and I'm accompanied by Dr. Ridbow and Dr. Renner to talk about incorporating learners into existing addiction psychiatry clinical services. So we'll go ahead and begin. None of us have any disclosures to report. Our learning objectives are to discuss the clinician's triad as a framework for increasing enthusiasm for treating patients with substance use disorders and also for reducing stigma and discuss how to evaluate organizational structures and addiction related knowledge and skillsets of existing staff members. And ultimately we'd like to have a discussion in which we can identify one way to incorporate an undergraduate or graduate learner into one's existing clinical practice. I will be speaking first about the UNMC experience from barriers to solutions at the University of Nebraska Medical Center. I'm the co-director of the Addiction Psychiatry Consultation Liaison Service and the Director of Addiction Psychiatry Education. Through those roles, I do a lot with learners and incorporating learners of various types into clinical services. So that is what I will be speaking about. But before I do that, I'd like to just give a landscape of the current state of addiction. So that way we're all on the same page about the necessity of all of this. So over 20 million Americans have a substance use disorder and only 6.9% receive treatment, right? So a tiny, tiny fraction. Estimates also show that 50% of patients with another psychiatric disorder also meet criteria for a substance use disorder. And those of us in clinical practice know that it's actually far higher than 50%. Among some disorders, the co-occurrence is very high, much higher in fact. And for example, up to 72% of patients with borderline personality disorder actually develop a substance use disorder at some point in their lives. The current state of addiction education on the other hand does not mirror the current state of addiction. So according to the LCME's annual medical student questionnaire, 143 of 145 medical schools at that time with students enrolled reported content on quote substance abuse that was required. However, there was nothing specified about what that requirement meant. So it could be as little as one lecture, like a one-hour lecture on intoxication and withdrawal syndromes. Or it could be the development of core competencies, dedicated course to substance use disorders and clinical experiences in addiction. As 102 also of the medical schools included this topic in elective coursework, meaning they had electives available to cover some of this content matter. So again, nothing prescribed about what needs to be taught in this arena. With regards to training, so ACGME guidelines require one month FTE in learning about addictions for psychiatry residencies, general psychiatry residencies. That is only 2% of residency training, which is the largest disparity between illness prevalence and time commitment to learning, right? I mean, you see if over 50% of the patients you see are gonna have a substance use disorder and you only spend 2% of time learning about it, it seems pretty lopsided. The median required curricular hours of addiction education also are quite minuscule. Eight hours is the median with a range of six to 14. There was a survey done by ADPR, the Association of Directors of Psychiatry Residency Training Programs in 2017. And they surveyed general adult training programs. And the key findings that they found was that addiction training often takes place in general psychiatry units instead of specialty units. Only 40% of programs responding to the survey required buprenorphine training. Lack of addictions trained faculty members was identified as an impediment to providing more comprehensive training. This is a theme that's pretty universal. And that programs have gaps in their curriculum in basic areas of training. Many programs indicated they would benefit from having comprehensive curricula because they do not have any. So this is just a chart showing what we just talked about. As you can see, the limited number of faculty and staff with time to supervise has the highest here at 51%. So that was quite a few respondents. So now that we've painted a picture of the barriers, let's talk about some of the solutions. So we'll have three examples from three different institutions across the country. And I will start by talking about the University of Nebraska Medical Center experience. So setting the stage back to 2016, which is when I joined the department, it was very small, less than 20 faculty at the time. Nearly all were educated and trained at UNMC, very homegrown, so to speak. There were some subspecialty offerings, outpatient child and adolescent geriatrics, as well as inpatient general consultation liaison. The consultation liaison service had been longstanding. However, it unfortunately did not address substance use. Very minimal engagement of substance withdrawal, really no experience or desire to use medications for addiction treatment. And historically, there were no substance use disorder services at the medical center whatsoever. Patients were referred out to community agencies by a social worker who would give them a packet of information and then kind of leave it up to them what they did with that. So I had a vision to, of course, initiate clinical services for these patients who were already there and already suffering. So eventually we did develop a continuum of co-occurring disorders care. Started with the addiction psychiatry outpatient clinic, which I directed for a number of years. The intensive outpatient program spawned from that as well. And then most recently in 2019, we developed the inpatient addiction psychiatry consultation liaison service, which would address substance use in hospitalized patients, as well as any additional psychiatric problems the patient may have. So we would help with intoxication withdrawal, initiate medication, and also streamline referral to our own clinic for, again, a very seamless continuity of care for these patients. So then we had two consultation liaison services. Then we have our general and we have our addiction. So fortuitously, the department and medical center leadership had some turnover and internal medicine approached our department asking for help managing these patients because of frequent admissions for alcohol withdrawal and really feeling that the general CL service wasn't meeting the needs of the primary teams and addressing substance use in their patients. In fact, so much so that they actually just didn't even consult anymore because they felt like the assistance wasn't what they were looking for. So given the buy-in from the largest department in the hospital, the internal medicine, this was what really propelled APCL to fruition. So APCL is what we call it. We have addiction psychiatry plus consultation liaison psychiatry equals the addiction psychiatry consultation liaison service, or as we call it, APCL. So behind the scenes barriers to starting up the service, which