Addiction and Chronic Pain: Training Addiction Psychiatrists.

OBJECTIVE: Addiction psychiatrists are increasingly asked to address chronic pain in patients with addiction. Because of historic "divisions of labor" between physicians who manage pain and addiction psychiatrists who manage addiction, limited guidance exists for preparing addiction psychiatry trainees to address this comorbidity. METHODS: A 1-h focus group composed of five geographically well-distributed addiction psychiatry fellowship directors/faculty was conducted to explore existing curricula, identify themes, and build consensus regarding educational goals for addiction psychiatry fellows in the area of chronic pain management. RESULTS: Discussion resulted in five broad categories of themes involving perceptions of the importance of chronic pain training for addiction psychiatrists; barriers to curriculum development (one notably being that the addiction psychiatrist's role in managing chronic pain is poorly articulated); facilitators to such development; and potential curricular content and roles of addiction psychiatrists in relation to chronic pain training. CONCLUSION: Educators in addiction psychiatry should clarify their role in the management of chronic pain and prioritize training in this area.

An Innovative Use of Case Conference to Teach Future Educators in Addiction Psychiatry.

Objective An innovative course was developed for fellows enrolled in the Yale School of Medicine Addiction Psychiatry program to educate them in key principles of adult learning, apply these principles in a case conference presentation, and to improve skills in providing and receiving feedback. Methods An initial training module on educational skills was followed by individual mentorship to prepare a case presentation. A feedback module provided space to learn and practice skills in feedback delivery. Results The program showed positive results and improved confidence levels of the participants in presenting and providing/receiving feedback. Conclusions Implementing a course designed to improve teaching and feedback skills is feasible in a 1-year Addiction Psychiatry fellowship.

Pilot results of a new model of addiction treatment: managing addiction as a chronic disease.

BACKGROUND: Addiction is increasingly conceptualized as a chronic disease, yet the current addiction treatment system is largely based upon an acute illness model, with weeks of residential care followed by intensive day programs. To address this mismatch between best practices and current standards of care, we initiated a new model of highly intensive, rigorously monitored, year-long outpatient addiction treatment in Connecticut between December 2012 andJune 2013. METHODS: We conducted a proof-of-concept pilot study, accepting everyone who was willing to participate and able to pay for the care. RESULTS: A total of five participants were enrolled during this period, all with DSM-5 substance use disorder (SUD), severe. These participants, who comprised the entire pool of pilot participants and each completed 12 months of treatment, all achieved sustained abstinence (defined as more than six months of continuous sobriety), as confirmed by frequent, random alcohol and drug tests. CONCLUSIONS: These pilot results demonstrate the feasibility and potential effectiveness of an innovative model of addiction treatment.

Management of Adolescents With OUD: A Simulation Case for Subspecialty Trainees in Addiction Medicine and Addiction Psychiatry.

Introduction: The opioid epidemic impacts all ages, yet few published medical education curricula exist to train physicians on how to care for opioid use disorder (OUD) in adolescents, a developmental stage where confidentiality protection is appropriate and contributes to quality health care. We developed a simulation-based educational intervention to increase addiction medicine and addiction psychiatry trainees' confidence in managing adolescents with OUD. Methods: Trainees completed a confidence survey and viewed an educational video covering state-specific confidentiality laws pertinent to treating adolescents with OUD. One week later, trainees participated in a simulated encounter where they described the scope of confidentiality to a trained actor, used the Clinical Opiate Withdrawal Scale to assess symptoms of opioid withdrawal, and explained adolescent-specific OUD medication treatment options. Immediately afterward, trainees completed a self-reflection and satisfaction survey and participated in a debriefing session with a faculty member where they identified learning goals. One month later, they completed the confidence survey to quantify changes in confidence. Results: Thirty-five fellows (21 male, 14 female) completed the simulation-based educational intervention between 2016 and 2019. When asked to answer yes or no, 96% of participants described the exercise as effective and 100% (n = 26) would recommend it to peers. In addition, learners identified future learning goals, including researching specific topics and seeking out additional opportunities to evaluate adolescents with OUD. Discussion: Based on our participants' report, this simulation-based educational intervention is an effective teaching method for increasing trainee confidence in managing adolescents with OUD.

Chronically homeless women report high rates of substance use problems equivalent to chronically homeless men.

INTRODUCTION: The U.S. federal government recently committed itself to ending chronic homelessness within 5 years. Women constitute one out of four chronically homeless adults and represent a particularly vulnerable group, but have been little studied. To identify potentially unique needs in this group, we report characteristics and 2-year outcomes in a large sample of male and female chronically homeless adults participating in a multisite, supportive housing program. METHODS: Men and women participating in the outcome evaluation of the 11-site Collaborative Initiative on Chronic Homelessness (n = 714) supportive housing program and who received at least one follow-up assessment were compared on baseline characteristics and up to 2-year follow-up outcomes. Mixed model multivariate regression adjusted outcome findings for baseline group differences. RESULTS: Few significant baseline differences existed between males and females, with both sexes self-reporting very high rates of lifetime mental health (83% women, 74% men) and substance use (68% women, 73% men) problems. Throughout the 2-year follow-up, both men and women dramatically increased the number of days housed, showed minimal changes in substance use patterns, and had modest improvements in mental health outcomes, without significant differences between genders. CONCLUSION: Unlike other U.S. populations, chronically homeless adults do not demonstrate substantial gender differences on mental health or addiction problems. Policy and service delivery must address these remarkably high rates of substance use and mental illness.

Does active substance use at housing entry impair outcomes in supported housing for chronically homeless persons?

OBJECTIVE: Recent clinical and policy trends have favored low-demand housing (provision of housing not contingent on alcohol and drug abstinence) in assisting chronically homeless people. This study compared housing, clinical, and service use outcomes of participants with high levels of substance use at time of housing entry and those who reported no substance use. METHODS: Participants in the outcome evaluation of the 11-site Collaborative Initiative on Chronic Homelessness (N=756), who were housed within 12 months of program entry and received an assessment at time of housing and at least one follow-up (N=694, 92%), were classified as either high-frequency substance users (>15 days of using alcohol or >15 days of using marijuana or any other illicit drugs in the past 30 days; N=120, 16%) or abstainers (no days of use; N=290, 38%) on entry into supported community housing. An intermediate group reporting from one to 15 days of use (N=284, 38%) was excluded from the analysis. Mixed-model multivariate regression adjusted outcome findings for baseline group differences. RESULTS: During a 24-month follow-up, the number of days housed increased dramatically for both groups, with no significant differences. High-frequency substance users maintained higher, though declining, rates of substance use throughout follow-up compared with abstainers. High-frequency users continued to have more frequent or more severe psychiatric symptoms than the abstainers. Total health costs declined for both groups over time. CONCLUSIONS: Active-use substance users were successfully housed on the basis of a low-demand model. Compared with abstainers, users maintained the higher rates of substance use and poorer mental health outcomes that were observed at housing entry but without relative worsening.