Addiction Medicine or Addiction Psychiatry?

The field of addiction is a highly multidisciplinary one, encompassing medical professionals, such as physicians and psychiatrists, as well as other healthcare practitioners like nurses, psychologists, and more. This multidisciplinary approach is crucial in addressing the complex nature of Substance Use Disorders (SUDs) and their associated physical and psychological challenges. Given this intricate landscape, the question that arises is: which term, ‘Addiction Medicine’ or ‘Addiction Psychiatry’, better encapsulates the comprehensive medical approach required to tackle the myriad aspects of addiction? While both terms recognize the importance of a multidisciplinary approach, they might lead to different expectations in terms of clinical practice and specialization. ‘Addiction Medicine’ may conjure an image of healthcare professionals primarily focused on the physiological aspects of addiction, whereas ‘Addiction Psychiatry’ may imply a more psychiatrically oriented approach.

The medical aspects of addiction encompass various dimensions, including the management of intoxications (Jung & Namkoong, 2014), withdrawal syndromes (Alexiou & King, 2023), and the treatment of associated medical complications (Diamond & Messing, 1994; Gardner & Mouton, 2015; Maurel et al., 2012; Wu et al., 2023). SUD has a profound impact on physical health, often leading to life-threatening situations that require immediate medical attention. Intoxication occurs when an individual consumes a substance in excessive quantities, resulting in a range of symptoms and potential medical emergencies. Medical professionals in the field of Addiction Medicine play a vital role in diagnosing and managing intoxications. For example, alcohol intoxication may manifest as impaired consciousness, respiratory depression, and metabolic disturbances, necessitating prompt intervention and supportive care. Withdrawal symptoms are a hallmark of SUDs and can vary widely depending on the substance involved. Managing withdrawal is a critical aspect of Addiction Medicine, as abrupt cessation of drug use can lead to severe physiological and psychological distress. Physicians specializing in Addiction Medicine are trained to assess withdrawal risk, develop appropriate treatment plans, and administer medications to alleviate withdrawal symptoms. SUD can lead to a myriad of medical complications affecting different organ systems. These complications may include cardiovascular issues, such as hypertension and arrhythmias, neurological problems like seizures and cognitive impairment, and gastrointestinal disorders, such as pancreatitis and hepatitis. Addiction Medicine specialists are equipped to address these medical issues and provide comprehensive care to individuals with SUDs.

In addition to the medical aspects, addiction is inherently intertwined with psychiatry. SUD often co-occurs with various psychiatric conditions, and the management of addiction requires a thorough understanding of the psychological and behavioural components (Bramness & Rognli, 2016; Rentero et al., 2021; Starzer et al., 2018; Vassos, 2023). The psychiatric aspect of Addiction Medicine involves the evaluation and treatment of addiction itself. Specialists in this field assess the psychological components of addiction, including the craving, compulsive use, and impaired control that characterize SUDs. Behavioural therapies and counselling are essential tools in helping individuals overcome addiction and achieve sustained recovery. Substance use can induce or exacerbate psychiatric disorders. For example, prolonged stimulant use may lead to the development of anxiety or psychotic disorders. Addiction psychiatrists are trained to recognize and differentiate between primary psychiatric disorders and those induced or exacerbated by substance use. Comorbidity is common in individuals with addiction, with conditions, such as depression, anxiety disorders, and post-traumatic stress disorder frequently occurring alongside SUDs. Addiction psychiatrists excel in diagnosing and treating these co-occurring disorders, as well as differentiating them from primary psychiatric illnesses.

Physicians interested in specializing in Addiction Medicine have several training pathways to consider. These pathways often vary by country, but two primary options are commonly available: direct Addiction Medicine training and Addiction Psychiatry training. In the case of Addiction Medicine (Kunz & Wiegand, 2016), a direct route involves completing a dedicated Addiction Medicine residency or fellowship program, providing specialized training in the assessment, treatment, and research of SUD. Similarly, specialities like Orthopedics, Neurosurgery, Sports Medicine, Physical Medicine and Rehabilitation, and Palliative Care offer direct access through specific residency programs tailored to their respective fields. This pathway allows physicians to acquire specialized knowledge and skills in addiction assessment, treatment, and research without the need for prior psychiatric training. It offers a more direct route to Addiction Medicine.

Conversely, some medical specialities require an indirect path to specialization. For instance, Addiction Psychiatry (Juul et al., 2022) typically involves first completing a Psychiatry residency and then pursuing additional training through an Addiction Psychiatry fellowship, allowing physicians to integrate psychiatric expertise with addiction treatment. Cardiologists follow an indirect route by starting with a residency in Internal Medicine before specializing further in Cardiology, providing a broader foundation in internal medicine to address complex cardiac issues. Pediatric Neurologists first complete a Pediatrics residency before undertaking a fellowship in Pediatric Neurology to diagnose and manage neurological conditions in children. Plastic Surgeons often begin with a general surgery or other surgical residency before pursuing a Plastic Surgery fellowship, ensuring a comprehensive understanding of surgical principles before specializing in plastic and reconstructive procedures. While this path may take longer, it provides a broader foundation in mental health and psychiatric care, which can be advantageous when dealing with the complex psychological aspects of addiction.