was from day one, it conceived as a teaching service, was that the red tape in a healthcare system, the committee application process, first of all, to add medications to the hospital formulary. I mean, I had to petition to add buprenorphine, buprenorphine naloxone, naltrexone, both kinds. At Camper State, none of these were available in the hospital formula. The only thing that was was methadone and it was used for pain. Collaborating with pharmacy, we were able to develop a program for no cost pharmaceutical assistance for extended release naltrexone for patients where they can get two free doses per calendar year since that was something we otherwise just did not offer. Also, it took over a year to develop the infrastructure technologically to comply with 42 CFR part two, which at that time had not been updated. Since then it has been updated, but we were in compliance with the original kind of more stringent version of it. And then of course, staffing considerations. So our pilot program was February, 2019 to June, 2019. And the consult order was only available to internal medicine and hospitals team. So nobody else in the hospital, no neurology, no trauma, no family medicine. And we had a 1.0 FTE subspecialty boarded certified psychiatrist. So my partner was consultation liaison, fellowship trained and boarded. And then myself and I boarded in addiction medicine through ADPM. We had one third year medical student on our psychiatry clerkship that would be with the attending. So it was literally a partnership of one medical student and one attending physician. July, 2019, we officially launched the entire hospital because our pilot was successful. And so we opened to the entire hospital. We have a 1.0 FTE again, psychiatrist, which is my partner and I who did the pilot. We have one PGY1 psychiatry resident from either Creighton or from UNMC and two third year medical students. That is how we started. And the need for a psychiatric social worker really became quickly apparent because while we can initiate medication, sometimes the follow-up is very difficult to achieve when we don't know the ins and outs of community agencies. At that time, Nebraska was not a Medicaid expansion state. And so our uninsured patients really had limited options for follow-up. And so starting a medication that they then can't continue wouldn't make a lot of sense. And so we really needed that resource and we were able to lobby, actually, the hospital to create a position, which we did. And the social worker began in October of 2019 and has been immensely helpful and just invaluable to our patients' needs. So what we do, comprehensive psychiatric evaluation, including substance use assessment. We develop the recommended treatment plan aligned with the patient's goals. So we're very harm reduction. We meet the patient where they're at. If they're not interested in reducing their alcohol use, we talk about ways to make it safer, like not drinking and driving and things of that nature. Use motivational interviewing on that front. Also the liaison part of what we do, of course, is to facilitate the mutual understanding between the patients and the primary teams, which sometimes there's a lot lost in communication there. We connect patients with appropriate community resources and follow-up for mental health, including substance use. And disposition planning for a higher level of care because sometimes our patients do need to go to inpatient psychiatry after a very severe suicide attempt while intoxicated. And so we're able to facilitate that as well. At any given time, our service consists of the 1.0 FT psychiatrist, a psychiatry intern, PGY-1, a third-year medical student, typically two to three third-year medical students, a fourth-year medical student doing an elective. We have a one-month addiction psychiatry elective on our service. So we'll have anywhere from zero to two, depending on who is doing the elective that month. Physician assistant students, we have really incorporated into our team. So at any given time, we have zero to two physician assistant students. Actually, presently we have three, which is even more than that. And then, of course, our psychiatric social worker. We also have a fourth-year psychiatry resident elective. So at times we will have a PGY-4. The addiction medicine fellowship, two months of the addiction medicine fellowship at our institution is spent on our service when we have a fellow. Pain medicine fellows have the option of rotating with us for one week at a time as part of their fellowship. And nurse practitioner students doing practicums are also able to rotate with us, and we've had one so far. So the growth of our service, starting in January of 2019, which we officially launched in February for the pilot. But as you can see, the upward trajectory is quite nice, right? It's a pretty chart to show how really needed the service has been in the hospital and how helpful it has been. So the numbers here are the number of consults that we're seeing per month, each of those months. This is a comparison of the addiction psych consult liaison service with the general psychiatry consultation liaison service. And so as you can see, we have not taken any business from the other team. We have worked synergistically to really just reach a whole nother population in the hospital that simply wasn't being cared for, right? These are psychiatric patients and their psychiatric needs of substance use management were not being met. The substance is seen, so this is likely going to differ from many of you attending this workshop because I know many are from the coasts. And we have a much different scenario when it comes to opioid use disorder in Nebraska. So as you can see, opioid use disorder is well, one, two, three, four, five, six on the list of substances. It is just not as common. Certainly we see it. In fact, just yesterday, we induced somebody onto buprenorphine for the first time in that patient's treatment trajectory. So that was exciting for the students, but alcohol really is number one and amphetamines, the methamphetamines are number two, I would say, in terms of what we see and what we try to intervene on or whether it's a sequela of use of those substances that has landed the patient in the hospital, such as cirrhosis, ascites, things of that nature. So with regard to education and training, I had said that the service was conceived as an educational teaching service. With undergraduate medical education, this is actually a core clinical site for the third year psychiatry clerkship. So it's the required clerkship and students spend three weeks on our site as an official site. So it's one of very few, from what I understand, institutions where a student's primary psychiatry site can be in a co-occurring disorder setting. We also have new one-month elective rotations that were developed for fourth-year medical students, as I mentioned. So our first year, five signed up and five medical students rotated with