Substance Use Disorders CORE PCIM Rotation

Lesson Plan
Substance Use Disorders Core PCIM Rotation

Optimizing care for patients with substance use disorders

Summary

1. Subject(s): Alcohol use disorders, Opiate use disorders, 

2. Objectives: 

   1. By the end of this rotation, the resident should have basic competency in the skills of: motivational interviewing to engage patients in behavior change conversations in a non-judgemental way, creating collaborative effective treatment plans

   2. Residents will also have basic understanding of common medications used to treat substance use disorders, the impact of trauma and social determinants of health as they impact substance use disorders, and methods to utilize systems-based resources to support the care of patients with substance use disorders

   3. The resident will rotate through the following outpatient experiences: Office based addiction practice, Opioid treatment program, Substance use Disorders Central Intake Unit / Walk In Clinic, and an inpatient addiction consultation service.

Adult Learning Tip: What do you know about these topics?  Have you cared for patients needing these procedures?  What questions have come to mind?  How could you integrate these procedures into your practice?  Use your questions as conversation starters to introduce to your subspecialty faculty as you get to know them over the next few weeks.

3. Time Allotment: A dedicated 2-week section of an X block for a focused learning experience.  

Materials & Resources

Adult Learning Tip: Use the resources below to familiarize yourself with the supplies, steps and techniques involved so you can have a more nuanced learning experience when you are on the rotation.  

Resources:

1. Modules

   1. Addiction Medicine PEAC Hopkins Module

2. MKSAP

   1. Chief created quizzes

   2. System based chapters / reviews

3. Videos & Websites & Podcasts

   1. The Curbsiders - Addiction Medicine Podcast - The Curbsiders 

   2. Journal of Addiction Medicine: Beyond the Abstract Podcast https://journals.lww.com/journaladdictionmedicine/pages/podcastepisodes.aspx?podcastid=1 

   3. National Institute on Drug Abuse (NIDA) 

      1. Clinical Resources NIDAMED: Clinical Resources | National Institute on Drug Abuse (NIDA)

      2. NIDA Learning Modules Science to Medicine: A CME/CE Activity | National Institute on Drug Abuse (NIDA)

      3. Director of NIDA Nora’s Volkow’s Blog Nora's Blog | National Institute on Drug Abuse (NIDA)

   4. Substance Abuse and Mental Health Services Administration (SAMHSA)Practitioner Training and Resources: Substance Use Disorder | SAMHSA

4. Readings

   1. EDUCATIONAL PAGES

      1. Addiction 101. The Recovery Research Institute provides a comprehensive overview of the epidemiology (prevalence), etiology (causes), phenomenology (experience), impact and the latest terminology on addiction.

      2.  The Brain in Recovery. The Recovery Research Institute’s educational page on the brain in recovery, citing the long-term impacts of substance use disorder on brain functioning and circuitry.

      3. Nature Outlook: Addiction. Read about the latest advances in addiction research in a special Nature supplement, co-sponsored by the National Institutes of Health’s National Institute on Drug Abuse (NIDA) and the National Institute of Alcohol Abuse and Alcoholism (NIANature Outlook: AddictionAA).

      4. The American Society Addiction Medicine (ASAM) defines addiction as a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Read the full Public Policy Statement and FAQs.

      5. Drugs, Brains, and Behavior: The Science of Addiction. The National Institute on Drug Abuse.  (NIDA)’s publication provides an overview of the scientific research evaluating substance use and addiction, including the identification of biological and environmental factors and an introduction to the search for the genetic variations that contribute to the development and progression of the disease.

      6. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health is an exhaustive report with much of value, Chapter 2: The neurobiology of Substance Use, Misuse, and Addiction is especially useful for developing foundational understanding of the brain disease model of substance use disorder.  It describes the brain circuits involved in addiction, and how substance use can lead to dysregulation of their functioning.

