Commuting to my office in Cambridge, MA, this spring, I listened with some shock to a National Public Radio story about a new problem in the neighborhood where I work: The cafes of Inman Square were struggling to cope with the rate of overdose deaths in their restrooms.1 Joshua Gerber, the owner of 1369 Coffeehouse where our residents and faculty regularly purchase their lattes and espressos, reported he had mounted a sharps box and is training baristas in naloxone use.
From 2002-2015, the number of deaths in the US due to all drugs increased 2.2-fold and the number of deaths due to opiates 2.8-fold (NIDA, drugabuse.gov). While New England and the Midwest have been particularly hard hit, the crisis is ubiquitous. In 2015 Everett, MA, a neighboring town to Cambridge and part of our catchment area, had a rate of 55 opioid-related deaths per 100,000 people. Princeton economists Anne Case and Angus Deaton have coined the term “deaths of despair” for the shocking increase in middle-aged deaths –- overdoses, suicides, alcoholic liver disease -- among non-Hispanic whites in this country, a trend not found in any other developed nation.
In 2016, Surgeon General Vivek H. Murthy, MD, MBA issued a report entitled “Facing Addiction in America.” The report, a call to arms for all of us, emphasizes the scientific understanding of addiction as a chronic disease and the availability of evidence-based treatments.
As a psychiatrist, I perceived a gap in this otherwise outstanding report: Where was the discussion of the important role of psychiatry in combatting the epidemic? What about the importance of treating those suffering from dual diagnoses, including mood disorder, trauma, and anxiety? Where was the call to arms for psychiatry to help our colleagues in primary care, addiction medicine, and addiction psychiatry confront the crisis?
With the important exception of subspecialists in addiction psychiatry and some general and child psychiatrists who treat patients suffering from addictions, psychiatry has seemed strangely absent from the national conversation about the addiction epidemic. Since 2001, ACGME hasrequiredgeneral psychiatry residents to complete only one month FTE of addictionstraining or addictions psychiatry;child psychiatry fellows have no specific requirement. Surveys of training programs indicate significant variability inthe settingand timing of current addictionstraining.2 Though experts suggest thatexposure to longitudinal treatment and recovery areideal in training, many programs rely on acute settings. A recent survey foundresidents’ attitudes towards Substance Use Disorders actually worsened over the course of their training.3
Efforts are underway in our allied organizations such as the American Psychiatric Association, the American Academy for Child and Adolescent Psychiatry, and the American Academy of Addiction Psychiatry to improve addiction training in psychiatry. AADPRT, through its new Addiction Taskforce chaired by Ann Schwartz, MD, from Emory, is committed to improving residency training in addictions by developing a strategic plan, formulating training goals, and providing a platform for disseminating educational resources and train-the-trainer sessions both in-person and virtually. Soon you will receive a survey asking about what you are doing now in addictions training and what you would need to have in place to be able to do more. Please help by responding to the survey.
For now, I ask you to consider these questions: What is our responsibility to our trainees in preparing them to help combat this addiction crisis? What is our responsibility to our patients and their families? What about our communities? What will it take for all of us in psychiatric education and training--what knowledge, skills, resources, and attitudes--to contribute to ending this unfolding tragedy?
As always, I welcome your thoughts. firstname.lastname@example.org
Sandra M. DeJong, MD, MSc
2.Shorter D andDematisH. Addiction training in general psychiatry training: A national survey.SubstAbus.2012; 33:392-394.Avery J, Han BHZerboE et al.
3.Psychiatry residents’ attitudes towards individuals with substance use disorders and schizophrenia. Am J Addict 2016;25.