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Addiction Medicine

Author

Mary Billington, MD 
Emergency Medicine Resident
University of Texas Southwestern

Faculty Editor

Henry Swoboda, MD
Assistant Professor of Emergency Medicine & Psychiatry
Rush Medical College

Special thanks to our 1st edition writing team

Kathryn Hawk, MD, MHS
Gail D'Onofrio, MD, MS, FACEP
Jeanette Tetrault, MD

INTRODUCTION

Description of the specialty 
Addiction medicine physicians work in clinical medicine, public health, educational, and research settings to advance the prevention and treatment of addiction and substance-related health conditions, as per the Addiction Medicine Foundation (AMF, formerly the American Board of Addiction Medicine or ABAM) Scope of Practice.

The 2014 National Survey on Drug Use and Health demonstrated that of the 21.2 million Americans who needed treatment for substance use disorders, only about 10% had received specialized treatment services. Though many barriers to treatment exist, one barrier to adequate treatment opportunities is a shortage of physicians with specialized training in addiction medicine. Other challenges arise from insufficient training in medical schools and graduate medical education, leading to limited appreciation of the biological mechanism of addiction and its foundation in the bio-psycho-social framework. According to the Addiction Medicine Foundation, there are 55 approved addiction medicine fellowships in 27 states and the District of Columbia. This number continues to grow. The AMF holds a goal of supporting 65 fellowship programs by 2020, and 125 by 2025.  

Emergency departments are often the only point of contact with the health care system for many out-of-treatment patients with active substance use and with substance use disorders, which highlights the importance of ED-based programs that provide screening, brief intervention, and referral to treatment (SBIRT), overdose prevention education, or otherwise facilitate treatment enrollment.

History of the specialty/fellowship pathway
Addiction medicine has had a seat in the American Medical Association House of Delegates since 1988, and it was recognized as a “self-designated specialty” in 1990. The American Society of Addiction Medicine (ASAM) supervised certification in addiction medicine from 1984-2008. In 2009, the ABAM assumed supervision of the certification, and it transitioned from being a certification by specialty society to a board certification. In March 2016, the American Board of Medical Specialties (ABMS) recognized addiction medicine as a subspecialty under the American Board of Preventative Medicine (ABPM), beginning the final step to becoming an ACGME approved specialty. The first board exam in Addiction Medicine was administered in 2017, and is currently administered yearly in the fall. Addiction psychiatry was recognized by ABMS as a subspecialty in 1991 and maintains an independent board certification process through the American Board of Psychiatry and Neurology.

As addiction medicine transitions to an ACGME recognized subspecialty under the purview of preventive medicine, a full 1-year fellowship training program will be required following completion of a primary specialty residency. Some fellowships offer an additional year of research or other scholarly training in addiction medicine. A written exam is required for board certification. Additional training avenues exist today, but these will be closed after the grandfathering period, which ends in 2022.

Why residents choose to follow this career path
Emergency physicians with an interest in prevention of unhealthy substance use and in the treatment of substance use disorders both during and after an ED visit are most likely to pursue this pathway. Addiction medicine fellowships provide specific training for clinicians regarding the knowledge and skills required to provide clinical care for patients with substance use disorders.

How do I know if this path is right for me?
If you have a specific interest in providing care for and improving the lives of patients affected by substance use and substance use disorders, and you are considering additional training, this path may be for you.

Career options after fellowship
Depending on specific skills and training obtained during your fellowship, you may work in a variety of clinical, policy, and research settings. Many academic emergency departments prefer to hire fellowship-trained faculty, and if you are drawn to addiction medicine, a fellowship can provide you the skills and experience to establish your niche in emergency medicine. Other opportunities can be found at specialized treatment centers, private practice, government agencies, consulting, and in health policy.

Splitting time between departments
This can likely be arranged if desired, depending on departmental funding and staffing. Training in addiction medicine will equip you to provide clinical care for patients at a variety of inpatient and outpatient addiction treatment settings.

Academic vs. community positions
Many physicians taking this route will take academic positions, although the need for addiction specialists is significant, and community/private practice options will be available.

