Bramness and colleagues demonstrate the varied addiction medicine and psychology training pathways across 16 European countries, through their online survey utilizing the European Federation of Addiction Societies (EUFAS) network [1]. We offer an Australian and New Zealand perspective on training pathways and workforce planning, commenting on many similarities with established programmes in Europe in addiction medicine, addiction psychiatry, and nursing, but also highlight particular issues relevant to our region including workforce shortages and planning needs.

Addiction treatment in Australia and New Zealand occurs in many different settings across primary and secondary care. While there are regional differences, the non-governmental or civil society organization sector plays a much larger role in addiction treatment than is the case for other chronic health conditions. The addictions workforce comprises a diverse multidisciplinary range of clinicians, including medical practitioners, nurses, psychologists, other allied health clinicians, support workers, and peer support staff with lived experience. In New Zealand, medical practitioners make up less than 10% of the clinical staff in this workforce [2] while across treatment settings in Australia, this is estimated at under 2% of the workforce [3]. Although psychologists form a core component of the multidisciplinary workforce, there is no specialized training pathway or curriculum in addiction psychology.

The addictions workforce faces challenges including high vacancy rates, staff turnover, and recruitment difficulties, particularly in rural/regional areas and areas with high levels of deprivation. A high percentage of the workforce is nearly retirement age and this presents future challenges with attracting newly qualified and younger clinicians to the field. The problems facing the addictions workforce show the need for strong clinical leadership, which requires a stream of well-trained addiction medicine specialists. Compared to addiction medicine, the nursing workforce is larger, comprising 10–20% of all clinical staff, with a growing pipeline of alcohol and other drug nurse practitioners across the region. However, attracting and retaining the nursing and nurse practitioner workforce has raised similar issues to those relevant for addiction medicine [4].

A specialist medical workforce in addictions has existed across Australia and New Zealand since the early 1990s. Prior to this, addiction medicine did not exist as a recognized speciality. The medical workforce mainly comprised physicians, psychiatrists, and general practitioners with an interest in the field. Within a relatively short space of time, there has been significant growth and formalization of training pathways in this field [5]. In contrast, there is still no national or binational approach to addiction psychology as a training pathway, nor in any other allied health specialty.

Subspecialists in addiction were recognized with the formation of the physicians’ Chapter of Addiction Medicine within the Royal Australasian College of Physicians (RACP) in 2002, and within the Royal Australian and New Zealand College of Psychiatrists (RANZCP) with the formation of a Section (1989), and then a Faculty of Addiction Psychiatry in 2015 [5]. These two streams provide a pathway to subspecialty qualifications for physicians and psychiatrists seeking accreditation in the field. Within Australia, there has been more recent recognition of these fields as a specialty by the National Medical Council and Medical Board, with subsequent allocation of reimbursement through national billing (Medicare) schemes [6]. These important steps have boosted awareness, visibility, and attraction of trainees to the area.

Broadly, subspecialty training in addiction in the Australia and New Zealand region appears comparable to pathways in many European jurisdictions, as delineated in the EUFAS survey [1]. Across Australia and New Zealand, subspecialty training in addiction medicine or psychiatry is available to final-stage physicians and psychiatry trainees who have completed basic or general training (usually 4–5 years in duration). Advanced training in addiction involves 2 to 3 years of training, and trainees are expected to rotate through a structured program of clinical settings to achieve a broad range of exposures and experiences, containing all of the domains set out in the EUFAS survey (Table 1, [1]; content including pharmacological and non-pharmacological therapies, medical emergencies, medical complications, and dual diagnosis management). The RANZCP utilizes a competency-based framework, which sets out expectations aligned with a series of entrustable professional activities. Rotations and exposures include opioid pharmacotherapy prescribing, acute and sub-acute withdrawal management, general hospital alcohol and other drug liaison, management of co-occurring mental health comorbidity, management of gambling and other behavioural addictions, and exposure to co-occurring pain management. Certification of competencies is through a professional society (either the RANZCP or the RACP), with a requirement for ongoing maintenance of continuing professional development, but no mandatory requirement for re-certification.

