Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements.

BACKGROUND: Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE: To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN: This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS: Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH: Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS: Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS: Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

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.

The problem of pain: Additive analgesic effect of tramadol and buprenorphine in a patient with opioid use disorder.

Background: There is a paucity of published literature on the optimal treatment of pain in patients on buprenorphine treatment (BT) for opioid use disorder. Using this case report, we hope to demonstrate that tramadol may represent an effective treatment option for pain in patients on BT while encouraging future clinical trials. Case: The patient is a 56-year-old Caucasian male with a history of opiate use disorder on treatment with buprenorphine/naloxone 8/2 mg 2 times a day (BID) who was followed in an outpatient general psychiatry clinic that specializes in patients with co-occurring substance use disorders. Although maintaining sobriety from opioids, the patient continued to struggle with acute on chronic pain secondary to osteoarthritis that had left him walking with a cane. The patient was started on tramadol 50 mg 3 times a day (TID) for acute pain by his primary care physician (PCP) while he awaited surgical intervention. He reported analgesic effect with buprenorphine/naloxone but noted that it did not last the full period between his doses. He reported further improvement in his pain along with greater daily functioning with the additional use of tramadol, without side effects or withdrawal symptoms. Discussion: Current recommendations for pain management in patients on BT include discontinuation of BT therapy and/or addition of an adjunctive opioid analgesic (including additional buprenorphine/naloxone) while continuing agonist medication for treatment of opioid use disorder. However, determining which medication to use can be difficult, as there has been no literature examining this issue. In this case, the combination of buprenorphine and tramadol demonstrated an additive analgesic effect. Randomized control studies need to be performed to further understand the changes in pain measurement in patients on BT with tramadol compared with other adjunctive analgesic medications.

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.

Pilot study comparing SPECT perfusion scintigraphy with CT pulmonary angiography in chronic thromboembolic pulmonary hypertension.

BACKGROUND AND OBJECTIVE: The management of chronic thromboembolic pulmonary hypertension (CTEPH) is dependent on the extent of pulmonary artery obstruction, which is usually evaluated by planar perfusion scanning and CT pulmonary angiography (CTPA). We previously reported that SPECT perfusion scanning is more sensitive than planar scanning for detecting vascular obstruction in CTEPH. The purpose of this study is to compare SPECT with CTPA for detecting segmental pulmonary artery obstruction in CTEPH. METHODS: SPECT and CTPA were carried out before pulmonary endarterectomy in 12 CTEPH patients. Field experts documented the anatomical distribution of perfusion defects disclosed by SPECT, the anatomical distribution of pulmonary arterial filling defects disclosed by CTPA and the segmental anatomy of the vascular obstructions based on a review of clinical and pathology records, without knowledge of scan results. RESULTS: Clinical/pathological evaluation disclosed 140 obstructed (15.5 ± 2.5 per patient) and 40 unobstructed lung segments. SPECT scanning identified 87/140 (62%) of the obstructed and 29/40 (72%) of the unobstructed segments. By comparison, CTPA identified 67/140 (47.8%) of the obstructed and 32/40 (80%) of the unobstructed segments. Sensitivity for detecting obstructed segments was significantly higher for SPECT compared with CTPA (62 ± 4.1% vs 47.8 ± 2.9%, respectively; P = 0.03). CONCLUSIONS: SPECT is more sensitive than CTPA for identifying obstructed segments in this small sample of CTEPH patients. However, even SPECT under-represents the extent of vascular obstruction from this disease.

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.

Pulmonary langerhans cell histiocytosis diagnosed in a cervical lymph node: a case report.

