An exploration of addictionology in an interview with Dr Jim Shames, Medical Director for both Jackson and Josephine Counties in southern Oregon, and certified addictionologist.
Transcript (edited):
CNS: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions. Howard LaMere here with Dr. Darryl Inaba and special guest, Dr. Jim Shames, the medical director for Jackson County and also Josephine County and the Jackson County Health and Human Services Director. Welcome Jim!
JIM: Thanks. Glad to be here.
HOWARD: We wanted to talk a little bit about addictionology. What it is and where its at, since addiction and all the aspects related are topics we talk about. We thought it would be interesting to have a different perspective from one of the relatively few addictionologists.
JIM: Well there are a couple and I think addictionologists probably tend to specialize. You know theyll have a particular kind of work they do and they bring that expertise along whether its residential work or work at the V.A. or work with alcoholics and in my case, I bring addiction medicine to public health. And I kind of put those two together to look at addiction issues that relate to the public at large and the health of the community.
DARRYL: You know, its really great, Howard, to have a health director here in Josephine and Jackson County who is also a board certified addictionologist. Its amazing to me, Jim, that despite all of the advances in this field and the knowledge and acknowledgement of addiction as a chronic persistent medical disorder, there is still a total lack of appreciation for that. The general public doesnt appreciate addiction as a primary persistent disorder or chronic persistent disorder and for me, its even more tragic that clients themselves, the addicts themselves, dont appreciate it and they struggle with their addiction until they finally recognize that they do have something to take care of. When you look at the science grow and the whole field grow weve also seen the profession grow and we have a lot more professionals involved .we can see that its a medical disorder. We now have board certified addictionologists. Exactly, what does that mean? What is a board certified addictionologist?
JIM: Well, for the last, I dont know for perhaps 10 plus years maybe 10 or 20 years there has been the American Society of Addiction Medicine, which has a stringent certification process for physicians requiring , I think thousands of hours of experience to qualify to take an exam, which is quite stringent. Once youve passed those, paid some money, had your background check, whatever then you can become an ASAM, an American Society of Addiction Medicine certified physician. That is not quite the same as board certification, which is what your family practice doctor or your surgeon or your cardiologist has. They would be board certified, usually implying a residency – specialty training after medical school as opposed to just experiential. There is now an American Board of Addiction Medicine and I suspect that they are creating residency programs to go along with that. So I grandfathered in and Im now a board certified addiction medicine specialist.
DARRYL: I cant think of anyone more qualified, having worked with you. So thats great! But you know, does that mean that an addiction specialist, like yourself has the same level of qualification as a medical specialist like an oncologist, or endocrinologist? Can an addictionologist, do things differently or are they allowed to do things differently than say a general practitioner who is treated addicts?
JIM: You know, I dont think it comes with that. I mean, when youre a board certified specialist, you are treated by your colleagues differently and your opinion carries more weight, as it should. There are certain positions that you would be more qualified for so if someone was running a large treatment program, as a physician or was the medical director thereof, they would presumably want somebody who had specialty training, who was certified as having that expertise. But, theres nothing that I can do thats different from what anyone else can do without these qualifications. And thats true in medicine in general. You can deliver babies and sew up lacerations and do lots of things regardless of your expertise, but it would be foolish to do so and you might not be able to do it in a hospital or some other facility unless you had the proper credentials.
DARRYL: What are some of the roles that addictionologists are playing now in the field? Are they traditionally the medical review officer with big urine (testing) programs?
JIM: There is that. First of all, I think that a good percentage are psychiatrists. I think that its often a subspecialty of psychiatry and I think that folks, in large hospitals might have an addiction medicine specialist as part of the psychiatric unit. If you had a large residential treatment facility, you might have an addiction medicine specialist and the Veterans Administration might have somebody on their staff. I think its a helpful adjunct for anybody that does large amounts of medicine. The numbers are increasing, so I suspect that we will find lots more uses. But as a corollary for a thoroughly qualified health center or a large, outpatient clinic for example, I think its very useful to have a specialist that people can turn to when addiction issues come up.
DARRYL: One of the things that has always concerned me, is the lack of scrutiny over our testing procedures urine testing procedures and things like that. We have specialists – like certified addictionologists – who can review urine results and make better evaluations. Right now, especially in the criminal justice system, theres no review. Somebody gives a urine test it comes up positive and negative and thats it.
