ADDICTION MEDICINE – PROBABLY A NEW SPECIALITY IN NORWAY

Strasbourg, May 12th 2010 Gabrielle Welle-Strand, senior adviser/MD [email protected] | gws

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WHO 2004 - Neuroscience of psychoactive use and dependence •

“Nothing less must be provided for the treatment of substance dependence than a qualified, systematic, sciencebased approach such as that developed to treat other chronic diseases considered untreatable some decades ago” | gws

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NORWAY • •

TROMSØ

•

5 million inhabitants 325 000 km² Not a member of EU

TRONDHEIM BERGEN OSLO STAVANGER KRISTIANSAND | gws

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POSSIBLE STRATEGIES •

• • • • •

To increase the general knowledge amongst doctors by university courses in addiction medicine To develop competence area in addiction medicine To integrate addiction medicine teaching in relevant specialities Individual certification in addiction medicine Sub-specialities A speciality in addiction medicine | gws

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OTHER COUNTRIES • • •

• •

Germany: Competence area – certification Certification by organisations (ASAM, CSAM, ISAM, Finland) The Royal Australasian College of Physicians: ”Fellowships” with specified training Certification by national boards (ABAM) Authorisation in special treatment techniques (Office-based buprenorphine - USA)

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A MEDICAL SPECIALITY IS CHARACTERISED BY •

A defined set of medical problems and diseases not covered by other medical specialities •

•

A specified theoretical base and knowledge base • •

•

The neurobiology of addiction Addiction psychology

Specified techniques and competence in examination and diagnosis •

•

Substance use disorders

Screening instruments, systematic interviews, biological markers

Specified therapeutic methods •

Detoxification, ”relapse prevention”, substitution treatment | gws

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A NORWEGIAN SPECIALITY IN ADDICTION MEDICINESUCCESS IN OUR THIRD TRY? •

First proposal was turned down in 1999 by the Norwegian medical association •

•

Existing specialities can take care of these patients

Second proposal was considered positive, but turned down in 2003 (National Council for specialities and specialist education) •

A better strategy is to increase the competence in addiction medicine in other specialities (psychiatry, general medicine, internal medicine)

•

In 1999 and 2003: It was considered to be difficult to fulfil the needs

for guidance, “on-call services” and enough training hospitals

•

Third proposal is currently being considered | gws

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DRUG TREATMENT IN NORWAY •

•

• • • •

The drug reform of 2004 – the specialised health care represented by the regional health enterprises got the responsibility for drug treatment Multidisciplinary specialised health care for the treatment of alcohol, prescribed drugs and illegal drugs was established Focus on the quality of the services Focus on accessibility of the services and the patient’s rights The user perspective Knowledge based medicine | gws

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KNOWLEDGE BASE Context: eg law

Clinical experience/ practitioner’s Research based knowledge Knowledge based knowledge = evidence recommendations Context: eg culture Patients experience / knowledge Context: eg policy 13 | gws

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DRUG TREATMENT FACILITIES •

Outreach work Low threshold clinics with focus on health

•

In-between services – co-operation reform

•

In each health enterprise

•

• • • •

•

Detoxification Out-patient treatment In-patient treatment Some other services

In each health region (4) •

Specialised treatment (dual diagnosis, compulsory treatment, treatment of pregnant drug users etc)

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WHAT HAS HAPPENED AFTER 2004? •

The Drug reform 2004 • •

•

Changes in the society •

•

Documented increase and severity of health problems amongst drug dependent patients, high overdose mortality rate

Research • •

•

The right to treatment – priority to the patients with most serious symptoms and best effect of treatment Multidisciplinary specialised treatment – administrative equal to somatic and psychiatric services

Increased research and knowledge-based medicine (Norwegian Center for Addiction Research) Improved therapeutic possibilities

Existing specialities •

Few signs of increased interest or competence concerning addiction medicine | gws

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NUMBER OF MAT PATIENTS IN NORWAY 6000

5000

4000 Oslo 3000

Resten av landet Totalt

2000

1000

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20

08

20

07

20

06

20

05

20

04

20

03

20

02

20

01

20

00

20

99

19

98

19

97

19

96

19

95

19

94

19

93

19

92

19

19

91

0

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OVERDOSE DEATHS IN NORWAY 400 350 300 250 Oslo 200

Resten av landet Totalt

150 100 50

20 08

20 06

20 04

20 02

20 00

19 98

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19 92

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19 90

19 88

19 86

0

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EVALUATION OF A NEW SPECIALITY IN ADDICTION MEDICINE Mandate from the Norwegian Medical Association

WORKGROUP Rune Strøm, leder Per Føyn Helge Waal Guri Spilhaug

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NEEDS ASSESSMENT • • • • • •

