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: 7/15/2021

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 – Weiler Hospital

o Opioid Treatment Program – Wellness Center at Port Morris or Melrose

o Intensive Outpatient Program – Next Steps North or New Directions Recovery Cntr

o Primary Care Addiction “Bridge” Clinic – Comprehensive Family Care Center

o Mutual-Help Group – Alcoholics Anonymous open meetings

• Self-study curriculum that covers foundational knowledge in addiction medicine

o Required readings, podcasts, videos

o Buprenorphine waiver training

B. Key Areas of Training

1. Taking an appropriate substance use specific 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 overdose education and distribute or prescribe naloxone to 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

D. Rotation Schedule

Two Internal Medicine residents will be assigned to each rotation block. In Week 1, one resident will start on inpatient (I) while the other will start on outpatient (O). In Week 2, the residents will switch so that one resident will be on outpatient (O) while the other will be on inpatient (I). Sample schedule is below:

Inpatient Week – Residents should report to the Addiction Consult Service at Weiler Hospital (1825 Eastchester Road, Office 224 Room 3 – see map) for Rounds starting at 8:30am on day 1 of the inpatient week. 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 Wednesdays from 9-9:30am, and Virtual Case Conferences occur on Fridays from 12-1pm. Please contact Dr. Kristine Torres-Lockhart (ktorresloc@montefiore.org) if any questions.

Inpatient/Outpatient Weeks – Residents should report to the “Bridge” Clinic at Comprehensive Family Care Center (1625 Eastchester Road, Adult Medicine Library) by 1:30pm on Tuesdays for both weeks of the rotation. The “Bridge” 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 patients who are new to or unstable in buprenorphine and naltrexone treatment. Please contact Dr. Tiffany Lu (tlu@montefiore.org) if any questions.

Outpatient Week – Residents should confirm reporting details for the Opioid Treatment Program and Intensive Outpatient Program by contacting Dr. Melissa Stein (mstein@montefiore.org) on day 1 of the outpatient week. Residents will be assigned to attend one of the two sites for each program.

• Opioid Treatment Program – Wellness Center at Port Morris (804 East 138^th Street) or Melrose (260 East 161^st Street). Opioid treatment programs are licensed under federal regulations to provide methadone and buprenorphine treatment, in addition to substance use counseling, primary medical care, mental health care, and other supportive services for persons with opioid use disorder. Meet with faculty preceptor at assigned site. A typical clinical day starts at 8am.

• Intensive Outpatient Program – Next Steps North (1510 Waters Place) or New Directions Recovery Center (2058 Jerome Ave). Intensive outpatient programs are licensed to provide individual and group counseling, medication treatment (including buprenorphine and naltrexone), mental health care, and other supportive service for persons with substance use disorders. Meet with faculty preceptor at assigned site. A typical clinical day starts at 8am.

Outpatient Week – Residents should attend an Alcoholic Anonymous meeting during the outpatient week. Please refer to www.nyintergroup.org for up-to-date list of meeting times and details. Choose a local in-person meeting or remote meeting – be sure to check that the meeting is “open” (do not attend meetings that are “closed” or only for persons with addiction). A listing of meetings that occur on Wednesdays has been compiled to facilitate attendance on the self-study day of Outpatient Week (see resource folder). The AA program provides non-professional mutual-help support for persons with alcohol use disorder; mutual-help groups that use 12-step facilitation can be an effective treatment option for increasing abstinence.

E. Self-Study Curriculum

Residents on the Addiction Medicine Rotation are expected to work through the self-study components throughout the two-week rotation. At least one rotation day will be allocated for residents to complete the self-study components without clinical responsibilities.

1. 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 (https://learning.pcssnow.org/p/onlinematwaiver).

• 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. Registration information will be shared via Chief Residents by September 1, 2021. Residents on ambulatory/elective blocks may work with Chief Residents to facilitate attendance in the in-person portion of the waiver training. (Note: 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.

2. Clinical Protocols: Be familiar with the clinical protocols implemented at Montefiore campuses for addiction care and naloxone distribution.

• Management of Opioid Use Disorder and Opioid Withdrawal in Hospitalized Patients – Access through Intranet (Policies à Medical Guidelines à Substance Use)

• Management of Alcohol Use Disorder and Alcohol Withdrawal in Hospitalized Patients – Not yet available on Intranet, access through resource folder for rotation)

• Perioperative Buprenorphine Management for Elective Surgery – Access through Intranet (Policies à Medical Guidelines à Substance Use)

• Naloxone Take-Home Kits at Weiler and Moses Campuses – Access through Intranet (Policies à Clinical Policies and Procedures à Patient Care Manual à N-05 or N-06)

3. Articles, Guides, Podcasts, Videos: Residents are required to complete three modules of key articles, reference guides, podcasts, and videos. Full articles can be accessed through the resource folder for the Addiction Medicine Rotation.

