Addiction Medicine Helped This Doctor Balance His Interests

Session 126

Addiction medicine checked off a few key things on Dr. Tim Brennan’s list of interests. He will bust some addiction myths, talk lifestyle, and more. If you haven’t yet, please check out all our other podcasts on Meded Media.

Tim shares his journey to addiction medicine starting off in internal medicine and then switching to pediatrics before finally realizing his passion for addiction medicine.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:00] His Journey to Addiction Medicine

Tim considers having come late to pediatrics compared to most people. He initially matched into a categorical medicine program when he was in medical school.

During his intern year in medicine, he decided to change to pediatrics and matched into it. When he saw more and more patients suffering from behavioral health pathology, his interest in child psychiatry peaked.

The more he explored, the more specific the disorders he was getting interested in. Ultimately, he ended up going into addiction medicine right after his pediatrics residency.

He thinks addiction medicine is the most medical of the psychiatric subspecialties and it was the most psychiatric of the medical subspecialties. There’s the classic, bread-and-butter withdrawal physiology as well as an intersection of public health, public policy, and organizational medicine. And more often these days, you’ve got politics.

'Legislators are looking at the opioid crisis seriously for the first time.'Click To Tweet

At that time, the fellowships were only one year in duration compared to the typical three-year pediatric subspecialty fellowships. He thought it was a benign value proposition so he dipped his toe and the rest was history.

Tim is boarded in both pediatrics through the American Board of Pediatrics and addiction medicine through the American Board of Preventive Medicine. Addiction medicine is a subspecialty of both the American Board of Pediatrics and the American Board of Preventive Medicine. 

That being said, psychiatrists paved the way. While he identifies himself as a psychiatrist, he’s mistakenly identified as a psychiatrist by the public. Apparently, it’s a field with a lot of overlap.

[05:05] Psychiatry in Addiction Medicine

'It would be unusual for an addiction medicine physician to not be psychologically minded.'Click To Tweet

Most, if not all, addiction medicine specialists are already interested in and adept at psychiatry. It’s important to have an appreciation and affinity for general bread-and-butter psychiatry treating depression and anxiety.

That being said, he doesn’t think an addiction medicine specialist needs to be facile at treating severe psychotic disorders and severe mood disorders or severe personality disorders. They’re comfortable leaving treatment for these to their psychiatric colleagues.

Having the extra skill set in psychiatry can be synergistic, not an absolute requirement. 

[06:25] Traits that Lead to Becoming a Good Addiction Medicine Specialist

Empathy is essential. We have the privilege of taking care of patients who are suffering from a horrible disease. There’s that stigma around people with addiction.

The physician who’s around those patients needs to emphatic. They should understand it’s not a volitional disease. It’s a disease like any other.

'Many of us were raised to think negatively of people who suffer from addiction.'Click To Tweet

Like any other field in medicine, Addiction Medicine is evidence-based. For too long, addiction treatment was provided in a non-evidence-based manner.

Physicians are admittedly very late to the addiction treatment world. But they have to bring their own unique skills of foundation in science and tradition of peer review to the treatment they provide.

[07:50] Other Specialties He Had in Mind

Tim knew he didn’t want to be a surgeon and he knew that while he had an interest in psychiatry, he felt it was far removed from the traditional medical skills he has been honing since premed. So he wanted to practice “regular” medicine of some sort.

'Internal medicine is a catch-all.'Click To Tweet

He initially thought he would be a primary care doctor with a panel of patients that he could progress through their lives. It was very clear very quickly to him that the modern internist is really, in a lot of ways, a geriatric specialist. Oftentimes, they find themselves taking care of people right at the end of their lives. And this didn’t appeal to him.

[09:15] Types of Patients

The addiction medicine physician takes care of all patients spanning age and socio-economic spectrum, and any demographic you can imagine.

'Addiction has so many sequelae in psychiatric and medical disease, we end up interacting with specialists and subspecialists in a variety of fields.'Click To Tweet

It’s not uncommon for him on a typical day to encounter an oncologist, gynecologist, rheumatologist, infectious disease specialist, and so on.

In that sense, he feels very much a part of the modern medical system. Addiction knows no bounds and affects all human beings. And he can see this heterogeneity reflected in his patient panel.

Unfortunately, addiction as a disease has been creeping earlier and earlier into our lifespans.

Kids as young as 10-12 years old are experimenting with drugs. He has interacted with children in that age group. More typically, he deals with adolescents, especially those in the emerging adult phase of their life (15-25 year-olds).

Situations change depending on the patient’s age. An 18-year-old adolescent is going to have different things going on in their life than a 13-year-old.