BACKGROUND: Pulmonary Langerhans cell histiocytosis (PLCH) is usually confined to the lungs and is therefore an unexpected finding in a cervical lymph node. CASE: A 52-year-old male with a 40-pack-year smoking history presented to our clinic with cough, fever and cervical lymphadenopathy. Chest computed tomography (CT) showed bilateral pulmonary nodules and enlarged mediastinal lymph nodes, worrisome for an infectious or malignant process. Bronchioloalveolar lavage was nondiagnostic. Fine needle aspiration cytology of the enlarged cervical lymph node revealed atypical histiocytoid cells, suspicious for malignancy. Immunohistochemistry revealed CD1a- and S-100-positive Langerhans cells. These findings, along with the patient's extensive smoking history and characteristic radiographic nodules, favored a diagnosis of PLCH with cervical lymph node involvement. The patient was advised to cease smoking, and no therapy was administered. Months later, follow-up chest CT showed spontaneous resolution of the lung nodules. CONCLUSION: The demonstration of Langerhans cells by immunohistochemical staining of CD1a and S-100 on a fine needle aspiration cell block is a useful diagnostic adjunct. In this case, definitive cytology for Langerhans cells in the appropriate clinical and radiologic setting allowed us to arrive at the correct diagnosis of PLCH in a minimally invasive manner.

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.

Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone.

BACKGROUND: Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone has been proposed, but its efficacy and safety have not been well studied. METHODS: We conducted a multicenter, randomized, placebo-controlled trial involving 326 opiate-addicted persons who were assigned to office-based treatment with sublingual tablets consisting of buprenorphine (16 mg) in combination with naloxone (4 mg), buprenorphine alone (16 mg), or placebo given daily for four weeks. The primary outcome measures were the percentage of urine samples negative for opiates and the subjects' self-reported craving for opiates. Safety data were obtained on 461 opiate-addicted persons who participated in an open-label study of buprenorphine and naloxone (at daily doses of up to 24 mg and 6 mg, respectively) and another 11 persons who received this combination only during the trial. RESULTS: The double-blind trial was terminated early because buprenorphine and naloxone in combination and buprenorphine alone were found to have greater efficacy than placebo. The proportion of urine samples that were negative for opiates was greater in the combined-treatment and buprenorphine groups (17.8 percent and 20.7 percent, respectively) than in the placebo group (5.8 percent, P<0.001 for both comparisons); the active-treatment groups also reported less opiate craving (P<0.001 for both comparisons with placebo). Rates of adverse events were similar in the active-treatment and placebo groups. During the open-label phase, the percentage of urine samples negative for opiates ranged from 35.2 percent to 67.4 percent. Results from the open-label follow-up study indicated that the combined treatment was safe and well tolerated. CONCLUSIONS: Buprenorphine and naloxone in combination and buprenorphine alone are safe and reduce the use of opiates and the craving for opiates among opiate-addicted persons who receive these medications in an office-based setting.

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.

Surgical management of endobronchial inflammatory myofibroblastic tumors.

BACKGROUND: Endobronchial myofibroblastic tumors are neoplasms composed of clonal populations of smooth muscle cells and a variable lymphocytic inflammatory component. They represent a challenge with respect to diagnosis, classification, and surgical resection due to their infrequent occurrence. METHODS: We retrospectively reviewed our experience with patients who had myofibroblastic tumors in the major airways over a 15-year period, in order to understand the incidence, natural biology, treatment, and long-term outcome of individuals with this type of neoplasm in an endobronchial location. RESULTS: Between 1995 and 2010, 11 patients (9 female, 2 male) underwent surgical resection of a myofibroblastic tumor arising within the tracheobronchial tree. The mean age was 39.6 years (range, 22.3 to 53.6 years). All patients were symptomatic, with cough and dyspnea as the most common presenting complaints. Rigid bronchoscopy with endobronchial biopsy was utilized to establish the diagnosis in 9 of 11 patients. Laser-mechanical debulking was performed to relieve airway obstruction prior to operation in 10 of 11 patients. Because of wide submucosal infiltration of the neoplasms, surgical resection for complete removal was required for all individuals. Tracheal resection was performed in 3 patients, carinal resection in 1 patient, mainstem bronchial resection in 2 patients, sleeve resection in 3 patients, bilobectomy in 1 patient, and right lower lobectomy in 1 patient. Resection with tumor-free margins was accomplished in all patients. Mean tumor size was 2.3 cm (range, 1.5 to 3.5 cm). There were no operative deaths, with all patients alive and disease-free at a mean of 6.1 ± 3.7 years. CONCLUSIONS: Complete surgical resection of inflammatory myofibroblastic tumors presenting in a major airway is safe and leads to excellent survival for patients with this uncommon disease.