JIM: Yes, thats really unfortunate because theres a lot of scrutiny for the laboratories. They have to comply with all sorts of appropriate regulations to be sure that when they say this much substance is present, that it is true, and yet the interpretation of the results is all over the map. I dont think thats entirely the fault of the physicians who ultimately are passing judgment or in some cases, non-physicians because it looks straight forward this says you have morphine sulfate in your urine this says you have a breakdown product of amphetamines in your urine, therefore .and its the therefore where the problem lies. You have to really understand the complex metabolic breakdown and the potential for false positives, false negatives and it is an area of expertise that really needs to be incorporated into the training of anybody who is utilizing urine drug screen. So there is this MRO process this process of physicians whether or not they are addiction medication specialists who can be certified to provide that kind of interpretation.
DARRYL: I know in addition to all your other hats and things you do in southern Oregon, you also help out with several recovery programs here and I wonder what it is about this field, what attracted you to become more involved with addiction and medicine?
JIM: Well, I dont know that I was necessarily attracted. I think I kind of got dragged, kicking and screaming into it! I was providing primary care medicine for folks who didnt have a lot of resources. Ive been doing that my whole life. And I kept running into issues of addiction and you know, Im a nice guy and I wanted to help people and I kept getting into trouble I was over my head in areas I didnt understand. I dont have addiction problems personally, so in my attempts to help, I often found myself doing more harm than good and at some point I figured, I really need to know what Im doing here. And so, and parallel to my primary care medicine background, which is what Ive done most of my life which is – basic medicine basic rural medicine really I took the job as medical director for our local methadone clinic and that was 20 some odd years ago. So, as time went on, it became clear to me that I needed more expertise. I had put in many hours working at the methadone clinic. I got myself some book learning, took some courses and then took the test and passed the test. So, I feel as if it became a responsibility. When I started primary care, I started delivering babies and I hadnt expected to do that. And so I realized I had to get expertise in the area of addiction and I did. So, I just think its a responsibility issue.
DARRYL: You know, you mentioned that you integrated or had to integrate addiction medicine into primary care, and it just seems to me right now, with the passage of the Addiction Equity Act of 2008 which hasnt been implemented yet sad to say but as they do implement it, what role do you see it having in primary care? An Addiction Equity Act recognizes addiction as a chronic persistent disorder. Are we going to put it in psychology? Are we going to put it in counseling, or in primary care if its a chronic persistent disorder?
JIM: Well, I think chronic disease management is an area of great growth in medicine. And I think those that are not aware of it, are going to see it as the years go by because thats a lot of what we do in medicine is take care of diabetes and hypertension and obesity and arthritis and diseases …acute diseases weve got down. Weve got that figured out. But there is a deep learning curve for how to take care of chronic diseases. And in fact, its a bit different than acute medicine. Were taught the art of medicine and we like to think that when we sit down with a patient, we get this magical relationship and we understand them and we have something we outline and they come back and see how you are doing. Well, in fact, the critical features for doing well in diabetes management is mostly cookbook. Its – check your feet, get an eye exam every year this kind of diet. These are the medications and its a very stepwise approach and peoples lives are saved if you practice that way. What this means is, you dont just need a physician, you need a program. You need a program. Addiction medicine, I think fits very nicely into where we are going in general. Docs need to understand what the approach is. Youre going to need a team. Just like for diabetes management, you need a team. You need a nurse. You need medical assistants. Same thing for addiction medicine, so I think its going to work nicely and I suspect that we will find the systems and somewhere in that system are going to be specialist. Physicians will say – Ive done this, this, and this things arent going very well, now I need to bring the addiction medicine specialist into play to help me decide what my next moves are going to be.
DARRYL: I think thats a great analogy to diabetes because in diabetes, the recommended treatment, theyre healthy. Theyre healthier than people without diabetes for the same age. But if a diabetic doesnt accept that they have this condition or ignores it and continues to live the same way – they can suffer horrendous consequences. Ive seen people with amputated toes and amputated ankles and legs amputated up to the knee and then lose their life very early with diabetes. If an addict can accept that they have this condition and follow recommended treatment, I think they can be healthier than everybody else around, but if they dont, they suffer horrendous consequences.
JIM: Right. Yes .it functions like a chronic disease and I think the more that the public and health care providers can see that, the better we will do with treatment.
HOWARD: Okay, Jim, I want to thank you and Darryl for being here and hope that you will come back and share some more experiences let us explore some other of the intricacies.
We are always interested in feedback so if you have comments or questions, please get in touch and we will respond. Darryl, Jim thanks!