Fellowship in Addiction Psychiatry
University of Massachusetts Memorial Healthcare (UMMHC)
Goal: To develop broad clinical and consultative skills in the direct care of the addicted patients in general hospital, acute psychiatry and ambulatory care setting (PC, MK, PL, PF, IC, SB).
· To gain knowledge and expertise in the treatment principles for substance dependence in acute general hospital setting (PC, MK, PL).
· To develop skills in consultation to acute and chronic, medically ill substance-abusing patients being treated on medical, emergency, intensive care, and / or surgical services of a general hospital (PC, MK, PL, PF, IC).
· To gain knowledge in the recognition and treatment of alcohol, tobacco, and other drug withdrawal syndromes and the acute management of intoxication, withdrawal, and overdose (PC, MK, PL).
· To develop skill in working with individuals who have serious medical sequelae from substance use/dependence (PC, MK, PL).
· To gain knowledge and skills in the evaluation of addicted patients with acute and chronic pain complaints to assist medical providers in prescribing analgesia (MK, PL, PF, IC, SB).
· To assess life-threat risk in individuals (e.g. suicidality in patients with unintentional overdose) (PC, MK, PL).
· To identify features that suggests appropriate and inappropriate medical clearance (PC, MK, PL).
· To gain knowledge and expertise in buprenorphine treatment for opiate dependent patient with severe co-occurring psychiatric disorders in the context of an Intensive Outpatient Treatment Program attached to a General Hospital (PC, MK, PL, IC, PF).
· To understand the current economic aspects of providing psychiatric and other health-care services to individuals with addiction disorders (with focus on primary care and general hospital setting) (SB, IC).
Emergency Department (Emergency Mental Health and Medical Toxicology Services)
The emergency room is a required 20% per week rotation for the total of six months at UMass Memorial as the primary placement. This service is located within the Duddie Massad Emergency and Trauma Center at UMass Memorial Medical Center’s University Campus. This rotation will consist of a shared rotation between the Emergency Mental Health and Toxicology Services in the ED. The primary supervisors of this rotation are Edward W Boyer, MD PhD, who is the Director of Toxicology and Program Director of Medical Toxicology Residency Program, and Patrick Smallwood, MD who is the Director of the Mental Health Emergencies. The UMass-Memorial ED is Department of Public Health funded for interventions for violence and substance abuse. Both children and adults are evaluated by EMHS on either a voluntary basis or involuntarily basis via a legal order for emergency evaluation.
The substance abuse patients treated at the UMassMemorial Emergency Department are a broad mix, but most are from the public sector and reflect the demographics of central Massachusetts, northern Connecticut, and southern New Hampshire. The Emergency Mental Health Service (EMHS) at UMass Memorial Medical Center evaluates all individuals who come to the UMMMC Emergency Department in crisis due to acute onset of mental illness, worsening of chronic mental illness, or acute psychosocial crises such as loss of important relationships, loss of a job, or severe medical illnesses. Treatment is primarily focused on emergency assessment and acute stabilization, with use of pharmacological, cognitive and behavioral interventions to reduce disruptive symptoms and behaviors. The EMHS offers telephone triage, rapid psychiatric evaluations, mobile outreach, and crisis stabilization in an emergency room setting for both the University and Memorial Campuses. In addition, EMHS provides essential diversionary services to patients who require intensive psychiatric care, but can be maintained in outpatient settings such as crisis stabilization units or intensive outpatient programs.
The fellows are able to participate in an ambulatory detoxification program and in program development responsibilities. Research opportunities at this site include Dr Boyer’s NIH-funded investigations into the relationship between Internet pharmacies and prescription opioid abuse, and the impact of club drug pharmacology on HIV risk behaviors. The fellows benefit from the additional training / supervision in Dr Boyer’s ongoing investigations into kratom as opioid replacement therapy and the impact of energy drink on adolescent substance use.
Psychosomatic Medicine Service (CL rotation)
The psychosomatic medicine service is a required 20 % per week rotation of the total of six months at UMassMemorial as the primary placement, including Tobacco Dependence. The Psychosomatic Medicine Service at UMassMemorial Hospital provides psychiatric consultation and interventions to the UMMHC medical community. The Primary Supervisor for this rotation is Patrick Smallwood. Other faulty of this consists of 2 full-time psychiatrists, and a psychologist expert in Spirituality and Health Care. Additional teaching and supervision includes several voluntary faculty members with expertise in Consultation-Liaison Psychiatry. Faculty all have additional training in Consultation-Liaison, Emergency psychiatry, Transplantation Psychiatry, HIV Psychiatry, and Geriatric Psychosomatic Medicine. Also, tobacco dependence consultation service is part of this service and services UMMHC. Greg Seward and Fernando de Torrijos are running this service and they are Tobacco Treatment Specialists and Drug and Alcohol Counselors. Also, as part of this rotation the fellow may performer addiction consultation to ambulatory clinics in Primary Care, HIV, Transplant service or Pain Management.