[11:40] Types of Addiction

As of the moment, addiction medicine is confined to the addictions you would find in the DSM-5 and addictions that can be reimbursed by a third party payor. Addictions can range from food, sex, internet – all of which are behavioral addictions. For the most part, these reside in the section of DSM-5, which is the psychiatric manual and the section that needs more research.

This is where diseases reside before they’re codified and thought of as actual diseases. For the most part, the modern addiction medicine physician is not interacting with them unless they’re in a private practice environment where they’re not going with a third party payor.

[13:09] Typical Day

The nature of addiction medicine is so hybridized. There are different career tracts. For one, it’s a field still in its infancy. It’s hard to find archetypes as you would see in cardiology or gastroenterology where you could predict their day or what the different phases in their life look like.

'The nature of addiction medicine is so hybridized. It's a field still in its infancy.'Click To Tweet

That being said, it’s not uncommon for Tim to make rounds on their inpatient detoxification unit. They see a few consults in the hospital or the emergency department. Or he could attend group meetings at their residential halfway house.

[14:10] Life Outside of the Hospital

Tim still considers having a life outside of the hospital. Addiction is a specialty that follows business hours for the most part. There are after-hour calls or weekend calls but not like a trauma surgeon or a critical care physician would have.

'We're accountable and reachable by our patients but this is typically a Monday through Friday career for most addiction medicine physicians.'Click To Tweet

[14:44] How Competitive is the Field?

Compared to surgical specialties, Addiction Medicine is less competitive. In the last 6-12 months, they’ve seen an explosion of interest from residents for their fellowship programs.

Going back 4-5 years, a lot of their fellowship programs did not have that many applicants to choose from. Now, all of their fellowship programs are inundated with applications, most of that is because of the interest in the opioid crisis. 

[15:53] Bias Against DOs

Tim has not seen any bias against DOs in the field. In fact, many leaders in addiction medicine have been osteopaths. Compared to other fields, addiction medicine is a lot more welcoming. There’s a pretty rich tradition of addiction medicine within the osteopathic association as well.

'It's a field that's been richly populated by osteopathic physicians.'Click To Tweet

[16:45] Opportunities for Training Within the Subspecialty

For example, if you come into addiction medicine from emergency medicine, you may find yourself practicing more of toxicology-based practice. Or a psychiatrist can do an addiction medicine fellowship can find themselves working in a much different capacity.

There are no sub-subspecialty fellowships within addiction but there are folks who specialize within addiction.

'Addiction medicine fellowships are not just teaching people about the opioid crisis.'Click To Tweet

The opioid crisis is our current addiction crisis in America but they also deal with other forms of addiction such as alcohol, tobacco (for many decades now). Inevitably, there will be another crisis around the corner.

The goal of the addiction medicine fellowship is to equip the workforce with the skillset that’s transferrable to whatever that next crisis is. 

Once we finally get our heads around the opioid crisis as a country, there will inevitably have been the dawn of a new crisis. Hence, addiction medicine specialists can use the opioid crisis to get themselves equipped.

[18:25] Working with Primary Cary Physicians

Tim thinks that the average primary care physician doesn’t know any addiction medicine physicians. It is therefore on the addiction medicine specialists to spread the word around.

His wish for their field is to have graduated enough fellows and credentialed enough physicians. So that when the average primary care physician is presented with a difficult addiction question, they know exactly who to call. They know who they can rely on in their community to refer patients for evidence-based medical care.

'The average primary care physician may not even know that addiction medicine exists.'Click To Tweet

[19:45] Special Opportunities Outside of Clinical Medicine

'This is a field with a lot of rich overlaps with the rest of society.' Click To Tweet

Legislators, law enforcers and so on, come up with addictions in their domains as they’re writing laws or prosecuting cases or creating public policy. It’s a real opportunity for physicians in the field to impact that work and speak from a place of science. As a result, they can help improve public health and reduce stigma.

[21:49] The Biggest Misconception Around Addiction Medicine

Tim explains the greatest myth around addiction medicine is that the patients don’t get better. He feels it’s a great privilege to take care of these patients. Unfortunately, when he tells people he does addiction medicine, they often give an offensive remark about how difficult those people are to take care of.

Physicians, nurse practitioners, and PAs are oftentimes interacting with addiction sequelae among patients who don’t want treatment. They’re taking care of patients in their clinic who might be asking for too much or too frequent pain medicine. They might be taking care of patients in the emergency department or on the wards who are not interested in addiction referrals.

He contrasts this with patients he does take care of. These are the patients that basically come to him because they want care.

'When people are interested in getting sober, it's really a privilege to take care of them and if you can be with them on that journey, they really do get better.' Click To Tweet

[23:35] What He Wished He Knew About Addiction Medicine

Tim didn’t realize how much medicine he’d still be practicing. When he went into Addiction, all he thought he’d be doing was addiction. But he was still managing hypertension and diabetes, and still treating people for infections. In that sense, he had a little trepidation. He thought he was giving up his primary field moving into addiction medicine. 