IN-DEPTH FELLOWSHIP INFORMATION

Number of fellowship programs
There are 55 AMF certified fellowship programs as of 2018, each with 1-4 training slots per year. AMF addiction medicine fellowships focus on the clinical care of patients with substance use disorders and many have an additional research component. A comprehensive document containing helpful information about each program may be found at https://www.addictionmedicinefoundation.org.  

Another option that would not result in addiction medicine board certification but would provide enhanced training is to pursue either a general research or an injury prevention fellowship with a focus on substance use or addiction medicine. Additional information can be found in the chapters for the respective fellowships. 

Finally, other options to gain research training in addiction medicine include institutional K awards such as Yale University’s 3 year NIDA-funded Drug Abuse, Addiction and HIV Scholar K12 Program (DAHRS), the National Clinical Scholars Program (NCSP), or individual K awards. One would need to investigate how to integrate this training into the clinical requirements to be able to apply for the board examination

Differences between programs
Within AMF certified addiction medicine programs, wide variation exists with regard to specific rotations, clinical training opportunities, and research requirements, although all programs provide a firm foundation in clinical addiction medicine. Individual program requirements will vary based on how the fellowship is funded and structured, as well as the clinical needs of the affiliated program. Core rotations include outpatient treatment, inpatient treatment, and detoxification. Fellowships may offer a special focus on adolescent substance use prevention.

If you pursue a research fellowship, the DAHRS or NCSP program, or an injury prevention fellowship, you may not receive significant training in clinical addiction medicine, and will likely not be eligible to sit for board certification.

Length of time required to complete fellowship
Most are 1-2 years. Generally, one year of clinical work is required for ABMS board certification, with some programs offering the potential for an additional research year.

Skills acquired during fellowship
This is highly variable across types of fellowships. The clinical addiction medicine fellowships focus on the clinical care and treatment of substance use disorders. Many fellowships also offer research or education training skills.

Typical rotations/curriculum
Traditional addiction medicine fellowships likely will focus on in- and out-patient management of substance use disorders. Research-focused addiction medicine fellowships may be largely research, with clinical EM, and little to no time working in specialized treatment centers.

Board certification after Fellowship
The American Board of Medical Specialties has recently recognized addiction medicine as a multidisciplinary subspecialty. Board certification is regulated by the American Board of Preventative Medicine. Currently there are three pathways to board certification, however, by 2022, all candidates will be required to complete a fellowship training program prior to sitting for the board examination. Current ABAM diplomats and addiction medicine practitioners meeting specific requirements may be eligible for board certification via “grandfathering” prior to 2022. The current specific requirements are delineated by the ABPM and can be found online at https://www.theabpm.org/

Average salary during fellowship
Salary varies depending on the program, but may be less than traditional EM-based fellowships. Some programs may allow moonlighting.

PREPARING TO APPLY

How competitive is the fellowship application process?
Traditional addiction medicine fellowship slots may go unfilled, although competitiveness varies by program. DAHRS and NCSP are small programs that usually have a very competitive application pool.

Requirements to apply
Graduation from an ACGME approved residency is generally required, although some programs will consider AOA trained applicants. Some addiction medicine programs may not be open to residents trained in EM, although most will consider EM trained applicants. Check individual program materials for specific program details.

Research requirements
Research expectations vary by program. Prior research experience and publications will be expected for most research-based fellowships.

Suggested elective rotations to take during residency
Rotations in toxicology, addiction medicine, injury prevention, or a research elective with a substance abuse focus may be helpful.

Suggestions on how to excel during these elective rotations
You will find allies who can foster specific exposures, experiences, and connections if you pursue these rotations as a motivated learner with a focused interest in addiction medicine.

Should I complete an away rotation?
Away rotations are not necessary, but may be helpful for gaining experiences that are not available at your own institution.

What can I do to stand out from the crowd?
Performing relevant away rotations and electives, publications in the realm of addiction medicine, and involvement in national organizations will make you an exceptional candidate.

Should I join a hospital committee?
This is not necessary, however, this type of experience could be very helpful in shaping your views of the benefits, challenges, and nuances intrinsic to the clinical practice of addiction medicine. It may help you establish connections within your community and the field, establish interest, round out your application, and most importantly, may allow you the opportunity to start making an impact in your community.

