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Addiction Medicine

Montefiore Medical Center

Internal Medicine Residency Program

Addiction Medicine Elective

 

Title

Primary Care in Special Populations:  Opioid Use Disorders and the Opioid Treatment Program

 

Overview

The  “Primary Care in Special Populations: Opioid Use Disorders and the Opioid Treatment Program” is a two-week elective that aims to provide advanced levelinstruction in topics of addiction medicine, as well as the practical application of these topics.  The rotation will consist of both self-directed/chief-facilitated learning modules based on influential articles in the field of Opioid Use Disorders (OUD) and an immersive experience at a local Opioid Treatment Program (OTP) and Buprenorphine Clinic.  The main facilitator will be the categorical ambulatory chief. The primary faculty mentor will be Melissa Stein, M.D.  Other faculty include OTP counselors, OTP group session leaders, Chinazo Cunningham, M.D. and Angela Giovanniello, PharmD. 

 

Goals

1. To provide training which allows Internal Medicine residents to obtain competency in the recognition, diagnosis, and management of Opioid Use Disorders.

2.  To educate Internal Medicine residents about the principles of safe opioid prescribing

3.  To instruct Internal Medicine residents on the management of pain in patients with Opioid Use Disorders

4.  To reduce stigma surrounding Opioid Use Disorders by introducing Internal Medicine residents to the context in which Opioid Use Disorders arise

 

Objectives (Measurable)

1.  After performing a detailed substance use history, justify a diagnosis (or not) of opioid use disorder  

2.Using the principles of opioid agonist therapy, develop a treatment plan for a new patient with opioid use disorder

3.  Counsel a patient about the differences between buprenorphine therapy and methadone maintenance therapy

4.   Using harm reduction strategies, counsel a pre-contemplative patient with an opioid use disorder

5.   Propose a strategy to treat acute pain in a patient with an opioid use disorder

 

Objectives by ACGME competency

1.  Patient Care:

-          Gather information about substance use in an effective, efficient, and sensitive manner by interviewing patients and reviewing the medical record

-          Synthesize information from the history, physical exam, and lab results to diagnose a patient with Opioid Use Disorder

-          Develop a management plan that considers both the patient’s medical and psychosocial needs

-          Counsel a patient with Opioid Use Disorder with an effective and sensitive communication style

-          Optimize management by using medical literature review to apply evidence based principles of addiction medicine

2.  Medical Knowledge:

-          Demonstrate an ability to apply knowledge derived from medical literature review, addiction medicine workshops, and discussions with facilitators to the appropriate clinical scenarios

-          Attend all workshops and experiential learning sessions

-          Evaluate literature offered in modules and apply to clinical encounter

-          Seek to address deficiency in medical knowledge by querying literature and actively seeking information from facilitators

3.  Professionalism:

-          Act with honesty and integrity by keeping commitments and attending sessions

-          Demonstrate responsibility by completing assignments

-          Collaborate with the other members of the treatment team

-          Interact with patients with compassion, patience, and respect

 4.  Interpersonal and Communication (ICS) Skills:

-          Effectively communicate with understanding and compassion about sensitive matters with patients

-          Address patients with appropriate language and with vocabulary that matches the patient’s level of education/understanding

-          Use active listening and reflection skills

-          Communicate respectfully with members of the treatment team and staff

5.  Practice-Based Learning and Improvement:

-          Demonstrate willingness and ability to identify knowledge deficiencies and learn from them

-          Actively search medical literature to address knowledge deficiencies

-          Interpret data and critically appraise information in required addiction medicine articles

-          Use medical literature, feedback, and direct instruction to change approach to the care of a patient with Opioid Use Disorders

6.  Systems-Based Practice:

-          Recognize how health system failures and limited access affect diagnosis and management of patients with Opioid Use Disorders

-          Identify factors that lead to stigmatization of patients with Opioid Use Disorders

-          Develop a strategy to coordinate care across healthcare domains in an effort to optimize care for a patient with an Opioid Use Disorder



 Activities

1.  Port Morris Wellness Center (Dr. Melissa Stein)

-          Counseling Sessions, DOT window, Group Sessions, Intake Appointments, Substance Use Appointments, Primary Medical Appointments

2.  CHCC Buprenorphine Clinic (Dr. Chinazo Cunningham)

-          Intake Sessions, Followup Sessions, Instruction by PharmD3. “Check In” Sessions led by Ambulatory Chief Resident - Moses