us. By word of mouth, I guess, that really number jumped in the subsequent year, and 15 were in the subsequent year. And then this year, we have 13 that are doing our one-month elective. And as part of that elective, buprenorphine training is required. So on PCSS, they actually have a medical student version of the eight-hour buprenorphine training course. And as part of our fourth-year medical student elective, that is a required component. And so students must complete their buprenorphine waiver training using PCSS for medical students. We also have a College of Medicine graduate program, Observership, where graduate students in anatomy who are basically doing a post-baccalaureate for medical school are able to rotate with us in an Observership capacity. For graduate medical education, we transcend several institutions. So we have Creighton University Psychiatry Residency. It's a required PGY-1 rotation for one month and an elective PGY-4 rotation for one month. UNMC Psychiatry Residency, which is in year two of existence, has a required PGY-2 rotation, which is two months. Well, it was two months. It recently actually went down to one month, so I should change that. We have our UNMC Addiction Medicine Fellowship, which required rotation of three months, which also recently went down to two months. And UNMC Pain Medicine Fellowship required rotation, which has now moved to optional to allow for flexibility in scheduling. Something very unique, I think, about the educational opportunities are the opportunity to teach and train advanced practice providers. As we know, advanced practice providers, APRNs, and PAs are really gaining steam and momentum as primary care providers in many parts of the country, including rural areas. So the UNMC College of Allied Health Professions, where I actually have a courtesy appointment, their Physician Assistant Studies School will have all of the PA students actually rotate for at least one week with us while they're on their required psychiatry clerkship. We also have the Psychiatric Nurse Practitioner students who are able to do one of their clinicals with us as well as part of their practicum. So assessing change and future directions, we actually recently presented an abstract at the Third Annual Heartland Interprofessional Education Conference on the integration of physician assistant students onto APCL. It is rare to have a service where physician assistant students and medical students really work hand-in-hand together synergistically to both learn the content matter. It's really the only regional institution offering this. Also, we have the Medical Condition Regards Scale, which is being anonymously administered at the beginning and end of the clinical time on service for medical students as part of their clerkship to assess quality improvement, to assess the stigma reduction that may occur from students having champion role models, their attending physicians, their residents on the service and seeing how we can intervene on substance use with the patients. So the data collection will continue for one year of that anonymous survey. So I'm really looking forward to analyzing that and seeing whether being on our service and doing the things that we do actually does help decrease stigma in a very objective way. So those are some of the future directions. And I will hand it off to my colleague, Dr. Ritbo. Thank you. Let me start my screen share here. Okay, let me know, Alana, if this is not, can you see that or is it showing the presenter view? It's showing the presenter mode. Yeah, swap your view. Yeah, let me try that again. Perfect up at the top, do you see the swap displays? Under it should say end show tips swap displays use slideshow. This is on. Oops. If you click swap displays, you can flip it and Oh, yep, I see it in within Okay, thank you. Okay, there we go. My name is Alexis Ripfo, and I am the program director for addiction psychiatry fellowship at University of Colorado. And I'm also the associate medical director there for our outpatient psychiatry clinic where the majority actually all of our third year psychiatry residents rotate. So I started here with this picture of this good Colorado train, because this was a real feat of engineering. And the fact that they were able to make this go up such high altitude on a limited amount of track was a big deal. And I think we can often feel like this is the kind of challenge we are up against in addiction with our our limited faculty available, but I think thinking about how we can incorporate learners in different ways and get them interested, whether or not they choose to go on to specialize in addiction is a good place to start. So just to give you a little bit of background about our department, unlike Nebraska, where we are much larger department, so about 300 regular affiliate volunteer faculty, we have about 45 to 52 general psychiatry residents per year, and then many other fellows. Currently we have three addiction psychiatry fellows. And I really am focused in a different realm in general outpatient psychiatry. So in the clinic where I work, which I'll refer to as the OPD, the outpatient psychiatry department, we provide general psychiatric care to patients that are within our large academic medical center system, which has also become huge. To give you some idea that the latest numbers I could find were that for the 2016 academic year, we saw about thirty four hundred patients and at that time had about seven psychiatrists on faculty that would be staffing with the residents. And at that time, and I was actually chief resident, we had a requirement that we did not manage any primary substance use disorders or any that were were active and unstable. And in general, the faculty, none of whom at the time had addiction training, really had minimal desire or experience using medication for addiction treatment. And kind of the general things you would hear them say were things like, it's not my specialty and I don't know what to do. As I transitioned onto faculty in 2018, worked with a medical student to conduct a survey of the psychiatry faculty to look at differences in attitudes and belief among those that had completed their buprenorphine training and those who had not. And when we looked at what barriers they identified to providing buprenorphine treatment, in particular for opioid use disorder to patients, there was significant difference in barriers identified depending on whether folks had done buprenorphine training. And that was if they thought that they had not done training and didn't have supervision from an experienced mentor, they were more likely to feel like they couldn't provide care. They didn't want to attract patients with opioid addiction to their office. They worried about patients becoming addicted to buprenorphine and they lacked comfort with instructing patients on a home induction protocol. Things that there was agreement on was that overall opioid use disorder was a treatable illness and that buprenorphine