      7. Americans Recognize the Growing Problem of Opioid Addiction. The Associated Press NORC Center for Public Affairs Research provides this Issue Brief on the findings of AP-NORC Poll on Opioids.  Notably, while more than half (53%) view prescription drug addiction as a “disease”, only 20% would closely associate with someone “suffering from addiction”.

      8.  DSM-5 Fact Sheet. In May 2013, the American Psychiatric Association issued the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). Although there is considerable overlap between DSM–5 and DSM–IV, the prior edition, there are several important differences, outlined here.

      9. “Addiction Is a Disease of Free Will”. A video presentation in which Dr. Nora Volkow, Director of NIDA, addresses the question of why addiction is a disease, and how addiction as a disease impairs the free will and decision-making abilities of those affected.

   2. COMMENTARY

What does it mean when we call addiction a brain disorder? 

1. In this Scientific American magazine article, NIDA Director Nora Volkow reviews the foundation for and progress of the concept of addiction as a brain disease over the past three decades, beginning with brain imaging evidence early in her career at NIDA, which helped to solidify the scientific basis of the disease model. Dr. Volkow responds to critics of the disease model and cites its benefits in driving a public health- focused response to increase access to treatment and reduce stigma.

2.  Neurobiologic advances from the brain disease model of addiction. This commentary, authored by NIDA Director Dr. Nora Volkow, NIAAA Director Dr. George Koob, and Thomas McLellan, reviews scientific advances in the neurobiology of addiction, including prevention and treatment strategies, as well as related developments in public policy.

3.  Brain disease model of addiction: Why is it so controversial? This commentary (Volkow & Koob, 2016) cites the scientific evidence for and advantage of the brain disease model of addiction. The commentary is a direct response to the criticism published by Hall, Carter, and Forlini (2015).

4. The development and maintenance of drug addiction. Authors Wise and Koob (2014) seek to come to a consensus on the defining property of addiction. While agreeing on its early and late stages, they describe their differing views as to “(i) the point…at which the diagnosis of addiction should be invoked, (ii) the relative importance of positive and negative reinforcement leading up to this transition, and (iii) the degree to which the specifics of negative reinforcement can be generalized across the range of addiction agents”.

5. What is a disease? Scully (2004) examines the philosophical definition of a disease, citing increasing health evidence and expectations as well social and economic factors which underlie the historical changes to the disease criteria: “If we want to ensure that limited healthcare resources are appropriately distributed…we must have a reasonably clear idea, first what a disease is, and second, which diseases are most worth the investment of time and money”.

3. JOURNAL ARTICLES

   1. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale. This article presents the issues considered by the Substance-Related Disorders Work Group in making recommendations for proposed DSM-5 changes and revisions, including the determination of combining substance abuse and dependence and establishing SUD severity levels (a departure from the DSM-4).

   2. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. This literature review (McLellan, Lewis, O’Brien, & Kleber, 2000) compared substance use disorders to type 2 diabetes, hypertension, and asthma on the parameters of etiology, pathophysiology, and treatment response, concluding that substance use disorders should be insured, treated, and evaluated in the same way as other chronic illnesses.

   3. Considering the Definition of Addiction. Authors Sussman and Sussman (2011) conduct a literature search to determine the definition of addiction, landing on and further defining five common elements: (1) feeling different; (2) preoccupation with the behavior; (3) temporary satiation; (4) loss of control; and, (5) negative consequences.

   4.  Evaluating, managing, and treating substance use disorders like other chronic health conditions. The authors (Dupont, Compton, & McLellan, 2015) describe how the treatment of addiction to alcohol and other drugs has been conceptually, organizationally, and financially segregated from the rest of health care, and advocate for a consensus on a consensus on how to measure and manage addiction services and for judging the effectiveness and value of addiction services based on the goal of five-year recovery. 

Assessment

At the end of your rotation, your faculty subspecialty attendings will be asked to complete an evaluation on your performance.  This will reflect your progress on the objectives outlined above.  You will have an opportunity to evaluate our rotation as well - we look forward to specific feedback which will help us grow and improve these experiences going forward!