Addiction Medicine and Substance Use Treatment
Montefiore Medical Center/Albert Einstein College of Medicine
Internal Medicine Residency Program
Rotation: Addiction Medicine
Rotation Directors: Tiffany Lu, MD, MS; Melissa Stein, MD; Kristine Torres-Lockhart, MD
Version Date: 6/30/2023
A. Overview
The Addiction Medicine Rotation is designed to train PGY-3 resident physicians in the knowledge and skills needed to evaluate and manage alcohol, opioid, and other substance use disorders. The two-week clinical rotation will include experiential learning and required self-study:
·Experiential learning in inpatient and outpatient settings
o Addiction Consult Service
o Addiction Medicine Clinic
·Self-study curriculum that covers foundational knowledge in addiction medicine
o Orientation videos
o Buprenorphine waiver training
o Required readings
B. Key Areas of Training
1. Taking an appropriate substance use history
2. Identifying alcohol, opioid, or other substance use disorders using DSM-V diagnostic criteria
3. Eliciting patients’ experiences and goals for substance use treatment
4. Counseling patients on treatment options for opioid use disorder and/or alcohol use disorder
5. Initiating and maintaining medication treatment for opioid and/or alcohol use disorder
6. Managing acute opioid or alcohol withdrawal in the hospital
7. Providing overdose education and distribute or prescribe naloxone
8. Reducing stigma surrounding addiction through non-judgmental, person-first language
9. Facilitating referrals to addiction treatment services in the community
10. Using a multidisciplinary team approach to addiction care
C. Objectives by ACGME Competency
Patient Care
Take an appropriate substance use history, including an assessment of past and current substance use and associated harms or risks
Manage acute opioid or alcohol withdrawal by applying evidence-based clinical protocols adapted for the hospital setting
Initiate and maintain medication treatment for opioid and/or alcohol use disorder, including methadone, buprenorphine, and naltrexone
Provide harm reduction counseling, including overdose prevention education for persons using opioids, cocaine, and/or other street drugs
Interpersonal and Communication Skills
Elicit patients’ experiences and goals for substance use treatment with a non-judgmental approach
Demonstrate motivational interviewing skills when counseling patients on substance use, including open questions, affirmations, reflective listening, and summarizing
Counsel patients on treatment options for alcohol and/or opioid use disorder, including medication and psychosocial treatment
Medical Knowledge
Differentiate type and severity of substance use disorders using DSM-V diagnostic criteria, including alcohol and opioid use disorders
Compare treatment options for alcohol and/or opioid use disorder, including medication and psychosocial treatment
Discuss elements of an appropriate substance use assessment and treatment plan for patients with substance use disorders
Systems-Based Practice
Address the stigma surrounding addiction by adopting and maintaining the use of non-judgmental, person-first language
Understand that addiction treatment encompasses a continuum of care, such that different intensity of treatment services and settings should be explored according to patients’ needs
Appreciate a multidisciplinary team approach to addiction care, including working with clinicians from psychiatry/other disciplines, as well as nurses, social workers, and peer recovery coaches
Practice-Based Learning and Improvement
Use medical literature, feedback, and direct instruction to improve the care of patients with alcohol, opioid, and/or other substance use disorders
Professionalism
Act with integrity when attending clinical sessions and delivering patient care
Demonstrate responsibility by completing rotation assignments
Recognize the connection between addiction care and other medicine specialties
D. Rotation Schedule
Max of 2 Internal Medicine residents are assigned to each rotation block.
Resident 1 and 2 will alternate their Thurs/Fri opioid treatment program visit and self-study time. Sample schedule as below:
Addiction Consult Service (ACS) – Residents should report to the ACS Workroom at Weiler Hospital (1825 Eastchester Road, Office 224 Room 3 – see map) for work rounds starting at 8:30am on Day 1 of the rotation. The Addiction Consult Service provides consultative services for inpatient evaluation and management of alcohol, opioid, and other substance use disorders, and is staffed by the Addiction Medicine Fellows and Faculty. In-person Addiction & Psychiatry Consult Service Joint Rounds occur on Tuesdays from 9-9:30am. Please contact Dr. Kristine Torres-Lockhart (ktorresloc@montefiore.org) if any questions.