in general was an effective treatment for opioid use disorder. And I just use this as an illustration of kind of where things were in that department. And I think this kind of conflict that faculty often felt that don't have addiction background of this is a problem. I recognize there are some treatments more likely to feel like they have some ability to address them if they've done buprenorphine training, at least for opioid use disorder to address it, but that overall still kind of feeling uncomfortable. And so here we'll introduce the idea of the clinician's triad and taking this from a paper that actually Dr. Renner wrote. So addiction psychiatrists are particularly well positioned to teach how to provide successful clinical care to patients with SUDs because they have an adequate knowledge base, a positive attitude toward the patient and benefits of treatment and a sense of responsibility for the clinical problem. We know that stigma plays a really unfortunate role in deterring students and trainees from wanting to work with patients with addiction and from pursuing careers in addiction psychiatry. And anything we can do to increase their exposure in the setting of faculty and supervisors that themselves are able to provide compassionate care with good knowledge base and experience will help decrease the stigma and help us improve folks going into addiction psychiatry, but even just feeling comfortable addressing it in the patients they treat no matter what specialty. So how I looked at this within the general outpatient psychiatry clinic was that our goal was to overall enhance the general psychiatry attending and residents' knowledge and comfort with providing co-occurring disorders care by having an addiction psychiatrist on staff. And so myself as that staff member would be both available to staff general psychiatry patient cases with the residents in the clinic, established a half day co-occurring disorder clinic within the general psychiatry clinic, and then have our addiction psychiatry fellows lead, along with actually our addiction medicine fellows, every July a buprenorphine waiver training course for all of our third year psychiatry residents, as well as any clinic attendings or other interested faculty. At the start of doing that training, we got all of our clinic attending psychiatrists buprenorphine trained, and now I've tried to make sure all of them are. And so by having an addiction specialist embedded within the general psychiatry clinic, I'm available staffing two days per week, but also make myself available for kind of consultations or questions via the electronic health system, staff messaging or chat. Able to provide immediate consultation, whether it's directly the resident and patient I'm staffing or while sitting in the attending room when a resident comes in with another case and someone that has a substance use disorder or they're wondering if they do and can help provide consultation. My goal has been to help all the residents feel more comfortable identifying and managing mild to moderate substance use disorder in their general caseload, but also helping them when they're less sure of things. And I make myself available to join their appointments, tell them which days I'm staffing to schedule patients on those days and give me a heads up and I'll join the session with them. And that if we determine that the patient's current substance use disorder is too complex or currently unstable, then we'll transfer them into the co-occurring clinic so that I can provide more direct supervision to a resident that has more kind of schedule flexibility. And we can also determine whether the patient may benefit and be willing and able to connect with a higher level of care even beyond the clinic. Some other things that we have done within the clinic that I think have been helpful in ensuring we're providing better co-occurring disorder care created a standardized ADHD evaluation process that has substance use screening and testing within the protocol when we're prescribing stimulants. We've also developed a library of addiction related electronic medical record dot phrases. So to help patients pull in or help residents pull in information into the patient chart. And that might include things like giving patients information about how to how to use naloxone if they're prescribing it or patient instructions for naltrexone. I've really pushed to recommend that we automatically prescribe naloxone and educate patients about it whenever we see there's a co-prescription for benzos and opioids and that we educate patients about the risk of being on both of those. And then also teaching the residents, even if a patient does not yet have a full use disorder or if they do and they're not in a place where they they want to seek treatment for for abstinence, how to engage them in discussion around harm reduction for heavy alcohol use or heavy cannabis use in particular. And then we've also been working with our ambulatory health promotion department on a nicotine cessation program and how to integrate what they're doing in primary care into our outpatient psychiatry using our mental health pharmacist. So I kind of already mentioned a lot of this as far as the co-occurring clinic, but we are currently able to provide psychiatric evaluations and med management for patients with co-occurring substance use disorders and other psychiatric disorders. I tell I have kind of a phrase that I will send folks that are interested in what we're doing or how to refer that kind of verbiage. And I tell them I'm happy to discuss a case to decide if it could be a good fit overall, taking a kind of no wrong door approach. So if they're not sure, welcome them to send the patient to me and we'll meet with them and determine if you know how we can help them at this level of care or whether they'd be interested and benefit from being connected to a higher level of care. We don't currently have and I would love to get in the near future a addictions therapist that has an addiction background. So that's a limitation. Certainly, my resident will do motivational enhancement therapy and engage. He's engaged a few of our current patients in some in some psychotherapy, like one patient with CBT for pain, but we just don't have the current capacity. And then one of the regulatory issues we ran into was just because we're not the general patient psychiatry is not a licensed addiction treatment facility. Patients have to have another non-substance use psychiatric disorder to be seen in our clinic. But as we all know, that's not hard to to come by. And I won't read this all to you, but it's just in the slides. One thing I did do in creating a phrase to share with especially colleagues like on our consult service or in other clinics to kind of get a sense of who is usually appropriate for outpatient level care was letting them know what the ACM criteria was for outpatient level of care and that that could also help them work with a patient to