuing the acquisition of a substance to being brothers, sisters, daughters [and] fathers making breakfast for their kids again," she says. "It's really powerful."
When Tamar finishes her residency, she's planning to pursue a fellowship in addiction medicine. She sees addiction medicine, like primary care, as a way to build lasting relationships with patients — and a way to focus on more than a single diagnosis.
"I love when I see addiction patients on my schedule, even if they're pregnant and on meth," she says. "More room to do good — it's exciting."
Doctors with Tamar's enthusiasm are sorely needed, says Dr. Anna Lembke, medical director of addiction medicine at Stanford University School of Medicine and a longtime researcher in the field.
"Even 10 years ago," Lembke says, "I couldn't find a medical student or resident interested in learning about addiction medicine if I looked under a rock. They were just not out there."
But Lembke sees a change in the upcoming generation of doctors who are drawn to the field because they care about social justice.
"I now have medical students and residents knocking on my door, emailing me. They all want to learn more about addiction," Lembke says.
Historically, the path to addiction medicine was through psychiatry.
But that model started to change in 2015, when the American Board of Medical Specialties — considered the gold standard in physician certification in the U.S. — recognized addiction medicine as a bona fide subspecialty and opened up the training to physicians from many other medical fields.
Until then, Lembke says, there had been no way to get addiction fellowships approved through the nationally recognized Accreditation Council for Graduate Medical Education. And that made recruiting young talent — and securing funding for their fellowships — difficult.
Last year, ACGME began accrediting its first batch of addiction medicine fellowship programs.
"We have got an enormous gap between the need and the doctors available to provide that treatment," Lembke says.
"At least the medical community has begun to wake up to consider not only their role in triggering this opioid epidemic but also the ways they need to step up to solve the problem," she says.
Build a program, and they will come
When Dr. Luke Peterson finished his residency in family medicine in Phoenix in 2016, there were no addiction medicine fellowships in Arizona.
So he moved to Seattle to complete a yearlong fellowship at Swedish Cherry Hill Family Medicine Residency. There he learned, among other things, how to treat pregnant women who are in recovery from drug use.
"I really needed to do a fellowship if I was going to make an impact and be able to teach others to make the same impact," says Peterson, who went on to help found an addiction medicine fellowship program in Arizona. His program is based in Phoenix at the University of Arizona's medical school, and its teaching hospital run by Banner Health, and the Phoenix VA Health Care System.
Arizona's two addiction medicine fellowship programs received ACGME accreditation last year — a stamp of approval that made the programs desirable choices for up-and-coming physicians, Peterson says.
Not every doctor who plans to treat substance-use disorders needs to do a fellowship, he says. In fact, his goal is to integrate addiction medicine into primary care settings.
But a specialist can serve as a referral center and resource hub for community doctors.
For example, physicians can learn from a specialist such as Peterson how to provide medication-assisted treatment like buprenorphine.
Public health leaders have been pushing to get more physicians trained in evidence-based treatments like buprenorphine, which has been shown to reduce the risk of death among people who have recovered from an opioid overdose.
"As we provide more education and more support to primary care physicians, they will feel more comfortable screening and treating for addiction," Peterson says.
Peterson's own journey into addiction medicine began during a rotation with a family doctor in rural Illinois.
"In moments that most doctors find uncomfortable — maybe a patient comes in to request pain medication and you're seeing the negative side effects — he did not shy away from that situation," Peterson says. "He addressed it head-on."
It was a formative experience for Peterson — one he wants other young doctors to have. And he recognizes the urgency.
"In 20 or 30 years from now," Peterson says, "those medical students are going to look back at my current generation of doctors, and we will be judged by how we responded to this epidemic," in the same way he and his peers now look back at how doctors handled the HIV epidemic.
One of the first steps in stopping the epidemic, he says, is making sure there are enough doctors on the ground who know how to respond.
Many of today's medical students, people like Michelle Peterson (no relation to Luke), say they feel the calling too.
