A call for increased addiction psychiatrist engagement in medical student education.

BACKGROUND AND OBJECTIVES: Addiction psychiatrists are ideally trained to provide trainees with supervised clinical experiences in caring for patients with co-occurring substance use disorders and other complex psychiatric disorders. METHODS: This is a call for addiction psychiatrists to step up as clinical champions in medical student education. Our targeted audience is practicing addiction psychiatrists who do not currently have medical students on their clinical services. RESULTS: We suggest several approaches to incorporating learners into existing addiction psychiatry clinical services both at academic institutions and in the community. DISCUSSION AND CONCLUSIONS: For medical schools without addiction psychiatrists on faculty, we suggest unique solutions for collaborating with external educational venues. SCIENTIFIC SIGNIFICANCE: There is limited literature on the role of addiction psychiatrists in providing supervised experiential learning experiences for medical students. There has been no previous publication specifically advocating for increased addiction psychiatrist engagement in the clinical education of medical students.

Counteracting the Effect of Stigma on Education for Substance Use Disorders.

The national failure to adequately respond to the opioid epidemic has exposed major deficits in the U.S. health care education system. Treatment services are inadequate; clinicians are ill prepared and uninformed about existing effective treatments; and even when specially trained, over 25% fail to provide any treatment, and the majority rarely treat more than a handful of patients. Stigma has been identified as a significant roadblock to the needed expansion of treatment services. Educators in the health professions need to rethink their approaches to the substance use disorder curriculum, both to significantly expand the training time and content and to devise programs that successfully modify the stigma that has undermined existing educational efforts. The neurobiological basis of stigma is described, along with techniques historically shown to reverse stigma. The Boston University Medical Center/VA (Veterans Affairs) Boston Healthcare System Psychiatry Program has developed a successful model curriculum that has expanded substance use disorders training and has incorporated clinical experiences that have been shown to modify stigma and generate enthusiasm for working with patients with substance use disorders. This article presents recommendations for implementing this model in other psychiatry training programs and adapting it for other clinical disciplines.

Training in Buprenorphine and Office-Based Opioid Treatment: A Survey of Psychiatry Residency Training Programs.

OBJECTIVE: Psychiatrists are well suited to provide office-based opioid treatment (OBOT), but the extent to which psychiatry residents are exposed to buprenorphine training and OBOT during residency remains unknown. METHODS: Psychiatry residency programs in the USA were recruited to complete a survey. RESULTS: Forty-one programs were included in the analysis for a response rate of 23.7 %. In total, 75.6 % of the programs currently offered buprenorphine waiver training and 78.1 % provided opportunities to treat opioid dependence with buprenorphine under supervision. Programs generally not only reported favorable beliefs about OBOT and buprenorphine waiver training but also reported numerous barriers. CONCLUSIONS: The majority of psychiatry residency training programs responding to this survey offer buprenorphine waiver training and opportunities to treat opioid-dependent patients, but numerous barriers continue to be cited. More research is needed to understand the role residency training plays in impacting future practice of psychiatrists.

The evolution of chronic opioid therapy and recognizing addiction.

Chronic pain is one of the most common complaints in the United States. Opioids have become a frequently prescribed treatment for patients with chronic nonmalignant pain. Concurrently, opioid use disorders have risen to epidemic levels. Studies investigating iatrogenic opioid addiction have been of limited quality. Aberrant drug-related behaviors may be warning signs of impending addiction. Proper screening and close monitoring are essential for managing patients on opioids for chronic nonmalignant pain.

Preliminary survey of office-based opioid treatment practices and attitudes among psychiatrists never receiving buprenorphine training to those who received training during residency.

OBJECTIVE: To compare the characteristics, attitudes, and current prescribing practices of recently graduating psychiatrists who completed buprenorphine training during residency to those who never completed any training. METHODS: A total of 359 psychiatrists completing residency training between 2008 and 2011 were recruited to complete an on-line survey. RESULTS: Responses from 93 psychiatrists were included for a response rate of 25.9%. Psychiatrists completing any buprenorphine training during residency were more likely to be male and report more favorable views of OBOT with buprenorphine than compared to those who never completed any training. Twenty (38.5%) of those psychiatrists who completed training during residency reported the current prescribing of buprenorphine. CONCLUSIONS: Completion of buprenorphine training during residency may be a factor in shaping future attitudes towards OBOT and buprenorphine prescribing practices. Further research is needed to clarify the impact of buprenorphine training during residency. SCIENTIFIC SIGNIFICANCE: Buprenorphine training during residency training may be a contributing factor in shaping future physician attitudes towards office-based opioid treatment and buprenorphine prescribing practices.