Table 1.

Attitudes objectives (Addiction Psychiatry Curriculum, RANZCP 2016) [6]

Attitude Objective 1 Offering respectful support to colleagues in health and social services working to provide services to people with substance use and addictive behaviours, including peer support workers, and showing an awareness of the level of knowledge and circumstances of others 
Attitude Objective 2 Communicating openly and broadly with the wider community by all available means, believing that the provision of accurate information will improve community responses to substance use and addictive behaviours 
Attitude Objective 3 Recognising and dealing constructively with stigma and biased attitudes towards people with substance use and addictive disorders 
Attitude Objective 4 Developing an awareness of the impact of substance use and addictive disorders on families and the wider community, and striving to balance the needs of our patients with those of families and the wider community 
Attitude Objective 1 Offering respectful support to colleagues in health and social services working to provide services to people with substance use and addictive behaviours, including peer support workers, and showing an awareness of the level of knowledge and circumstances of others 
Attitude Objective 2 Communicating openly and broadly with the wider community by all available means, believing that the provision of accurate information will improve community responses to substance use and addictive behaviours 
Attitude Objective 3 Recognising and dealing constructively with stigma and biased attitudes towards people with substance use and addictive disorders 
Attitude Objective 4 Developing an awareness of the impact of substance use and addictive disorders on families and the wider community, and striving to balance the needs of our patients with those of families and the wider community 

Extending the domains outlined in the EUFAS survey, the addiction medicine and psychiatry curriculum in this region specifically highlights the need to address stigma and to foster attitudes that enhance provision of care. The addiction psychiatry training curriculum supports trainees to develop competencies in attitudes, as well as knowledge and skills (see Table 1) [7]. The curriculum takes into account the central role of stigma, prejudice, and discrimination in the lives of individuals and families living with addictions and the need for trainees to actively counter this in their practice. This emphasis on the development of attitudinal alignment highlights the grounding of this specialty curriculum within the broader context of cultural and societal influences, training specialists who foster hopeful, accepting, and non-judgemental attitudes towards people with substance use and addictive disorders [7]. Within curricula, specific attention is paid to health inequities faced by highly marginalized populations, particularly First Nations populations in Australia and New Zealand, who face a disproportionate burden of addiction-related harm as a result of transgenerational disadvantage and the impact of social determinants of health.

Bramness’ article also demonstrated the variability in the number of specialists per capita and the number of professorships across the European region [1]. For the Australian and New Zealand region, comparator countries with similarly mature training programmes have between an estimated 60 (Sweden) to 150–200 (Norway, the Netherlands) addiction medicine and psychiatry specialists nationally. Within Australia and New Zealand, no definitive statistics on workforce numbers currently exist, but based on previous workforce planning activities and current key informant data from professional societies, this is estimated to be about 300 specialists binationally (approximately 100–150 addiction medicine specialists and an estimated 150 addiction psychiatrists). These specialists work across two countries with a combined population of about 31.7 million people, with about 9.6 specialists per million inhabitants, much lower than several Western European nations.

Whilst Bramness and colleagues’ paper primarily focused on workforce training, it is important to consider workforce planning and context, which is closely linked to resourcing, implementation, and sustainability of training pipelines. Although there has been substantial growth in specialist numbers in the region, what is funded and supported can vary across jurisdictions, similar to across different European countries, where health funding, oversight, resourcing, and strategic priorities differ from country to country. Although Australia and New Zealand have uniform training programs and pathways, the implementation and resourcing of this differs from state to state, and between Australia and New Zealand, which then translate to inconsistencies in the workforce distribution and sustainability. Within the Australian and New Zealand context, workforce funding and pathways vary across jurisdictions, with some states in Australia having funded addiction roles and pathways as part of their health system (e.g., NSW, QLD, SA, WA), while other states predominantly fund a non-governmental organizational model, where medical practitioner roles and training positions have traditionally not been funded. The heterogeneity in training pathways and pipelines across the region is underpinned by this variability in funding streams and whether or not addiction services sit within mainstream health budgets, mirroring the context across diverse countries and funding environments in Europe as mapped by the Bramness and colleagues’ survey.