Addiction Medicine Clinic – Residents will report to the Addiction Medicine Clinic at Comprehensive Family Care Center (1625 Eastchester Road, Adult Medicine Library) by 1:30pm on alternating Tuesdays during the rotation. The Addiction Medicine Clinic at CFCC is a multidisciplinary clinic session on Tuesday afternoons that provides primary care-based addiction care for persons with opioid and/or alcohol use disorders, including those new to or unstable in buprenorphine and naltrexone treatment. Please contact Dr. Tiffany Lu (tlu@montefiore.org) if any questions.
Addiction Medicine Rounds – Residents should attend Addiction Medicine Rounds via Zoom on the second Friday of the rotation from 12:30pm-1:30pm. Each resident is expected to prepare a case presentation for 20-25 mins; case presentations should include a clinical question, review of evidence, and take-home points for clinical management. Resident case discussions may be cancelled when there are special talks given by invited speakers. Check out the Addiction Medicine Rounds calendar for updated dates and topics, as well as Zoom log-in information. Please contact Sadyn Angeles (sangeles@montefiore.org) if any questions.
Self-study Time – Please see below for orientation videos, buprenorphine waiver training, and readings to be completed throughout the rotation.
E. Self-Study Curriculum
Residents on the Addiction Medicine Rotation are expected to work through the self-study components throughout the two-week rotation. In addition, 2 half-days will be allocated for residents to complete the self-study components without clinical responsibilities during the rotation.
1. Addiction Medicine Orientation Videos: Residents should review orientation videos recorded by Montefiore’s Addiction Medicine Faculty. Please start viewing videos on Day 1 of the rotation. You can access the orientation videos through the rotation resource folder (tinyurl.com/AddictionMedicineRotation).
· Video 1: Addiction Consult Service Orientation
· Video 2: Addiction Care 101
· Video 3: Alcohol Use Disorder 101
· Video 4: Opioid Use Disorder 101
· Video 5: Acute Pain and Opioid Use Disorder
· Video 6: Discharge Planning for Addiction Care
2. Buprenorphine waiver training: 8 hours of buprenorphine waiver training must be completed by all Internal Medicine Residents as a graduation requirement. Buprenorphine is an effective treatment for opioid use disorder that can be prescribed in diverse medical settings. Federal regulation changes now allow physicians to apply for a limited waiver to prescribe buprenorphine for up to 30 patients without completing the waiver training. However, most physicians report a lack of knowledge and training as a key barrier to buprenorphine prescribing, while other physicians will need to treat more than 30 patients. The 8-hour buprenorphine waiver training is therefore required as a part of the Addiction Medicine Rotation to better prepare our graduates to tackle the public health crisis of opioid overdose deaths and opioid use disorders.
Options to complete the buprenorphine waiver training are as follows:
· Complete the free online 8-hour waiver training through PCSS during the Addiction Medicine Rotation (PCSS 8 Hour Online Waiver Training)
· Attend a free ‘half-and-half’ waiver training (4-hours in-person, 4-hours online) taught by the Addiction Medicine faculty at Montefiore in the fall of the academic year. (Residents in Primary Care Social Internal Medicine Program are registered for these trainings during their intern year.)
· Residents who previously completed the ‘half-and-half’ waiver trainings at Montefiore can retrieve their certificates by following instructions posted on the rotation resource folder.
Submitting Certificates of Completion for the buprenorphine waiver training:
· Submit the Certificate of Completion to buprenorphine program coordinator, Sadyn Angeles, (sangeles@montefiore.org) by the last day of the Addiction Medicine Rotation.