In a review conducted by Balasanova et al. (2021), which explored the primary speciality board certifications held by U.S. Addiction Medicine-boarded physicians as of May 2020, interesting insights were gained. The findings revealed a diverse range of medical backgrounds among Addiction Medicine specialists, highlighting the multidisciplinary nature of the field. Notably, 44.9% of these specialists held certifications in Psychiatry and Neurology, showcasing the integration of psychiatric expertise within Addiction Medicine. Additionally, certifications in Internal Medicine, Family Medicine, Anesthesiology, Emergency Medicine, Obstetrics & Gynecology, Pediatrics, Physical Medicine & Rehabilitation, and Preventive Medicine were also represented, further emphasizing the breadth of medical disciplines contributing to addiction medicine (Balasanova et al., 2021).

Furthermore, Nunes et al. (2020) conducted a review that provided valuable insights into the U.S. landscape of Addiction Medicine and Addiction Psychiatry. It highlights the historical roots, board examination content areas, and fellowship training program requirements for both subspecialties. Addiction Psychiatry, a subspecialty under the American Board of Psychiatry and Neurology, has been certifying diplomates since 1993, with ∼1202 active diplomates and 50 accredited fellowships. In contrast, Addiction Medicine, a subspecialty under the American Board of Preventive Medicine, began certifying diplomates in 2018 and has 2604 diplomates, with more expected before the practice pathway closes in 2021, after which fellowship training becomes mandatory. Currently, there are 78 accredited Addiction Medicine fellowships, with more in development. Their review highlighted the substantial overlap between the examination content areas and fellowship training requirements of both fields, emphasizing their shared commitment to addressing SUD and associated comorbidities. While Addiction Psychiatry places extra emphasis on psychotherapeutic and psychopharmacological management strategies and is open only to Board-certified psychiatrists, Addiction Medicine welcomes physicians from any primary medical speciality, including psychiatry (Nunes et al., 2020). This distinction underscores opportunities for collaboration as both fields work toward the common goal of providing a well-trained workforce to address the public health challenge posed by addiction.

Unfortunately, the quality and level of training in Addiction Psychiatry among General Psychiatry trainees are suboptimal, as highlighted by a study conducted by Orsolini et al. (2020). Their study involved a comprehensive assessment of psychiatric trainees from 47 European countries plus Israel. A 76-item questionnaire was distributed through online anonymous data collection methods and hand-to-hand distribution. The findings revealed that out of 1,118 psychiatric trainees from 30 European countries who participated, only 59.9% reported having received training in addictions. However, among those who had received training, 43% described it as not well-structured, and 37% found it unsatisfactory, primarily due to the inadequacy of the knowledge acquired during their training (Orsolini et al., 2020). Furthermore, a staggering 97% of trainees acknowledged that addiction should be a core component of their curriculum, highlighting the recognized importance of this field within psychiatric training. Interestingly, the study found variations in knowledge and training quality among trainees specializing in different psychiatric subspecialties. General adult psychiatric trainees generally exhibited a better understanding of addictions compared to their counterparts in child and adolescent psychiatry (Orsolini et al., 2020).

It is regrettable to note that among the psychiatric subspecialties, Addiction Psychiatry is not as widely offered in many countries, presenting a distinct situation when compared to other subspecialties, such as Geriatric Psychiatry, Child and Adolescent Psychiatry, and Forensic Psychiatry. While these other subspecialties have gained recognition and prominence within the field of psychiatry, Addiction Psychiatry continues to face challenges in terms of availability and accessibility in many regions. This discrepancy underscores the need for greater attention to the importance of addiction-related issues within the psychiatric profession and the importance of expanding training opportunities in Addiction Psychiatry to address the growing public health concern posed by SUD.

Regardless of the chosen training pathway, there is an urgent need for more healthcare professionals specializing in addiction. This demand arises from the high prevalence of SUD in the general population, encompassing substances, such as alcohol, tobacco, opioids, cannabis, and stimulants (Khushalani et al., 2022). Additionally, behavioural addictions, including pathological gambling, internet and gaming addiction, and compulsive sexual behaviours, are emerging as significant public health concerns. The global burden of SUD extends far beyond individual suffering, impacting families, communities, and healthcare systems (Wu et al., 2023). Addressing this crisis requires a comprehensive approach that combines medical and psychiatric expertise, making addiction medicine and psychiatry indispensable disciplines in today’s healthcare landscape.

Concerning Addiction Medicine and Addiction Psychiatry, it is also paramount to acknowledge that the psychosocial aspects of SUD cannot be overlooked. These aspects are typically addressed by members of the multidisciplinary team, including nurses, psychologists, occupational therapists, physical educators, dentists, and social workers, among others. In this perspective, there are other well-established areas of specialization, such as Addiction and Psychiatric Nursing (Jozaghi & Dadakhah-Chimeh, 2018), and Addiction Psychology (Corbin et al., 2013), which also play crucial roles within the field. Recognizing and integrating these specialized areas is essential for providing comprehensive care and addressing the complex interplay between the psychological and social dimensions of SUDs.

Addiction Medicine and Addiction Psychiatry are essential disciplines in addressing the multifaceted nature of SUD. These fields encompass medical and psychiatric aspects of addiction, including the management of intoxications, withdrawal syndromes, comorbid psychiatric conditions, and the treatment of associated medical complications. Physicians interested in specializing in addiction can choose between direct Addiction Medicine training and Addiction Psychiatry (indirect) training, each offering its advantages. The pressing need for more addiction specialists cannot be overstated, given the high prevalence of SUD and the emergence of behavioural addictions. As society grapples with the challenges posed by addiction, the role of healthcare professionals in these fields remains pivotal in providing effective treatment and support to individuals affected by addiction and their families. The integration of medical and psychiatric expertise is essential to addressing this public health crisis and improving the well-being of those struggling with addiction.