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Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