determine whether they might need or benefit from a higher level of care. But as I mentioned, ultimately, no wrong door to treatment and tell them I'm happy to provide consultation and a level of care assessment for any patient able to show up. So that's an overall overview. I don't have as many or didn't track down as many kind of numbers to give a sense of how many folks were seen. But I can tell you currently in the last six months for half day, I think we're following about thirty five or forty patients in the co-occurring clinic and see most of those people, you know, no less frequently than than monthly and some of a few of them as frequently as weekly. So with that, I will stop sharing and hand it over to Dr. Renner. Well, I'm going to describe how we developed a dual diagnosis outpatient clinic experience for the residents at the BU VA psychiatry program. Let's see here. And then and then I'll end up by talking a little bit how we integrated buprenorphine treatment into the program. We start out by establishing support from the the residency training director, and I'll talk a little bit more about that in a second. I think what's the critical thing here is that we didn't develop a new clinic from scratch. We adapted an existing outpatient psychiatry consultant, which is a We adapted an existing outpatient psychiatry continuity clinic. This was a third year experience for the BU psychiatry residents that extended into the fourth year. We added addiction training to this experience. There was no loss of their general psychiatry, basically took what was their continuity psychiatry clinic and added an addiction experience there. We added seminars and clinical supervision. We didn't have to bring in the patients because we were like many VA outpatient clinics, 80 to 90 percent of our patients were already dual diagnosis. They had a wide variety of other disorders. But we did acknowledge directly that it was a dual diagnosis program, that we were treating substance abuse problems as part of the services that we offered. And we made it very clear, and this may be a problem in some settings, that the clinic has to be willing to accept people with a substance use disorder and they are welcome to accept people following detox or intensive outpatient care. First of all, we want to talk about how we develop leadership support. We've we always had a very supportive chairman of psychiatry. I think you need to have the director of the clinic. In this case, I was the director of the outpatient clinic where we started. So that wasn't a problem. But depending on where you're going, and I'll comment in a section, if you're doing something like CL or other settings, I think you have to make sure that you have management buy in to this operation. I think one of the things that all of you need to do if you're thinking about developing an addiction psychiatry rotation is identify the appropriate faculty. So to do a survey of the department faculty or the faculty in your facility, how many trained addiction psychiatrists are there? How many people are boarded in addiction medicine? Are there any psychologists or social workers or nurses who already work with addiction patients or are particularly interested in working with them? So you want to find out what your resources are. The location can vary. I think we developed our program because I was in place that we had a few other addiction psychiatrists attached to our clinic. So it was relatively easy to do. But in other facilities, as Alona described, you can build it from a CL service. So it's not something that can only be done in one setting. I think you really need to identify faculty who are interested in addiction, who want to teach, because I think it's critical that you have the faculty in place to lead this program. So try and just make sure that you found the right program, that you have a skilled faculty. But I think what's most critical here is that this is a situation in which the trainees can have a continuity experience. The reason I like an outpatient clinic is that in most psychiatry programs in the country, residents are going to have a continuity clinic that may go on for a year or two years or more. And you want to really make sure that they do that, because I think that is the ideal environment in which to do the training. I think you can do it well in CL, but my preference is still a long term outpatient clinic. I would avoid the emergency department or detox rotations. I think there's some programs that historically have used rotations in medical detoxification facilities, but I don't think for psychiatrists that that is the best type of exposure to this patient population. So look for a rotation that's going to run from four to 12 months or longer, and the reason for that is I think one of the things that's critical for a psychiatry trainee is that they see the patient over a course of time. They get to follow the patient if they have relapses. They see how recovery can be gradually built and can occur in treatment works. They also need to have enough time to actually get to know the patients. In this setting, the residents that I worked with were expected to spend 30 to 60 minutes a week with any individual patients, particularly in the beginning. And I was able to structure time so that they could do that more intensively for the first couple of weeks with the patient, and as the patients became more stable, they were able to spread out the visits or shorten the time. But they have to have that time in the beginning to get to really know the patient. I think you need to do two things in terms of the training they're going to learn. One is which they have to become skilled in psychotherapy that worked with addiction patients. And I'll talk about more of that in a second. And obviously, medications for addiction treatment, that's going to be a critical part of their skill set. I think the other thing to think about is how you get the faculty available. I know that we hear complaints from all over the country that people can't start addiction training programs because they don't have enough faculty. When I started this clinic, and it was more than 20 years ago, I was really the only addiction psychiatrist who could devote time to the training. But I was able to control my schedule in such a way that I could oversee the seminars, I could supervise the residents, I could be available for walk-in crisis counseling. And you need to have someone who can do that with the patient population. But what I also did was I used the trainees as training faculty. Each of our residents was expected to do four or five seminars a year. As the training program developed, we did case presentations and they each had about three times during the year where they presented cases. Occasionally, we would bring in guest speakers. Faculty themselves would do eight or nine, five to seven seminars a year. But I found out in the beginning that a single faculty person could start this program and could