Estimate for number of patients Analysis of diseases and clinical problems involved Analysis of type of treatment needed Analysis of the need for competence Description of the existing treatment institutions/modalities Analysis of the needed development in the treatment system | gws

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EXISTING PROBLEMS • • • • • • •

Multidisciplinary specialised treatment without medical specialists Patient’s rights – demand for safe treatment Lack of systematic training and competence among doctors Lack of senior doctors giving guidance No carrier possibilities for young doctors in addiction medicine Large problems with recruiting doctors Low esteem among doctors | gws

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•

• • • • •

FAVOURABLE PRECONDITIONS FOR A SPECIALITY IN ADDICTION MEDICINE After the Drug reform Multidisciplinary Specialised Treatment is law-based with a specified medical responsibility A well-built out treatment system based on catchment areas Survey: At least 102+ medical doctors in TSB System of national post graduate courses for doctors University based research/Norwegian Centre for Addiction Research Guidelines - 1 published, 3 on the way | gws

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SPECIALITY IN ADDICTION MEDICINE – GOALS: •

• • • •

Prevent, assess, diagnose, treat, inform about and research on clinical problems and diseases caused by addictive drugs and prescribed drugs On basis of nationally developed and scientifically based standards Within interdisciplinary specialist units, Collaborating with GPs and social institutions Collaborating with parents, users and NGO’s

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CURRICULUM AND TRAINING •

General (integrated psycho-socio-biological ethical etc)

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Biological (addiction biology, drug effects, markers etc )

• • • • • •

Co-morbidity (somatic, psychiatric) Psychosocial genesis and interactions Prevention Collaboration and cooperation Legislation Research, evaluation and quality standards | gws

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SUGGESTED SPECIALITY RULES •

Time frame: 5 years internship in accredited institutions • • •

• • • •

Three yrs: Inpatient, outpatient, detox, rehabilitation, OMT One obligatory year in psychiatry One unspecified year i.e research

Individualized learning plan Supervision (clinical and specific in treatment methods) Hospital based internship teaching National addiction medicine courses | gws

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HOW MANY DOCTORS DO WE NEED?

• •

200-250 specialists in addiction medicine 200-250 doctors in specialist training

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HOW MANY DOCTORS DO WE HAVE? • • • • • •

Identified a total of 102 doctor’s position 80 of these positions were official 78 of these positions were occupied 32 psychiatrists, 14 GPs, 3 community specialists and 10 doctors with other specialities Half the doctors had been working > 2 years in addiction medicine The respondents told of great difficulties in recruiting doctors to the field | gws

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ECONOMIC AND ADMINISTRATIVE CONSEQUENCES • • • •

Establish new positions for doctors Establish on-call systems for In-hospital training and national training Guidance

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INTERIM REGULATIONS •

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•

Doctors with broad and long experience and competence in addiction medicine – can be appointed as specialists immediately. N=40? Doctors with some years of experience in addiction medicine, but who need some work experience and training to become specialists. Should become a specialist within 1-2 years. N=40? Younger doctors with some experience in the field. Should have some of their practice accepted. An important group to take care of, to have some younger doctors in the field. Will be specialists within 2-3 years. N= 40?

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Year

Specialists

In-training

Total

1.år

40

80

120

2.år

55

110

165

3.år

70

140

210

4.år

85

170

255

5.år

100

200

300

6.år

120

240

360

7.år

140

260

400

8.år

160

260

420

9.år

180

260

440

10.år

200

260

460

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POSSIBLE TEACHING HOSPITALS – TO BE ACCREDITED •

Helse Nord RHF: UNN – Tromsø • UNN – Narvik • Nordlandssykehuset – Bodø • Nordlandssykehuset – Mo i Rana •

•

Rusbehandling Midt-Norge RHF: Sunnmøre • Nordmøre og Romsdal • Trondheim/Sør-Trøndelag • Nord-Trøndelag •

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Aktuelle utdanningsinstitusjoner/miljøer forts •

Helse Vest RHF • • • • • • •

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Helse Førde HF Helse Bergen HF Helse Fonna HF Helse Stavanger HF Stiftelsen Bergensklinikkene Blå Kors Vest Rogaland A-senter

Helse SørØst RHF • • • • • • • •

Oslo Universitetssykehus AHus Vestre Viken Sykehuset Østfold Psykiatrien i Vestfold Sørlandet Sykehus Sykehuset Innlandet Borgestadklinikken/Sykehuset Telemark | gws

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DECISION IN THE NATIONAL COUNCIL 1.

2.

NR recommend that a speciality in addiction medicine should be established. The specialist training program should safeguard that the specialists can be used both in the specialised services and in the municipalities health services NR recommend that the specialist training in relevant specialities (GP, internal medicine, psychiatry) should be strengthened to ensure that other specialists also have competence in addiction medicine | gws

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