She's in her first year at the University of Arizona College of Medicine in Phoenix and became interested in addiction after working at an outpatient treatment center.
She says she's already learning about addiction in her classes, hearing from doctors in the field and seeing other classmates equally engaged.
"It's definitely not just me," she says. "There are quite a few people here really interested in addiction."
It's a trend she and her mentors hope will continue.
This story is part of NPR's reporting partnership with KJZZ and Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
AILSA CHANG, HOST:
The U.S. surgeon general estimates that more than 20 million Americans have a substance abuse problem, but there aren't enough doctors to treat them. Will Stone of member station KJZZ in Phoenix looks at new efforts to train more doctors as addiction specialists.
WILL STONE, BYLINE: Hillary Tamar wasn't thinking about addiction medicine when she started medical school in Illinois. And her early experiences seeing how some doctors dismissed patients who struggled with substance use did not necessarily encourage her.
HILLARY TAMAR: Because as a medical student, honestly, you do your ER rotation. People label a patient as pain-seeking, and it's bad. And that's all that you do about it.
STONE: But in her fourth year of school, she just happened to be assigned to a rehab facility. Working with those patients showed her how doctors with the right training can help patients heal and rebuild their lives.
TAMAR: They can go from spending all their time pursuing the acquisition of a substance to being, like, brothers and sisters, daughters, fathers making breakfast for their kids again. It's really powerful.
STONE: Tamar's now in the next stage of her medical career, a family medicine residency based here in Phoenix. Afterward, she plans to do an extra year of in-depth training, known as a fellowship, in the subspecialty of addiction medicine. Tamar sees addiction medicine as a natural fit for doctors in primary care. Both fields emphasize forming long-term relationships with patients focused on more than just a single diagnosis.
TAMAR: I love when I see addiction patients on my schedule. Even if they're pregnant and on meth, like - I don't know - more room to do good. Like, it's exciting.
STONE: Doctors with Tamar's enthusiasm are sorely needed and, until recently, tough to find according to Dr. Anna Lembke. She directs Stanford University's Addiction Medicine Fellowship. We spoke via Skype.
ANNA LEMBKE: You know, even 10 years ago, I couldn't find a medical student or a resident interested in learning about addiction medicine if I looked under a rock. I mean, they were just not out there.
STONE: It's entirely different now. Students are hounding Lembke to learn more.
LEMBKE: At least the medical community has begun to wake up and to consider not only their role in triggering this opioid epidemic but also the ways in which they really need to step up to help solve the problem.
STONE: In 2015, the medical establishment recognized addiction medicine as a bona fide subspecialty open to many kinds of doctors. This also meant addiction fellowships could get official accreditation and government funding. There are now more than 60 fellowships nationwide. But doctors like Lembke say the country needs double that number to deal with the ongoing epidemics. That's especially true in a place like Arizona. Dr. Luke Peterson had to leave Phoenix to get the training.
LUKE PETERSON: So anybody who wanted to do addiction medicine, we've had to go out of state.
STONE: After finishing his training in family medicine, Peterson moved to Seattle for a year, where he learned how to treat pregnant women who are in recovery.
PETERSON: It was just an incredible experience working with these moms, seeing their successes and being a part of that.
STONE: Peterson decided to come back to Arizona with his new skills. And now he's helping to start one of the new fellowships here. Not everyone who treats addiction needs that extra training, but Peterson says a fellowship also creates a hub, a place where doctors in the community can ask questions. In 2017, drug overdoses killed more than 70,000 Americans. That's more deaths than even the worst years of the AIDS epidemic.
PETERSON: And in 20, 30 years from now, those medical students are going to look back at my current generation of doctors, and we will be judged on how we respond to this epidemic.
STONE: And that begins with making sure there are enough doctors on the ground who know how to respond. For NPR News, I'm Will Stone in Phoenix.
CHANG: This story is part of a partnership with NPR, KJZZ and Kaiser Health News.
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