While the number of people nationwide needing substance abuse treatment continues to grow, access to treatment combined with a looming physician shortage worsen the issue for patients seeking treatment. This month’s Behind the White Coat explores the need for additional training programs for physicians specializing in substance abuse disorders and spotlights a program at Montefiore Health System in the Bronx, NY.
Shadi Nahvi, MD, Associate Professor of Medicine and Psychiatry and Behavioral Sciences at Montefiore Health System and the Albert Einstein College of Medicine, is the Co-Director of the General Internal Medicine and Addiction Medicine Fellowship programs. The Addiction Medicine program launched in July 2019 and recently received accreditation by the Accreditation Council for Graduate Medical Education (ACGME). Dr. Nahvi began her career at Montefiore in 2004 as a clinician in the opioid treatment program and has transitioned to researching ways to optimize outcomes for people with opioid use disorder, with a focus on tobacco control.
Dr. Nahvi spoke to GNYHA’s Anu Ashok about the fellowship programs at Montefiore Medical Center and the importance of training residents to treat patients with substance use disorders.
Anu Ashok: How have you seen the management of patients with substance use disorders (SUDs) change since you first entered the field of practice?
Dr. Nahvi: SUD treatment has traditionally been conducted within specialty care settings, such as opioid treatment programs. Over the past few decades, Montefiore and other places have led the charge to integrate SUD treatment into primary care settings. At Montefiore, we have a very well-established buprenorphine treatment program integrated within our primary care practices and have launched an offsite clinic in partnership with a community-based organization (CBO). Patients can get buprenorphine treatment or primary care onsite at the CBO. People are now turning their attention to how to best serve people in acute care settings—so thinking of innovative strategies to bring more people into care is our next step.
AA: What role do you see teaching hospitals and GME playing in managing SUDs and the perceived increase in SUDs? Specifically, as someone leading a new program, how do you see that role evolving?
SN: I think that role is twofold: One, we need more of a workforce trained in the specialty care of SUDs to really lead the clinical care across both inpatient and outpatient settings, and beyond into community-based settings. Two, we need to take the next step to integrate SUD treatment into pre-clinical training, into general medicine training, anesthesia and surgery, and obstetric training. We have a very important role to play in broadening the scope of interprofessional care of people with SUDs at all of the different touchpoints they have with the health care system.
AA: How did the conversation about the need to develop a very specific fellowship program focused on addiction medicine begin?
SN: We have a very long history of providing SUD treatment at Montefiore and Einstein. We were approached by the City’s Department of Health and Mental Hygiene (DOHMH), which wanted to expand the addiction medicine workforce and help us start a fellowship program. We have one fellow this year funded by DOHMH. That catalyzed us to both formalize an educational program in clinical care of SUDs and apply for ACGME accreditation to ensure that fellows could receive specialty certification in addiction medicine.
AA: What leadership was involved in the discussion to pursue this as a specially accredited fellowship?
SN: Addiction medicine was recognized as a specialty by the American Board of Preventive Medicine a few years ago. We worked very closely with our GME office on the accreditation piece. We are the 99th program accredited by ACGME at Montefiore, so they had a lot of wisdom and expertise in what the ACGME requirements are and what we needed to do to ensure we were complying with regulatory structures. Luckily, we had a strong clinical program and faculty that preceded the fellowship that made it straightforward and natural for us to do.
AA: Can you describe the curriculum for the Addiction Medicine fellows?
SN: Our fellow spends six months of intensive immersion across ambulatory care settings and then trains for three months in an inpatient setting, including consults, detox, and integration with emergency department care. This is followed by two weeks of adolescent care programs, one month at DOHMH looking at public health approaches to SUD treatment, and then training for a period of time at Rikers Correctional Facility. As of now, our program can accommodate one fellow a year. We hope to get more funding to expand what we can offer.
AA: There is a lot of discussion about the opioid epidemic in New York State and nationally. GNYHA has been advocating for passage of the Opioid Workforce Act, a bill that would provide 1,000 additional GME slots in addiction medicine. How do you see those investments addressing a national epidemic or public health crisis?
SN: I think those investments are critical. The opioid crisis has highlighted what a need there is for those trained to provide compassionate, evidence-based treatments in addiction medicine. We need investments like the Opioid Workforce Act to make it happen. The growth of addiction medicine programs nationally, including our program at Montefiore, began as a labor of love by the clinicians leading these programs and a labor of commitment by the health care institutions that are sponsoring them. Many of the programs that are seeking accreditation are funded through cobbled-together institutional support. All of these health systems are above the Centers for Medicare & Medicaid Services’ resident cap and don’t have other sources of funding for these fellowship programs. I think the Opioid Workforce Act is critical for long-term support of these programs.
AA: Do you have any advice for program directors who are interested in starting a specialty fellowship in addiction medicine?
SN: Programs should go for it. We have been fortunate to have clinicians across our system who have very enthusiastically responded to our requests for their wisdom, their time, and their labor, so I would advise leveraging the expertise and passion of your colleagues. It’s a huge, collective effort, and a very rewarding one.