 

 Target Learners

- PGYII or III Categorical or PCSIM residents seeking a more in-depth, immersive experience in the treatment of Opioid Use Disorders

- To be eligible, residents must complete the introduction to substance abuse didactic series during PGYI year


Methods/Educational Activities

1.  Chief Facilitated, Self-Directed Learning Modules

Learning modules consist of 2-3 addiction medicine articles grouped by topic and an accompanying series of questions/case-based scenarios that the resident will work through with the chief facilitator.  4 learning modules will be offered.  Topics include Introduction to Addiction and Urine Toxicology; Methadone; Buprenorphine; and Pain Management in Patients on Opioid Agonist Therapy.  Additionally, the safe opioid prescribing learning module from Scope of Pain (Scopeofpain.com) will be offered. 

2.  Immersive Experiential Learning

Residents will rotate through Port Morris Wellness Center as well as the Buprenorphine clinic at CHCC.  At Port Morris, residents will attend sessions with substance abuse counselors; participate in group sessions led by patients; evaluate new patients during intake appointments with OTP medical directors; care for the primary care concerns of patients engaged with the OTP; and contribute to weekly interdisciplinary conferences at the OTP site.  Additionally, residents may be provided an opportunity to visit a local Syringe Exchange program (depending on site availability). 

 

Sample Schedule

 

Monday

Tuesday

Wednesday

Thursday

Friday

Week 1

Continuity Clinic

Dr. Melissa Stein – Port Morris Wellness Center (804 E 138th St, Bx)

Module 1 (Addiction, Urine Testing)

 

Module 2 (Methadone)

 

Meet with Ambulatory Chief in PM – Moses

Dr. Melissa Stein – Port Morris Wellness Center  (OTP) (804 E 138th St, Bx)

Meet with Ambulatory Chief in AM – Moses

 

Module 3 (Pain Management in Patients On Opioid Replacement Therapy)

 

Module 4 (Buprenorphine)

 

Week 2

Continuity Clinic

Dr. Chinazo Cunningham – Buprenorphine Clinic, CHCC

Angela Giovanniello, PharmD - Buprenorphine Clinic, CHCC

Dr. Melissa Stein – Port Morris Wellness Center (OTP) (804 E 138th St, Bx)

 

 

Dr. Melissa Stein – Port Morris Wellness Center (OTP) (804 E 138th St, Bx)

 

Evaluation

The resident is evaluated continuously during their two weeks on this elective by on-site mentors as well as the chief medical resident.  The final evaluation, which will reflect assessment from the supervising mentors/chiefwill be made available on New Innovations.  A summary performance assessment will be discussed in a meeting with the resident by the chief resident. The evaluation will assess overall clinical competence as reflected by the resident’s clinical performance in each clinical setting, professionalism, and attainment of the learning objectives listed above.  Residents will have the opportunity to evaluate both the rotation and the specific faculty with whom they worked most closely, using assessments on New Innovations.

 

Bibliography

1.      Alford, D. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med.  2006;144(2):127-134  MODULE 3

2.      Dole VP, Nyswander, ME. A medical treatment for diacetylmorphine (heroin) addiction: A clinical trial with methadone hydrochloride. JAMA 1965; 193(8):80 – 84  MODULE 2

3.      Eyler, E.  Chronic and acute pain and pain management for patients in methadone maintenance treatment.  Am J Addiction 2013; 22:75-83. MODULE 3

4.      Fudala, P. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone.  N Engl J Med 2003; 349(10):949-958  MODULE 4

5.      Kleber, H.  Methadone maintenance 4 decades later: thousands of lives saved but still controversial.  JAMA 2008; 300(19): 2303-2305  MODULE 2

6.      Leavitt, S.  Methadone drug interactions.  Addiction Treatment Forum. 2004  MODULE 2

7.      Sellman, D.  The 10 most important things known about addiction.  Addiction 2009. 105:6-13  MODULE 1

8.      Sullivan, L et al.  Narrative review: buprenorphine for opioid-dependent patients in office practice.  Ann Intern Med 2008.  148:662-670  MODULE 4

9.      Tenore, P.  Advanced Urine Toxicology Testing.  J Add Dis 2010; 29:436-448  MODULE 1

 

 

 

 

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