The American Society of Addiction Medicine (ASAM) has released a document that it believes helps to fill a critical gap impeding full recognition of addiction medicine specialists as an integral part of medical care.
ASAM's Standards of Care for the Addiction Specialist Physician, formally released last month, address both direct care management by addiction specialists and oversight of care delivered by other providers in systems. The standards emphasize collaboration with other professionals as well as patient-centered care, and acknowledge the need for comprehensive approaches to treatment that for some patients might include both psychosocial interventions and medication-assisted treatment.
The chairperson of an ASAM expert panel that drafted the standards says a number of factors contributed to the pressing need for such a document. These developments include the continued evolution of specialty certification for addiction medicine practitioners, as well as heightened interest among some physicians in treating addictions because of the emergence of effective medication options such as buprenorphine.
“We've asked ourselves, 'What else do we need to do in this field to be like other medical specialties?'” says Margaret Jarvis, MD, FASAM, medical director of the Marworth treatment facility in Pennsylvania. Also, “There has been concern that some people who get the Suboxone waiver [to prescribe to patients] may not really understand this disease,” Jarvis adds.
The standards project was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the document has been endorsed by the American Osteopathic Academy of Addiction Medicine. The standards are intended to apply to all physicians overseeing addiction care, not just those who belong to ASAM.
Assessment through continuing care
The standards cover the clinical domains of assessment and diagnosis; withdrawal management; treatment planning; treatment management; care transitions and care coordination; and continuing care management. While emphasizing the importance of physicians' exhibiting leadership in healthcare systems for the management of addictions in affected patients, the language throughout the document emphasizes collaborative decision-making with other professionals and with patients.
For example, in the section on treatment planning, a standard titled “Providing Therapeutic Alternatives” reads, “The addiction specialist physician discusses and offers all available clinically indicated psychosocial and pharmacological therapies to all patients, assisting the patient to collaborate in clinical decision-making, assuring that the patient is aware of therapeutic alternatives. This will include the advantages and disadvantages of medications for addiction, taking into consideration cost, availability, and potential for diversion.”
Jarvis says the clinicians and researchers on the expert panel on standards, a subsection of ASAM's Practice Improvement and Performance Measurement Action Group, generally avoided major controversy in a deliberative process that took up most of 2013. That doesn't mean that all physicians see the provision of medically supervised addiction treatment in the same way, however.
While some observers might assume that all addiction medicine specialists are strong backers of maintenance medication for addictions, there is also a vocal group espousing that “everybody ought to try to live without these kinds of medications,” Jarvis states.
She adds, “What we decided made the most sense was that everyone has a valid point of view. There is an evidence base for all of these things. It makes sense that the doctor and patient decide what works best.”
The standards do call for an active approach on physicians' part in instances where confidentiality issues could stand in the way of effective care. In the document's section on care transitions and care coordination, the authors of the standards state, “If the patient asserts their privilege to not permit sharing of confidential addiction treatment information with other providers, the addiction specialist physician educates the patient about the health and safety risks inherent in poorly coordinated care.”
Performance measures next
ASAM already has begun work on developing a set of performance measures to assist in evaluating whether its standards of care are being met. The goal is to establish performance measures that physicians could easily embed into an electronic medical record (EMR) system, says Jarvis.
The standards of care are worded to be relevant specifically to substance addictions. But drafters of the document state that as research and practice begin to define more clearly the most effective approaches to treating sex addiction and other addictive behaviors that fall under the process addictions category, future statements about standards of care will address management of addictions more broadly.