Like the rest of the country, Tennessee hasn’t been a spared the opioid crisis. Between 2011 and 2015, over 6,000 lives were lost in the state due to overdose deaths from opioids.
There are other longstanding addiction problems as well.
For instance, alcohol is still the most commonly abused substance in Tennessee. About 1 in 20 Tennessee residents abused or were dependent on alcohol in 2016.
Following a hub and spoke model, the University of Tennessee Health Science Center is on the forefront of creating a national model for the treatment of addiction.
“The difference in what we are doing in Tennessee is that we want to create an addiction workforce. Our proposal is linked to a fellowship where we recruit and train the doctors. It’s similar to the hub-and-spoke model of other states, like Vermont, but based in the university system with a focus on education,” said Dr. David Stern, vice chancellor for Health Affairs for Statewide Initiatives at University of Tennessee Health and Science Center.
Other states are doing a variation of what Dr. Stern is proposing – the hub and spoke model.
“The hub is where there is greater expertise and the spoke is lesser expertise but greater numbers of practicing physicians who can screen and care for patients who aren’t as sick,” said Stern.
The first hub and spoke model for addiction medicine was Vermont. Its addiction specialists are connected to primary care physicians - some experience treating addiction.
Here in Tennessee, only about 10 percent of patients in treatment are helped by a physician trained to address substance abuse.
It’s a nationwide problem rooted in the postgraduate educational system. Addiction treatment isn’t addressed in most medical school curriculums. Nor does it come up in residency.
“One really has to create an informed workforce and these addiction fellows are the lightning rod – they are the specialists - and then they can train the primary care physicians and others around them,” said Stern.
With the rising need in treatment alternatives, addiction medicine is a trending specialty in health care. Traditionally, physicians have received little training in addiction treatments.
Dr. Kevin Kunz, Executive Vice President of the American Board of Addiction Medicine and The Addiction Medicine Foundation, is working to address the shortcoming. Dubbed the “father” of Addiction Medicine, his efforts have led to an increase in fellowships in universities across the country.
In 2006, Kunz’s foundation began efforts to provide certification in Addiction Medicine as a subspecialty. They developed year-long training programs. After primary training, physicians could become clinical experts in the field of addiction medicine.
“It took us 10 years to get the buy-in from official medicine. There are now 44 of those in the United States, and one of the best happens to be here in Memphis at the University of Tennessee Health Science Center,” said Kunz.
UTHSC started preparing for its new addiction medicine fellowship program three years ago. They took the first two fellows on July 1, 2016. Now, they are in the second year of the fellowship and are starting to interview for fellows for July 1, 2018. The programs also train faculty, teachers, researchers, and change agents in the field.
The Accreditation Council for Graduate Medical Education now accredits the one-year addiction medicine specialty training. ACGME is responsible for accrediting most graduate medical training programs for physicians in the U.S.
“Addiction medicine has now formally entered the house of medicine and health care so that patients can see a physician with this specialty. Their insurance will pay for it. Physicians will be willing to go into the field because it’s a recognized field,” said Kunz.
Considered a model program, UTHSC was designated the first Center of Excellence in addiction medicine and addiction science last year.
“Our foundation gave them the first formal recognition as a Center of Excellence in Addiction Medicine because not just are they training physicians to be specialists, consultants and team players in the prevention and treatment of addiction, but they are connected to their community and providing services to a community in need,” said Kunz.
The fellowship program has fostered partnerships within health care systems and hospitals, as well as the community.
“Since having a workforce for addiction medicine is an issue, this fellowship is valuable. The fellows we send out, we are looking to send them out all over Tennessee to form a network of addiction providers. These fellows are the nodes in the network that reach out to the local population – whether it be rural or in the urban centers,” said Stern.
With Dr. Kunz’s collaboration, a proposal was pitched to the state to expand the fellowship to recruit physicians from different cities and regions within the commonwealth.
The idea is to recruit fellows from across the state. Once trained, they would return to their community and become a hub in the network of treatment providers.
Fellows would have access to electronic medical records. A standardized practice regiment will be adhered to. Additionally, consultations with primary care physicians will be held to provide a complete medical picture.
Outreach and prevention efforts will also take place in the communities.
“So, it’s taking those initial fellows we train and organize them into a network to make them an essential group of expert providers for addiction services in Tennessee,” said Stern.
Federal and state funding is being sought for the fellowships and building the network. According to Stern, $25 million is needed to fund the program. But he says it would become self-sustaining in six years.
One proposal is student loan forgiveness in exchange for three to four years of practice in a high-needs area.
They are also looking for funding to establish practices and service a network to collect outcomes – how well are these doctors doing in treating these patients, how can they do better.
“It’s comprehensive proposal to develop an addiction network by standardized training, followed by standardized practice, and standardized education of providers,” said Stern.
Peer counseling is also recommended. Medication alone will stem cravings and withdrawal. Through long-term counseling the patient can gain tools as well as moral support to gain control of their addiction.
Mental health professionals and case managers will be a part of the network, too.
“The most common co-occurring condition with an addiction problem is a mental health issue,” said Stern. “Therefore, you need to develop a holistic network around the patient of wraparound services, and that’s what the case manager and behavioral health consultant can do.”
Students in Tennessee will learn from a curriculum of prevention and treatment. After they finish their residency in family medicine, they move onto their fellowship – and then back to their communities.
“This changes the health care workforce dramatically. It’s the model that is settling into place nationally and what’s happening in Tennessee reflects it,” said Kunz.
If Stern and Kunz are successful selling this concept to the state, then they will begin the work of building out a statewide network of addiction medicine experts through state universities and then roll out to private practices and rehabilitation centers across Tennessee.
The hope is the Tennessee model becomes an example nationally. By 2025, AMF hopes to see 125 resident training programs up and running.
To reach the goal, UTHSC held a meeting on Sep. 7 to develop ways to bolster an addiction medicine workforce. The fellowship program was also discussed.
Representatives of medical schools from Alabama, Mississippi, South Carolina, North Carolina and Kentucky were in attendance.
“The interest they have in replicating what UTHSC has done is strong,” said Kunz.