Office-Based Buprenorphine Treatment & Addiction and Comorbidity Treatment Service (ACTS)
The Buprenorphine Clinic within the Addiction & Comorbidity Treatment Service (ACTS) for Co-Occurring psychiatric and medical disorders attached to a General Hospital is a required 20% per week rotation of the total of six months at UMassMemorial as the primary placement. The Primary Supervisor for this rotation is Gerardo Gonzalez, MD. Additional faculty for this rotation includes Drs. Kagan and Kolodziej. ACTS provides comprehensive evaluation and treatment recommendations for patients with addictive disorders, both with and without comorbid psychiatric or medical disorders. Evaluation and treatment occurs in a structured clinical setting and care is administered by a multi-disciplinary team with specific psychiatric expertise. In addition, ACTS also serves as a meaningful training site for psychiatric residents and medical students, and may also be used as a valuable resource for clinical research. The fellow is expected to evaluate new patients and present succinct case formulations, induct patients onto buprenorphine, carry a patient caseload between 15-20 patients and participate in weekly team meetings. The fellow should select appropriate patients for long-term psychotherapy.
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Community Healthlink (CHL)
Goals: To develop broad clinical and consultative skills in the direct care of patients with substance abuse disorders with and without co-occurring psychiatric conditions for adolescents and adults (PC, MK, PL, PF, IC, SB).
· To develop an attitude and skills that consistently demonstrate a culturally-sensitive approach to patients with addictive disorders that is compassionate, responsive to their needs and aiming at establishing an appropriate therapeutic alliance (IC, PF, SB).
· To develop skill in working with and functioning as an integral member of a multi-disciplinary treatment team (PL, IC, PF, SB).
· To develop skills in taking a comprehensive alcohol, tobacco, and other drug history, including assessing other psychiatric and medical conditions (PC, MK, PL).
· To develop acute and long-term management strategies, including types of treatment modalities and expected outcomes, and selection of treatment evaluation tools (PC, MK, PL, SB).
· To gain knowledge and experience in individual and group therapy with adult and adolescent substance abusers and dually diagnosed in early recovery and later stages of recovery (PC, MK, PL, IC, SB).
· To gain knowledge and experience with evidence-based management of withdrawal syndromes in adolescent substance abusers ( PC, MK, PL).
· To gain knowledge and experience in evaluating and treating complex substance abuse patients with co-occurring condition such as infectious disease, psychotic disorders and homelessness (PC, MK, PL, PF).
· To gain knowledge and expertise in office-based buprenorphine treatment for opiate dependent patient with and without co-occurring psychiatric disorders (PC, MK, PL).
Community Healthlink (CHL) is a required 6 month primary rotation where the Addiction Psychiatry Fellow will be for 20 hours per week. CHL is a comprehensive community mental health center located four miles from UMass Memorial Medical Center in Worcester. CHL is the principal provider of outpatient public sector psychiatry care to seriously and persistently mentally ill individuals in Worcester County. Community Healthlink, Inc. is part of the UMass Memorial Healthcare system.
Motivating Youth Recovery (Adolescent)
This is a required 20% per week rotation of the 6 months as the primary placement at CHL. The primary supervisor for this adolescent rotation is Dr. Lisa Fortuna. This is an adolescent detoxification and stabilization unit which provides assessment and treatment for substance abuse and for dual substance and psychiatric diagnosis. It is one of two such units in the entire state of Massachusetts. The maximum duration of stay is normally 30 days with the usual shortest stay being one week. There are approximately 12-16 active cases at any time. Diagnoses of patients include a variety of dual diagnostic combinations including most commonly polysubstance dependence, Major Depression, Attention Deficit Hyperactivity Disorder and Bipolar Disorder. Fellows spend their time becoming proficient in the following evaluation and therapeutic modalities: Assessment of adolescents with addiction disorders, individual psychotherapy, family assessment and intervention, group psychotherapy, milieu therapy, behavior modification techniques psychopharmacology, consultation-liaison, and somatic therapies. The Addiction Psychiatry fellow may offer addiction consultation to Highland Grace House that is a 15 bed residential home for adolescent girls 13-17 years old with substance abuse and dependence problems. In addition, at the CHL rotations fellows will have the opportunity to evaluate patients with multiple ethnic backgrounds, with a large representation of Hispanic and Asian origin. Supervising faculty and staff are sensitive to cultural factors and the fellow will benefit from the experience.