'You're not giving up your primary field. You're still going to be practicing medicine. People with addiction have all the same problems that people without addiction have.' Click To Tweet

Oftentimes, he ends up being a primary care provider to his addiction patients when they’re with them. But they’re very careful to not do this in the long term.

[24:40] The Need for Longitudinal Care

There’s been this myth in addiction that’s been perpetuated in the country, typically in Hollywood that addiction is best treated in a one-off residential setting. 

'There's this popular narrative that people with addiction go away to rehab and they come home cured.' Click To Tweet

From decades of experience, this is not the case. Like cancer, you can’t simply excise a tumor and forget about it for the rest of your life. It often involves longitudinal care. The same is true for addiction.

Tim very much feels the need to deconstruct that idea and make people aware that people with addiction need to see longitudinal care. 

Likewise, when patients transition away from them, it’s important to realize they’re not necessarily going to be at their center for the rest of their lives. So very early on in their treatment, they try to pull people in the primary care and their communities so they can have that follow-up moving forward.

It’s not uncommon for people coming to them who have neglected their preventive medicine needs for a long time. 

A lot of people come to them and they realize they need pap smears or mammograms or colonoscopies. And although they would set this up they’re not looking to replace the primary care physicians.

[26:15] The Most and Least Liked Things

Tim never thought he would be thanked so much going into the field. He had no idea people would be that grateful.

He thinks it’s a shame actually, as this speaks to how stigmatized and maybe disillusioned they’ve been with their healthcare before they’ve gotten to an addiction physician.

'People are really grateful if you can provide them some dignity and some respect and help them get sober.' Click To Tweet

What he likes the least about the field is the third party payor. He wastes hours out of his week doing prior authorizations. Most of the time, he’s talking to a robot that’s not even good at being a robot.

When he speaks to a person, they’re always reading a script. They’re shocked they’re talking to a physician. They expect a secretary or an administrator. This is a waste of their time as well.

That being said, he has to continue being on the call because the patient needs the medicine. It’s just a shame they’d have to jump through those hoops.

Ultimately, if he had to do it all over again, he’s still would have chosen the field in addiction medicine. He even tries as many medical students as he can that he’s happy coming to work each day.

Some of their patients get better and some get worse. That’s part-doctor and that’s part-healthcare. But it’s an absolute privilege to take care of these patients. They’ve been maligned and stigmatized by the rest of society.

[28:55] Thoughts on the Decriminalization of Drugs in the U.S.

Recently, Portugal has decriminalized drugs in their country. But Tim emphasizes that we are not Portugal nor are we Scandinavia. That being said, he doesn’t want any of his patients in jail for something he considers as a medical disease.

'I don't want any of my patients in jail for something I consider to be a medical disease, especially a medical disease that is not their fault.' Click To Tweet

In fact, Tim was happy that he was asked about the decriminalization instead of the legalization of drugs. This has been evidenced by the Portuguese experience.

Decriminalization an important middle ground between legalization and the draconian rule like in Singapore. 

Tim loves to see America moving in that direction. Some states are already doing more of He thinks the sheer legality of drugs is oftentimes enough of a roadblock to prevent use.

However, the pediatrician in him is very mindful that if we somehow decriminalize all drugs, will we accidentally make drugs a bit more appealing to a typical youngster? And this gives Tim a reason to pause.

He wants to be moving quickly as we’re doing now, but at the same time judicious on our way there.

Tim admits that he feels uncomfortable as a physician when people try to force him to use his M.D. to prescribe cannabis or mushrooms. He is very uncomfortable with it because he was never able to learn what’s in those products. So he personally it’s a bit of a fraud on his part.

In that sense, the decriminalization, legalization, and medical usage of cannabis have been conflated into one issue. It’s a shame because a lot of these are nuanced issues with very specific realities.

Tim firmly believes that it’s very important to figure out the schedule and decide on the exact route, duration, and frequency of usage. So they can send people to the pharmacy with much conviction as they would for any other product.

[33:13] Final Words of Wisdom

You’re not giving up your primary field. Addiction medicine is a field full of internists, family medicine doctors, OBs, surgeons, radiologists, anesthesiologists, psychiatrists, pediatricians.

You’re still going to be practicing your primary specialty. There are a lot of really hybridized career paths out there, particularly in addiction medicine.

If you’re interested, try to dip your toes in the water. Reach out to a fellowship director. They have over 70 addiction medicine fellowships in the country. They’re all tightknit family. It’s their passion project.

So look into it. Don’t be dissuaded thinking you’re somehow going to give up your primary specialty because you’re really not.

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