Publications other than research
Publications are generally viewed favorably, but not necessary for most addiction medicine fellowships.

How many recommendations should I get? Who should write these recommendations?
Requirements will vary by program. Plan to provide 3 letters of recommendations from individuals who have worked with you, who support your choices to pursue additional fellowship training, and who can attest to the qualities that will make you successful in research, policy or providing clinical care for patients with substance use disorders. One of these should be from your EM residency program director or chair.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, although you should use that time to expand on this interest and further explore this field of medicine.

What if I’m a DO applicant?
AOA trainee acceptance may vary from program to program; check individual program literature prior to applying. 

What if I am an international applicant?
There are no current barriers to international applicants.

APPLICATION PROCESS

How many applications should I submit?
This will be highly variable depending on which types of programs you choose. As a general rule, apply to as many programs as you can. Don’t apply to programs in locations where you don’t want to live or whose curriculum does not fit your career goals.

How do I pick the right program for me?
Talk to mentors, people in your field, and physicians who do the kind of work you are interested in pursuing. This route is a bit off the beaten path, so it’s about knowing what you want and finding a program whose needs fit with your goals.

Common mistakes during the application process
Contact program directors early and ensure eligibility prior to applying. Be sure to have your application submitted as soon as possible.

Application deadlines
Deadlines vary, but it is best to research programs as early as possible to find a program that suits you well. Keep an eye on changing deadlines and new opportunities as programs become accredited for new fellowships and increased numbers of training positions. You should reach out to programs you are interested in as early as possible in the application cycle to get the specifics of their application process, but some positions may go unfilled, so your application may be considered at any time.

Tips for writing your personal statement
This is your chance to convey who you are and why you are interested in addiction medicine. Explain not only what sparked your interest in this field, but also how you plan on contributing to this specialty as a whole.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
Depending on your exact interest, there is always another way to get involved. Reach out to your mentors, program directors, and physicians doing the kind of work you are interested in pursuing.

INTERVIEW PROCESS

How do I stand out from the crowd?
Your background in EM already sets you apart. Your job is to communicate how that can be an asset to the fellowship program and your career in addiction medicine.

What types of questions are typically asked?
Expect to discuss your past clinical training and interest in addiction medicine, and your goals/expectations for fellowship training and beyond.

How many interviews should I go on?
At least a handful, but this will vary based on your geographic preferences as well as the kind of program you are interested in.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Herron, A., & Brennan, T. K. (2015). The ASAM essentials of addiction medicine. Lippincott Williams & Wilkins.
  • Ries, R. K., Fiellin, D. A., Miller, S. C., & Saitz, R. (2014). The ASAM principles of addiction medicine. Lippincott Williams & Wilkins.

 

Important skills to practice while in residency to prepare for fellowship
Patient communication, motivational interviewing, empathy, and patient advocacy.

Tips on how to succeed as a fellow
Similar advice as with residency: show up early, work hard, be enthusiastic, and treat others as you would like to be treated.

CONCLUSION

Additional resources

Websites:

Journals: Addiction, Drug and Alcohol Dependence, Substance Abuse, Journal of Substance Abuse Treatment, Addiction Science & Clinical Practice

National organizations

Conferences
ASAM, AMERSA, and CPDD are all excellent annual meetings that offer competitive travel awards for those in training. These travel awards are an opportunity not only to offset the costs of attending the meeting, but also put you on the radar of experts in the field and provide additional mentorship opportunities. Applications for these are often due up to six months prior to the meetings.

How to find a mentor
This is crucial to your success in finding a fellowship that suits your needs. Look for experts who are doing the type of work or research you want to learn. If you are still defining your interests, cast a broad net and talk to several people with different backgrounds and foci in addiction medicine to see what appeals most. Use the internet, PubMed, and NIH Reporter to identify potential mentors. If your goal is to become an independently funded NIH researcher, find a mentor who has NIH funding. Remember that mentors do not need to be in the field of EM. Most people with expertise in addiction medicine are passionate about their work and are highly invested in the development of the field.