Aside from specialist numbers, there are two key factors that impact on addiction medicine workforce planning efforts in this region. Firstly, succession planning is a critical issue. A 2016 workforce survey of addiction medicine specialists identified that 47.7% were aged 60 years or older and 67.5% intended to retire within 10 years [8]. Secondly, our nations are large and geographically diverse, with significant disparities in access to specialists between rural and metropolitan settings; 2016 estimates suggest 86.7% addiction medicine specialists were located in a metropolitan area.

A further critical need is for greater diversity among specialists, in particular better representation of Māori and Pasifika in New Zealand and Aboriginal and Torres Strait islander clinicians in Australia, and clinicians with cultural expertise working with immigrant populations, and those for whom English is not their first language. Achieving gender parity and greater representation of trainees from LGBTQI backgrounds is also much needed.

Regional workforce planning has been directed at addressing these issues for some time, through initiatives to attract and retain trainees and creation of workforce pipelines, including in rural and regional settings. For instance, advocacy efforts by professional societies at a state and national government level have supported increased funding for trainee positions and professorships. Training bodies have incorporated flexibility and agility in the design of traineeships outside of tertiary specialist settings, particularly in rural and regional areas. Data from the RANZCP demonstrate the success of these initiatives, alongside growth in mentoring, role modelling, and other succession planning efforts, resulting in a record number of doctors (n = 105) binationally undertaking subspecialist certification training.

Nevertheless, despite these efforts, specialist workforce numbers are unlikely to ever be sufficient to address the significant burden of harm associated with addictive disorders. A recent health economics report estimated the cost of addiction in Australia, combining the impact of productivity and associated losses to the economy, at over AUD$80 billion annually [9]; approximately one in four Australians will struggle with alcohol, other drugs, or gambling problems in their lifetime [10]. This highlights the need for broader capability and competency in addiction treatment across the general health workforce and the need to integrate training into health professional curricula. Despite this need, addiction medicine is still not an established core component of the curricula of some medical schools across the region and is not taught within nursing curricula or in other health professional undergraduate training. Additionally, there are few opportunities for clinical placements for health professionals within alcohol and other drug settings during undergraduate and postgraduate training, meaning that limited real-life exposure can reinforce stereotypes and entrench stigma within the health workforce.

The tension between generalist and specialist competencies arises in the context of addiction being a relatively new specialty, with the focus of workforce initiatives internationally being on attraction of trainees, through subspecialization and creation of identity and awareness for the field [11]. However, in several regions internationally, enhancing generalist capacity is an imperative. Within Australia and New Zealand, generalism is necessary for practitioners in rural and regional settings to support the diverse needs of local populations. The RANZCP has recently commissioned a new rural psychiatry roadmap to specifically enhance the capacity of psychiatrists to train and to remain in rural settings, incorporating flexibility to achieve a breadth and range of competencies rather than narrower subspecialism [12]. More broadly, generalism is essential in other settings where resource, funding, or geographical constraints limit access, such as in lower and middle-income countries [13]. Supporting generalist capacity to address addiction also enhances the ability to address multi-morbidity, within integrated care models for both mental health and physical health comorbidities.

In summary, within this region, despite success in formalizing training pathways and growing specialist and trainee numbers in a short space of time, the workforce continues to face challenges in succession planning and lacks the size to meet demand. Over the past decade, training and workforce initiatives have focused on establishing a distinct specialty, with efforts aimed at attraction and retention of trainees. However, as the specialty grows, it will be essential to support integration of addiction into medical and health professional curricula, enabling generalist capacity. This will support opportunities to address lower severity and higher prevalence problems across the population, as well as associated stigma, thereby encouraging help seeking and earlier intervention across the spectrum of addictive disorders.

The authors have no conflicts of interest to declare.

No funding was received for this work.

Author 1 prepared the first draft of the manuscript. Authors 1, 2, and 3 edited the manuscript and approved the final version.

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