· Completion status will be tracked by Addiction Medicine Rotation Directors and shared with Residency Program Leadership.
3. Addiction Medicine Readings: Residents should review key articles that review foundational principles in addiction care for internal medicine physicians. You can access the required readings through the rotation resource folder (tinyurl.com/AddictionMedicineRotation).
General Approach to Addiction Medicine (Covered in Video 2)
Olsen Y. What is Addiction? History, Terminology, and Core Concepts. Med Clin N Am. 2022; 106:1-2. https://doi.org/10.1016/j.mcna.2021.08.001
NIDAMED. Words Matter: Terms to Use and Avoid When Talking About Addiction. https://www.drugabuse.gov/sites/default/files/nidamed_words_matter.pdf
Starrels JL and Wu B. Urine Drug Testing – Reference Guide for Clinicians. (https://ciswh.org/wp-content/uploads/2017/06/Urine-Drug-Testing-Guide-2013.pdf)
Chan CA, Canver B, McNeil R, and Sue KL. Harm Reduction in Health Care Settings. Med Clin N Am. 2022; 106:201-217. https://doi.org/10.1016/j.mcna.2021.09.002
NYC Department of Health and Mental Hygiene – Opioid Overdose Response with Naloxone. https://www.youtube.com/watch?v=p5st4Raik-8
Alcohol Use Disorder (Covered in Video 3)
Day E and Daly C. Clinical Management of the Alcohol Withdrawal Syndrome. Addiction. 2021;117(3):804-814. https://doi.org/10.1111/add.15647
Kranzler HR, Soyka M. Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA. 2018;320(8):815–824. doi:10.1001/jama.2018.11406
Opioid Use Disorder (Covered in Video 4)
Torres-Lockhart K, Lu T, Weimer M, and Cunningham CO. Clinical management of opioid withdrawal. Addiction. 2022 Feb 3; 1-11. https://doi.org/10.1111/add.15818
Wakeman SE. Opioid use disorder diagnosis and management. NEJM Evid 2022; 1(4). Published March 22, 2022. doi: 10.1056/EVIDra2200038
Cohen SM, Weimer MB, Levander XA, Peckham AM, Tetrault JM, Morford KL. Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach. J Addict Med. 2021 Dec 23. doi: 10.1097/ADM.0000000000000945.
Pain Management and Opioid Dependence (Covered in Video 5)
Alford DP, Compton P, and Samet JH. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med. 2006;144:127-134. doi:10.7326/0003-4819-144-2-200601170-00010
4. Montefiore Clinical Protocols: Be familiar with the clinical protocols implemented at Montefiore hospital campuses for addiction care and naloxone distribution. Access through the rotation resource folder or on the Montefiore Intranet (Policies à Medical Guidelines - Archived à Substance Use):
Management of Opioid Use Disorder and Opioid Withdrawal in Hospitalized Patients
Management of Alcohol Use Disorder and Alcohol Withdrawal in Hospitalized Patients
Perioperative Buprenorphine Management for Elective Surgery
Naloxone Take-Home Kits at Weiler and Moses Campuses
5. Podcasts & Readings: Readings related to alcohol or opioid use disorder treatment are available through the rotation resource folder.
Optional: Curbsiders Podcast, Episode #212 – Sober Talk: Managing Inpatient Alcohol Withdrawal with Dr Joji Suzuki. https://thecurbsiders.com/podcast/212 (start at 8m10s)
Optional: Curbsiders Podcast, Episode #194 – Treatment of Alcohol Use Disorder with Dr. Marlene Martin. https://thecurbsiders.com/podcast/194-alcohol (start at 9m45s)
Optional: Curbsiders Podcast, Episode #187 – Buprenorphine Master Class: Managing Opioid Use Disorder for the Generalist with Dr Michael Fingerhood. https://thecurbsiders.com/podcast/187-buprenorphine (start at 16m45s).