General Approach

• • • Pace CA and Samet JH. In the Clinic: Substance Use Disorders. Ann Intern Med. 2016;164(7):ITC49-64. doi: 10.7326/AITC201604050

    • Hawk M, Coulter RWS, Egan JE, et al. Harm reduction principles for healthcare settings. Harm Reduct J. 2017;14(1):70. https://doi.org/10.1186/s12954-017- U0196-4

    • 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)

Alcohol Use Disorder

• • • 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

    • Perry EC. Inpatient Management of Acute Alcohol Withdrawal Syndrome. CNS Drugs. 2014;28(5):401-10. doi: 10.1007/s40263-014-0163-5

    • Curbsiders Podcast, Episode #212 – Sober Talk: Managing Inpatient Alcohol Withdrawal with Dr Joji Suzuki. https://thecurbsiders.com/podcast/212 (start at 8m10s)

    • Curbsiders Podcast, Episode #194 – Treatment of Alcohol Use Disorder with Dr. Marlene Martin. https://thecurbsiders.com/podcast/194-alcohol (start at 9m45s)

Opioid Use Disorder

• • • Buresh M, Stern R, Rastegar D. Treatment of Opioid Use Disorder in Primary Care. BMJ 2021;373:n784. doi:10.1136/bmj.n784

    • 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

    • NYC Department of Health and Mental Hygiene – Opioid Overdose Response with Naloxone. https://www.youtube.com/watch?v=p5st4Raik-8 (Video can also be shown to patients)

    • 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).

4. Optional Readings: Key articles related to alcohol or opioid use disorder treatment are available through the resource folder for the Addiction Medicine Rotation.

Learning Objectives:

After participating in this experience, residents should be able to:

1. Differentiate between hospice and palliative medicine.

2. Identify patients that are appropriate for home hospice referral.

3. Demonstrate the communication skills and professionalism necessary for providing home hospice care.

4. Identify the range of skills and services provided by members of the interdisciplinary hospice team.

5. Report key components of the Medicare Hospice Benefit.

Schedule and Contact:

PGY3 residents rotating on the Outpatient Week (O) of the required 2-week Addiction Medicine and Substance Use rotation will spend Thursday doing home hospice visits.

Point of contact:

Nina Selvaggio is the person in charge to handle communications with residents and Calvary staff please contact her at: 347-390-8338 or nselvaggio@calvaryhospital.org

Jamie Geraghty is also involved in the visiting residents and can be reached at: 347-390-8307 or jgeraghty@calvaryhospital.org.

Nancy D’Agostino, RN, MSN, CHPN

V.P. Community Patient Services

Home Care and Hospice

Calvary Hospital

1740 Eastchester Road, Bronx, NY 10461

tel: 718-518-2298 Office: 718-518-2465

email: ndagostino@calvaryhospital.org

Thursdays Morning Meeting Place/Time:

Our main office is not in the hospital building. It is located just on the other side of the Calvary Hospital parking lot at the Hutch Metro Atrium so residents should come directly to this office.

Meet at 9:30 a.m.

Meeting location and time can vary so please communicate with the assigned Calvary staff member the prior to your visit. The assigned Calvary staff member contact will be sent by email prior to your visit.

Logistics of the rotation:

1. Each resident will meet directly with a Calvary Staff member assigned to them for that day

2. Residents are to wear street clothes, carry their Montefiore ID and supply their own PPE. Medical tools are not required

3. Each resident will follow and travel with their respective Calvary liaison from the first to last patient visit of that day. Residents will not need to return to our building at the end of the day.

Resources and Reference Material:

CAPC

Montefiore has a membership to the Center to Advance Palliative Care (CAPC) through a grant which provides unlimited access to the wealth of CAPC on-line materials. These materials can be found at https://www.capc.org. Each resident user will have to create an account to access the content by creating a login/password and selecting Montefiore membership. See PDF linked for detailed one-page instructions for creating an account: How to create a CAPC user account

CAPC’s introductory course and modules on pain management, communication skills and symptom management are excellent content areas to explore prior to the home hospice visit.

See PDF linked for course catalog: CAPC online - course catalog

See PDF linked for each CAPC module objectives/competencies: CAPC course objectives

MOLST

Here is a link to a resource on completing a molst: https://molst.org/how-to-complete-a-molst/

Vital Tips app

It is recommended that you download the Vital Tips app to your smart phone. It is created by the Vital Talk Team and gives useful tips for easing communication in various conditions. Here is the link to the Vital Talk Tips website for more information: https://www.vitaltalk.org/vitaltalk-apps/