Clinician beliefs and attitudes about buprenorphine/naloxone diversion.

BACKGROUND AND OBJECTIVES: Concern about diversion of buprenorphine/naloxone (B/N) in the United States may affect prescribing patterns and policy decisions. This study examines addiction treatment clinician beliefs and attitudes regarding B/N diversion. METHODS: Participants (n = 369) completed a 34-item survey in 2010 during two national symposia on opioid dependence. We conducted multivariable regression, examining the relationship of perceived danger from B/N diversion with clinician characteristics and their beliefs about B/N treatment and diversion. We compared causal beliefs about diversion among clinicians with and without B/N treatment experience. RESULTS: Forty percent of clinicians believed that B/N diversion is a dangerous problem. The belief that B/N diversion increases accidental overdoses in the community was strongly associated with perceived danger from B/N diversion. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Attitudes and beliefs, not education level, were associated with clinician's perceived danger from B/N diversion. Clinicians with greater B/N patient experience were more likely to believe treatment access barriers are the major cause of B/N diversion.

The Physician Clinical Support System-Buprenorphine (PCSS-B): a novel project to expand/improve buprenorphine treatment.

Opioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. Our goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. We provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. We provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidances, a warmline and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1-125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidances were downloaded more than 1000 times. The warmline averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care.

What do psychiatric residents think of addiction psychiatry as a career?

OBJECTIVE: The authors attempt to better understand the recent decline in the number of applicants to addiction psychiatry training. METHODS: The Corresponding Committee on Training and Education in Addiction Psychiatry of APA's Council on Addiction Psychiatry sent out a 14-question anonymous e-mail survey to all postgraduate-year 2 (PGY-2) through PGY-4 APA Members-in-Training. The questions explored residents' beliefs and attitudes toward addiction psychiatry and sought their opinion on how training in addiction psychiatry can be made more attractive to them. RESULTS: Of 2,511 eligible psychiatric residents surveyed nationally, 276 (10.6%) residents responded to the survey. Residents who responded had a generally positive impression of addiction psychiatrists but expressed much less favorable attitudes toward the practice of addiction psychiatry. Respondents provided three major subsets of suggestions: employment security and compensation, optimize PGY-1-4 addiction training, and fellowship training issues. CONCLUSION: These findings may be used to improve addiction psychiatry training and recruitment.

Factors affecting willingness to provide buprenorphine treatment.

Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine.

Training psychiatrists to diagnose and treat substance abuse disorders.

Addiction training in psychiatric residency programs needs expansion. Epidemiology research has shown that patients with substance use disorders and co-occurring mental health disorders are the norm in nearly all clinical settings. Unfortunately, traditional training approaches built around brief rotations on detoxification or intensive substance abuse rehabilitation units do not adequately train psychiatrists in long-term management skills, and may reinforce misperceptions that these patients do not respond to treatment. An enhanced addiction curriculum coupled with an extended outpatient clinic rotation is an ideal model for teaching the skills needed to successfully care for these patients. Training must include an adequate knowledge base, an opportunity to cultivate positive attitudes toward these patients, and recognition that psychiatrists must take responsibility for treating the addiction problem and any co-occurring psychiatric disorders. The program developed at Boston University Medical Center successfully integrates expanded addiction psychiatry training into the general psychiatry residency.

How to train residents to identify and treat dual diagnosis patients.

Medical training has failed to address the needs of patients with comorbid substance use and psychiatric disorders. Addiction teaching is limited and often fails to change the negative attitudes of many physicians. In many psychiatry residencies, addiction training occurs on inpatient or detoxification units and the focus is on screening, detoxification, and referral. Most residents do not gain adequate experience in the long-term management of dual-diagnosis patients. Successful clinical care is based on three critical elements (the "clinician's triad"): an adequate knowledge base, a positive attitude toward the patient and the benefits of treatment, and a sense of responsibility for the clinical problem. The Boston University Psychiatry Residency has designed an addiction training program to address these three issues. In addition to a comprehensive addiction seminar series, there are several unique features. The required clinical rotation occurs in an outpatient dual-diagnosis clinic and permits residents to follow a caseload of patients for 12 months. Extensive experience is gained in motivational interviewing, cognitive behavioral therapy, and pharmacotherapy. Self-directed learning approaches are used to maximize the educational experience on services that lack addiction faculty. Guidelines are provided for establishing a similar program and for more effective approaches to resident teaching.