Detoxification and Rehabilitation Units
The Detoxification and Rehabilitation Units are linked together at CHL and this is a required 20% per week rotation during the 6 month placement at CHL. The primary supervisor of this rotation is Amy Harrington, MD. Other faculty at this site includes Jeffrey Baxter, MD who is the Medical Director of both units and Gerardo Gonzalez, MD will help supervise the fellow during the psychiatric consultation of patients with co-occurring diagnoses as part of the Enhanced Acute Treatment Services (EATS). The population (N= 2242) that were treated in the CHL detoxification unit during the previous year were predominately males (76%) Caucasian (70%) followed by Hispanic (14%) and African American (5%) substance dependent patients. Opiate dependence (56%) followed by Alcohol Dependence (29%) and Cocaine Dependence (1%) were the most frequent diagnoses that accessed services. Co-occurring disorders were documented in 20% (450/2242) of these patients in which Depressive Disorders were predominating. The CHL detoxification unit provides a biopsychosocial assessment and treatment planning. The Addiction Psychiatry Fellow may also be involved in other relevant programs at CHL such as the Homeless Outreach & Advocacy Project, and Structured Outpatient Addictions Program that will enhanced his learning experience.
Substance Abuse Outpatient Services
This rotation is a required 20% per week rotation during the 6 month placement at CHL. The Substance Abuse Outpatient Services are composed of Outpatient Substance Abuse Program and Buprenorphine program. The primary supervisor of this rotation is Gerardo Gonzalez, MD. The fellow is responsible for evaluation, treatment planning and case management and discharge planning under the supervision of Medical Director of Addiction Services. The fellow will evaluate and follow-up a caseload of patients. The fellow will be responsible for running the biweekly team meeting.
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Goals. To gain knowledge and experience in specialized in-patient and outpatient treatment for adults with substance-related disorders with and without complex co-occurring disorders (PC, MK, PL, PF, IC, SB).
· To gain knowledge and experience in medically managed detoxification and rehabilitation programs, with specific emphasis on treatment for persons with co-occurring disorders (PC, MK, PL).
· To learn about provision of treatment as a front-line provider and will acquire experience in functioning as an important member of a multidisciplinary team. (IC, PF, SB)
· To gain experience with several modalities of group treatment programs for individuals with co-occurring disorders (PC, MK, PL).
· To gain knowledge of self-help, 12-step programs and their role in recovery of persons with co-occurring disorders (MK, IC, SB).
· To gain knowledge of applied clinical research and quality improvement endeavors at a community-based treatment setting (MK, PL, IC, SB).
Adcare is a JCAHO-accredited 114 bed specialty addictions hospital licensed by the Division of Healthcare Quality that serves approximately 5,200 inpatients per year. AdCare Hospital specializes in treating adults with substance-related disorders by offering inpatient treatment and outpatient services. Inpatient services include medically managed detoxification programs as well as rehabilitation services for individuals with co-occurring psychiatric and chronic medical conditions. Several modalities of group treatment programs and individual or family counseling are provided at the outpatient clinics. Adcare is also part of the NIDA Clinical Trials Network as a Clinical Treatment Program in which drug addiction research studies occur within the agency.
Co-occurring disorders rotation within an Addiction Treatment Center
This placement is a required part-time rotation for 4 months, that may be extended to 6 months. The Primary Faculty supervisor for this rotation is Patrice Muchowski, Sc.D. The fellow will be able to increase his or her knowledge of medically managed detoxification programs, rehabilitation, and acute residential services for individuals with co-occurring psychiatric and medical conditions. The fellow will be able to gain experience with several modalities of group treatment programs. Some of the groups that are geared specifically towards persons with co-occurring disorders include the dual-diagnosis groups that are implemented during the intense daily treatment program and as a long-term weekly group, the Seeking Safety group for women (an evidence-based intervention for persons with substance addiction and post-traumatic stress disorder), and soon-to-be implemented early recovery group for persons with Hepatitis C and substance dependence (the majority of whom also have a mood disorder). The fellow will be able to observe and then co-lead certain groups by meeting with his or her clinical supervisor and group facilitator to prepare and implement specific session curricula.
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Spectrum Health System
Goals. To gain knowledge and expertise to successfully assess and treat patients with opioid dependence on agonist maintenance therapy, with and without other comorbid substance dependence disorders and psychiatric disorders (PC, MK, PL, PF, IC, SB).
· To develop a working understanding of indications, contraindications, side-effects and expectable clinical course for the opioid maintenance medications used to treat these disorders (PC, MK, PL).
· To gain experience and knowledge in the treatment elements of an modern therapeutic community (PC,MK,PL)
· To develop a working understanding of the treatment elements of a program specific for women and children.