sustain it if you knew how to cultivate your residents, engage them in the training capacity. You don't need to have a large crew of faculties to support the training. I think one or two dedicated people can probably make a program like this work. Pretty well. Now, this grid just shows the hours of seminar and supervision that happened. I think Alona talked about how when they did a survey before, we found out that did many residencies about eight hours in four years was the amount of addiction training that was provided. Well, look at what we did here. The BU program provided about six hours during the first and second year. But the third year, which is our clinic, we provided eight hours. Well, how do we do that? That really turned out to be one or two hours a week. That meant that every week we usually had one academic presentation and maybe one case conference. The trainees were the presenters in most of these conferences. They presented the cases. They designed lectures on specific topics. And I learned that this was a very effective way to get them to learn. It wasn't that much of a strain on me. After I put together five or six lectures I could do myself, I was able to basically supervise the residents as they designed their lectures. In the fourth year, at one time, we had 35 hours of extra training on addictions that's available. That is not being done currently. I can see that as an add-on, but it's not a critical part of the training. So this is what the clinic looked like. This was a VA outpatient clinic. It was based in a very large CBOC, which any of you who are VA staff know how those work. The residents were there 20 hours a week. It was a core rotation for them. It lasted for the entire year. So they were there full-time two days a week, half-time one day a week. It was a 12-month rotation. In the fourth year, it extended for another half day a week. At times, we went from two to three hours of academic seminars, case presentation, journal clubs. We covered a whole range of topics during these sessions. And 80% to 90% of the patients had significant psychiatric comorbidity. We eventually were able to link with the methadone clinic, which was in the same facility, and then eventually added buprenorphine patients. So part of the caseload for all of the residents usually were at least one or two patients who were being treated with methadone and one or two patients who were being treated with buprenorphine. The skills and competencies that the residents learned in this experience was certainly diagnosis and evaluation, but most critically, long-term management of dual diagnosis patients. We gave very specific skills in psychotherapy, motivational enhancement, CBT, seeking safety, harm reduction. We read a textbook on harm reduction. We have a number of seminars on motivational enhancement. We have a number of seminars on motivational interviewing CBT and seeking safety. We added a group of seminars on the management of patients with co-occurring psychotic disorders. And we particularly focused on medications for addiction treatment and the skills that the residents needed to use those medications effectively. This gives you an idea in one year breakdown of the topics that we covered and the number of hours that were spread out over the course of the year on these various subjects. So you can see that we ended up with a very rich curriculum. And I would again emphasize that while it took two or three hours of my time to oversee every week, I didn't present most of the topics. The residents did. I didn't have a lot of extra faculty that were coming in to give lectures. So we were able, I think, to do it very effectively if we used the residents as part of the training faculty. And I have to say that they did good jobs. So I thought it was a very up-to-date review of the topic and a question. And the residents learn how to do presentations. And they learn how to research topics. And they made it a very effective environment. These are some of the references that we used in the course. Pat Denning's book on harm reduction, we read a significant part of that. We've used various books on motivational interviewing, most recently Dr. LaLunas's book, Lisa Najevich's book on seeking safety, and my book on office-based buprenorphine treatment. So these are the topics we covered. There certainly are other options for all of these topics. And you can use whatever you find most helpful in your setting. In the fourth year, the residents spend another four hours a week in the clinic. They all have other rotations, but many of them elect to do extra time in that fourth year. And the seminars in the fourth year tended to be more in-depth scientific, more research-oriented clinical trials. These were all very good add-ons, but I think were not absolutely critical to get residents up to speed in terms of managing addiction psychiatry patients. Now, what about buprenorphine training? In the beginning, the problem was getting residents trained, and then how did we get the orders signed? I think there are many more options nowadays for doing the training. We still can provide eight hours of training. There are APA courses online. There are PCSS courses online and available. The half-and-half course is readily accessible online. So there are a lot of ways that residents can get their training. BU requires all the residents in their first or second year to take a course. So by the time the residents arrive, they have all had at least a basic exposure to buprenorphine. Of course, none of them, when they begin the third year, have a mass license, so they really are not able to have their own prescribing capacity. But often, by the end of the fourth year, at least several of them may have obtained their state license, and as soon as that has occurred, they may be able to get their own waiver. But if they don't have the waiver, it basically means that there will be a supervisor available to them who will sign the orders. Legally, the supervisors are the responsible clinicians for any resident's patient. And if your system is well-organized, it's relatively easy to have the residents see the patients, make the decisions about treatment, adjust the buprenorphine doses, pass on the orders by computer to their supervisor, and then get them signed. And just a sense of the breakdown of the cases, depending on the workload of the residents, the length of the rotation, the number of hours a week, I think you'd go from 60 to 20 to up to 24 cases per resident. It's a very active caseload. As I mentioned earlier, it's probably important that the residents can spend enough time with individual patients, particularly in the beginning of the rotation. But we found that at the end of the third year, the residents were able to move most of their patients along with them into the fourth year by seeing them less frequently so they could carry most of that caseload, even though they were only in the clinic for about four hours a week. Through all of this, they