Spectrum is a required secondary site where the fellow will rotate for four months 8 hours per week. Spectrum is a national substance abuse and mental health treatment organization, serving nearly 18,000 individuals each year through more than 55 institutional and community-based programs. Spectrum offers a comprehensive continuum of care for substance abuse such as detoxification services, transitional support Services, post detoxification Step Down, rehabilitation, outpatient counseling, mental health services, and opiate treatment. The Opioid Treatment Program at the Worcester site is located 3 miles from the UMass Main Campus and the Westborough Treatment Campus is the largest substance abuse treatment facility in New England, providing inpatient detoxification, transitional support services and residential rehabilitation.
Opioid Dependence Continuum of Care
The Spectrum rotation is a required four month part-time rotation. During this rotation fellows will participate in the continuum of treatment for opioid dependent patients with co-occurring psychiatric and medical disorders. The primary faculty supervisor of this rotation is Jeffrey Baxter, MD. Other supervisors are Heidi Shah, MD and James Broadhurst, MD. Dr. Baxter is the Medical Director of the Methadone Treatment Program and Board Certified in Family Practice. Dr. Shah is the Medical Director of Spectrum and is Board Certified in Family Practice with added qualifications in addiction medicine. Dr. Broadhurst is Board Certified in Family Practice.
There are 824 clients enrolled in the outpatient Opioid Treatment Program at the Spectrum site. Clients are primarily public sector patients. They have multiple medical, psychiatric, and social problems, including unemployment, family problems, and legal problems. In addition to opiates, most have a history of other substance use disorders, including alcohol 29% and cocaine 20%. In addition, 40% have co-occurring psychiatric disorders including depression, anxiety, and personality disorders. The types of treatment services include outpatient addiction and dual diagnosis evaluations, individual and group treatment, medication management for co-occurring psychiatric disorders, methadone maintenance and detoxification.
Transitional Support Services
Following detoxification, Spectrum's 32-bed short-term transitional support services program further stabilizes clients and prepares them for the next phase of recovery. Intensive case management services address individual discharge needs. Length of stay is generally two to four weeks, depending on the aftercare goals of the client.
Women and Children Program
This program serves female offenders with their children for substance abuse problems in the context of services that is gender specific. This is an observational rotation and provides learning experience about female offenders treated in a substance abuse facility.
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Bedford Veterans Center for Addiction Treatment (VCAT)
Goal: To gain knowledge and expertise in evaluation and consultation to veterans and older veterans with a wide variety of substance abuse, mental-health, and neurological problems as well as treatment of dual diagnosis patients in outpatient rehabilitation setting ( ASAM level I - III) including ambulatory detoxification .
(PC, MK, PL, PF, IC, SB).
·To gain knowledge and experience of treatment of substance abuse in the context of PTSD using specific modalities. (PC, MK, PL, PF).
·To gain experience treating elderly patients with substance abuse disorders with and without co morbid psychopathology and medical problems in outpatient and nursing home inpatient setting (PC, MK, PL, PF).
·To gain knowledge and treatment experience of substance use disorders with and without co morbid psychopathology among Homeless Veterans (PC, PL, PF, IC, SB).
·To gain knowledge and experience in evaluating and treating complex substance abuse patients with co-occurring condition such as cognitive disorders, psychotic disorders and homelessness (PC, MK, PL, PF)
·To gain knowledge and expertise in office-based buprenorphine treatment for opiate dependent patient with and without co-occurring psychiatric disorders within the VA setting (PC, MK, PL, SB).
·To gain an exposure in developing use of Telemental health in treating addiction and dual diagnosis.
Bedford VA is a 350 bed joint commission accredited hospital .It has a strong addiction treatment program called Veteran's Center for Addiction treatment ( VCAT ) . This program offers Intensive Day treatment ( ASAM II - III ) including ambulatory detoxification, Suboxone induction and maintenance , Relapse prevention track ( ASAM - II ) and outpatient services ( ASAM I- II ) .It provides services to predominantly dual diagnosis patients , has a specialized treatment for patients with co occurring PTSD. Treatment is provided by multidisciplinary team using the modalities of group therapy , Individual therapy , psychopharmacological interventions and behavioral therapy.
Additionally Bedford VA also offers inpatient short term detoxification services. It has residential nursing home care units where elderly service connected veterans are housed who requires various levels of addiction treatment that will be offered as in form of consultation by the Addiction Program. Bedford VA has successfully used Telemental health to provide psychiatric care to patients living in distant are, it is now planning to offer addiction treatment by this modality.
Each of the fellows will rotate 6 months at a time at Bedford VA as the primary site of training. They will be spending 70% of the time gaining the expertise in above mentioned addiction treatment while being supervised by the faculty at Bedford VA. They will spend 30% of the time with other required didactics at UMass while rotating at Bedford VA.
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