continue to see a mix of patients with depression, anxiety disorders, PTSD, other substance use problems. So they had all of this with their patients with addictions. So it was a combination, dual diagnosis, patient experience. Ultimately, each of the residents carried at least two cases of buprenorphine and ideally another two cases with methadone. Yeah, thank you, Dr. Renner. Absolutely. And I will just add that I am a product of the BU model. And it was phenomenal. So it definitely works. And it got me invested and interested in addictions care when I had absolutely zero intention in doing so when I started. So I think the sheer exposure and normalizing addictions as part of psychiatry, which of course they are, is very effective. And so again, incorporating learners into these existing services is one way to do that and to reduce stigma. Are there any questions in the chat that anyone would like? I see two just pop up. So I'll read them. And I'd also be curious if other people have different models they think they're using that are effective to share. So Sarah Zachman says, really appreciate everyone sharing their experience and advice on the topic. Curious of any thoughts about optimizing the experience when only one student or resident is able to rotate in clinic at a time. Lola, do you want to take that? Yeah, well, yeah. So I will. I will. And Dr. Zachman is actually, well, I'm not going to out her. But she's an addiction psychiatrist with working in my department as well. So she is a fellowship trained addiction psychiatrist that we're really excited to have on board. And so LIMSOC, which is a model that I developed, the Longitudinal Integrated Mental Health Substance Use Outpatient Clinic, as kind of an offshoot of the model Dr. Renner just presented on, which is one half day a week of a clinic, a dual diagnosis clinic. And having just one trainee, which is what I've frequently had, at times I have had up to three, there's really a lot of individualized attention to the trainee. And so what I have found is to cover a core base of topics as part of supervision. So we talk about benzodiazepines and co-prescribing benzodiazepines. We talk about naloxone. We talk about buprenorphine, just some core topics that are very bread and butter in addiction psychiatry. And then allow the patients to really guide the learning. Since, of course, the resident is already getting their didactics from the formal didactics curriculum, you can really tailor your supervision to be based on the patients that the trainee is seeing. And so the education can be based around meth psychosis, for example, something we see very frequently, and management of meth psychosis, and differentiating that from schizophrenia, et cetera. So I think that lends itself to more personalized teaching by the supervisor. And it is only one half day a week. So it's easy on the supervisor's time. Yeah, and I think, Alona, are you simultaneously, is there like a general psychiatry clinic going on? Yes, there is a general clinic going on at the same time with other trainees. And so one trainee of that cohort, so like, for example, they have, I think, two or three days total in outpatient clinic. And they are allowed to do one half day of specialty clinic. And so LIMSOC is considered specialty clinic. And so LIMSOC is considered specialty. So one half day of their general outpatient training experience is spent in LIMSOC. And is that, like, in my case, some of the residents that rotate with me, and they'll do either six months or a full 12 months, it is meeting their addiction requirements. Some of them do it as an additional elective. Additional elective. Yeah, this is an additional elective. Yeah. And I have one question here about how do we cover other general psychiatry topics when we've added this addiction curriculum. We mix the two together. And for instance, we would have a topic or maybe two or three topics on how do you handle a depressed patient who also has substance use problems? Or how do you handle ADHD patients with substance use problems? So you could give a resident a particular topic to research, a particular psychiatric diagnosis, and then look at it from the perspective of managing the addiction along with the other disorder. So I think we were really pretty effective in combining basic psychiatric topics along with the addictions. And Dr. Renner, is that, does your didactics, is that the general psychiatry didactic time, or this is in addition to it? This is in addition to the general time. And I think that, I mean, if you look at, well, where do people learn about depression? Well, if you look at their various inpatient rotations, various other clinic settings, they're going to get topics on particular disease states in various places. So I don't think any of them will lack a basic understanding of how they manage certain disease conditions. Mm-hmm. And there's another comment here from Sheila Cooperman. I think the model Dr. Renner described can be adapted to train non-addiction psychiatrists and other outpatient clinics. And I think that's totally true, as well as other specialists. And we have nurse practitioner, students, social work interns that all rotate through. And at least in my case, they're not specifically necessarily in the co-occurring clinic, but same thing where I will supervise them on cases. Dr. Renner, have you all had? No, we absolutely did that. We had nursing students. We've had nurse practitioners. We've had PharmD students. Our clinic was a rotation for a PharmD school. So we would often get them for three or four months at a time. And they both could see patients as well as do presentations. So I think you could use this model to integrate other professionals. And I think it's actually a good model for multidisciplinary teaching and multidisciplinary care. People learn together, and they learn how to work together. I think it can be very effective. Yeah. I know we've had our school pharmacy, our PA school, and our nurse practitioner program approach our clinic looking for more experiences specifically in addiction. So I think those are places to outreach to try to collaborate with. Yeah, I would agree. One question here about how have we adapted with telepsychiatry. I think we've been able to make the transition to telepsychiatry. We can certainly hold the seminars regularly. The residents may be seeing their patients with telehealth. We're holding our seminars that way. Personally, I don't think it's as effective as face-to-face learning, but I think it can be done. I don't know how the two of you, what kind of perspective you have on that in your settings right now. Yeah, so of course, at the onset of the pandemic, we pivoted to 100% telepsychiatry. At that time, I had one resident who was at home. I mean, it was really interesting because he was at home. And so I was logged into the Zoom as well with my camera off, because we have direct supervision in our clinic. So afterwards, we would do supervision on Zoom after the clinic was done. Basically, we had a half hour at the end of the day where we would do supervision. Presently, it is more of a medley. So the resident will have some telepsychiatry cases, I would say probably half and half, and then some in-clinic cases. And so we actually have observational systems in place with cameras in the rooms, so I can observe either way and be there for either online telepsychiatry or in-person. Yeah, I think we had another question about how do we find the time, if you will, to do the training and carve that out of the learning experiences. For most of the residents, this really ended up being two or three hours a week. I think more recently, I think because of the pressure or demand of cases, we've cut it down to two hours a week. But I think most training programs are willing to cover that in a rotation of 20 hours a week. 10% of that is devoted to formal training, and that has been acceptable to our program. Yeah, we also have, in our general clinic, our PGY3s are split into two multidisciplinary teams that meet once a week and, within that, do a case review. Now, it's not exclusively addiction-based case, but there's that opportunity as well as for bringing up difficult cases. I think, depending on our system, it's not a VA. There is some focus, as I'm sure for many, on productivity. But I think, as a whole, if you're able to balance between saying what is necessary for good education and patient care, as well as keeping whatever reasonable expectations for fill rate, that's how you approach it. Yeah. I see one question about, I guess, the concern of someone who likes detox experiences and why we're recommending something other than detox. I think the reality is there are going to be relatively few addiction psychiatrists who are going to work in a detox. I think addiction medicine people are probably the larger number of staff who are ending up in that facility. I've always had the bias that most addiction psychiatrists are going to work either in CL or long-term addiction outpatient settings. So I just bias the training in that direction. The other concern I have about detox is the patient turnover. You're seeing patients often when they're in the very early stages of recovery. Sometimes they're really not able to focus as well as they can on the issues that are behind their addiction. And because of the turnover, I just don't think it gives the trainee the best possible exposure, particularly if they're not interested. And I think, Alona, if I could use you as an example, unfortunately, we can take a resident who really was not interested in addiction, who would not have sought out an experience as an elective, yet when they were required to see patients regularly, get to really know the patients, and particularly see recovery. I think that's a very positive experience. And I think that long-term continuity clinics are really, I think, the best place to expose trainees to what's possible in recovery. Yeah, I think you can. I mean, if we can get people interested in addiction, they can get the detox experience in fellowship. But I can think of a handful of the patients I'm supervising my current resident with who are very challenging patients. And I think if he had seen the same patients, I can think of one who's had a few ED presentations while we've been seeing them. If his only exposure to that patient had been in the emergency room, he probably wouldn't want to work with the patient. He's not in his, he's in a really difficult place when he's presenting to the ED in the setting of his addiction and other psychiatric disorders versus we've been able to hang in there with him and over the course of six months actually see him make very substantial gains in his substance use and in his ability to manage his chronic pain and actually think. And part of it's because we've hung in there with him. I think that makes a big difference. The other thing I'll add is that sometimes on general consultation liaison services, you are able to get detox experiences. So just on my general seal months in residency, we did manage, we did do withdrawal management for patients in the hospital setting, oftentimes with alcohol, but sometimes opioids as well. So sometimes that's also an opportunity if available for detox. I did want to comment on this really great question by Martin Lehman, when you have residents in the clinic less than full time, it can be challenging to manage learner opportunity with patient access issues like the residents only here on Tuesday afternoons. So how do you address that? So that's exactly the issue that we have at University of Nebraska Medical Center because it is only Monday afternoons and that's when LIMSOC is. So that's when the resident can see patients. And so the way that we've really been able to remedy that is by working cohesively with the rest of the clinic. What I mean by that is we have two PAs that do part-time in the clinic. One does two full days, one does one half day. We also have a new, Dr. Zachman, our new addiction psychiatrist who is in the clinic. And we are able to then transfer patients to another provider if they say they're not able to make that date and time. So say the resident does the initial evaluation, obviously we would like for the resident to continue with the patient, but we always say, I'm only here on Monday afternoons, is this going to work for you? And if the patient already knows that's not going to be a possibility, then we immediately transfer them. So that way they do have an opportunity to start with somebody who they can continue to see. And there's no deficit of patients. So the resident will always have a full clinic because there's no deficit of patients. Like other patients can get scheduled if they're not able to continue with the patient they just saw. So that helps with the patient access issues because we can still initiate treatment and then just transfer onto another provider that is more flexible in scheduling based on the patient's needs. Go ahead. I think we want to finish up and then I think we need to close out. So why don't you do that, Alexis? Yeah, no, I was just going to say same thing. I would say overall, especially with telehealth now, I feel like actually it's been less limiting to only be a half day per week, but I feel like as long as you can identify other providers, they don't have to be addiction specialists, but residents that are interested in addiction, if there's other time you have in the clinic that you can then transfer folks to, I actually, it hasn't been as limiting as I thought it would be. Well, I want to thank everyone for attending. It's been a very interesting discussion. We hope you found it enjoyable and we hope you enjoy the rest of the meeting.

incorporation

learners

addiction psychiatry clinical services

substance use disorders

reducing stigma

co-occurring disorders

continuum of care

undergraduate and graduate learners

dual diagnosis patients

integrating addiction training