The consequences of people being addicted to alcohol, illicit drugs, and tobacco is costly to our nation, exacting more than $740 billion annually in costs related to crime, lost work productivity, and health care.1 We are amid an opioid epidemic, yet there is a significant dearth of addiction psychiatrists who can provide the medication-assisted treatments that have been shown to decrease opioid morbidity and mortality.2 Addiction psychiatry fellowships offer specialized training in the evaluation and management of patients with addictions and co-occurring mental health disorders. Recruiting more specialists to the field of addiction psychiatry is a critical health care need.
Addiction is a global phenomenon.3 It affects rich and poor nations, developed and developing countries. In the United States, opioid overdose deaths continue to rise. Although the startling number of opioid-related deaths has received much attention, it is critical to remember the effect of other substance use disorders. An estimated 16 million Americans meet criteria for alcohol use disorders and an additional 40 million demonstrate unhealthy or high-risk drinking.4 The current prevalence of smoking is 15.1%, which means that 40 million people in the country are addicted to nicotine. The emergence of newer tobacco delivery products (primarily “e-cigarettes” but also other electronic nicotine delivery systems) has increased the rates of nicotine use among adolescents5 and threatens the 2020 Healthy People Tobacco Use Objectives.6 Of the roughly 23 million Americans who suffer from alcohol and drug use disorders, only 11% receive treatment at a specialty facility.7 Thus, millions of Americans have substance use disorders, and the vast majority of patients with addictions do not receive specialized care from an addiction psychiatrist.
Addiction psychiatry, a recognized subspecialty of psychiatry, is an exciting area of practice that involves working with a challenging and complex illness. The field focuses on the evaluation, diagnosis, and management of patients struggling with addictive disorders, including those involving illicit drugs, prescription medications, gambling, sex, food, shopping, and the Internet. As a further layer of complexity, patients with addictions often have other co-occurring mental health disorders that also require psychiatric care. Addiction psychiatry fellowship training provides physicians with the knowledge and skill to care for these patients who have complicated addictions. Fellowship-trained physicians serve the public by providing subspecialty care, acting as a community resource for expertise in their field, creating and integrating new knowledge into practice, and educating future generations of physicians.
Given the permeability of addictive disorders in most aspects of mental health treatment, additional training in addictions expands the knowledge base of the physician so that he or she can provide high-quality, evidence-based care, making the physician more confident and effective. Most residents choose to pursue this training due to their inherent interest in this field, often spurred by patient interactions during training or personal (family, friend) experiences with addictions. There is a tremendous potential for research in all aspects of addictions, ranging from molecular and gene therapy to pharmacotherapy and public health studies.
Although the field of addiction psychiatry has existed for many years, the designation of addiction psychiatry as a subspecialty of psychiatry occurred relatively recently. The American Board of Psychiatry and Neurology (ABPN) is one of 24-member boards of the American Board of Medical Specialties (ABMS). In October 1991, ABPN and the ABMS, with support from the American Psychiatric Association, established a “Committee on Certification of Added Qualifications in Addiction Psychiatry,” and “Addiction Psychiatry” was granted subspecialization status in 1993. In 1997 the committee was renamed the “Committee on Certification in the Subspecialty of Addiction Psychiatry” and became more geared toward developing the subspecialty of addiction psychiatry. Since 1998, completion of an Accreditation Council for Graduate Medical Education (ACGME) recognized addiction psychiatry fellowship has been required for completion of the ABPN board certification examination in addiction psychiatry. Presently there are 49 addiction psychiatry programs that have ACGME recognition with a total of 129 positions.8
Fellowship Application Process
Addiction psychiatry fellowships are generally 1-year of clinical training; however, some programs offer a 2-year fellowship in which the second year is research focused. Residents interested in pursuing training in addiction psychiatry are encouraged to begin learning about programs 18 months in advance of the anticipated fellowship start date, typically midway through the third year of general psychiatry residency training. Like general psychiatry residency programs, addiction fellowship programs have a similar core training structure; however, some offer specialty experiences like exposure to adolescent addictions or perinatal addictions, and others may offer training specifically in addiction therapy or research. Interested applicants can learn more about programs by talking to peers and mentors informally at conferences or other venues. A full listing of addiction psychiatry residency programs is available on the website of the American Academy of Addiction Psychiatry (AAAP; https://www.aaap.org/jobs-fellowships/), and the AAAP staff and members of the AAAP Education Committee ( https://www.aaap.org/about/committees/) are an additional resource for learning about fellowship programs.8
Programs generally start accepting applications in late spring (14 to 15 months before anticipated fellowship start date), with typical applicants submitting applications at the end of post-graduate year 3 or the beginning of post-graduate year 4. The application is similar in content to what is used for the residency application (eg, personal statement, CV, letters of recommendation, including one from the applicant's general psychiatry training director, and other documents listed on the program websites). Strong applications will demonstrate interest in and experience with addiction beyond the 1 month of addiction training required for all general psychiatry residents. This level of interest may be demonstrated by additional clinical rotations, holding positions on committees related to addictions, involvement in teaching or advocacy activities, writing journal commentaries or textbook chapters, involvement in research projects, or involvement at an addiction psychiatry conference. The application is submitted directly to the fellowship program, as there is no common application service or match for addiction psychiatry fellowships. Applicants typically apply to 2 to 5 programs, as it is typically not difficult to secure a fellowship position. However, reputable programs and/or programs in attractive geographical locations can be more competitive. After review of the completed application by the fellowship training director, appropriate candidates are then invited to interview. On the interview day, the applicant typically receives an overview of the program by the training director and will meet with several faculty members and ideally with at least one current fellow. Although some fellowship programs offer rolling admissions in which a candidate may be offered a fellowship position shortly after the interview, other programs do not make any offers until all applicants have been interviewed. Applicants must successfully complete their general psychiatry residency training before starting addiction psychiatry fellowship. Some programs prefer that applicants have completed the 8-hour Drug Addiction Treatment Act 2000 waiver training to prescribe buprenorphine prior to beginning fellowship; some programs also prefer that fellows are fully licensed to practice medicine by the state medical board at the beginning of fellowship.9
The Fellowship Year
Fellowship training includes developing knowledge in the biological basis for addictions, pharmacology of abused substances, medically assisted withdrawal treatment (“detox”), pharmacotherapy for addiction and comorbid psychiatric disorders, including medically assisted treatment with methadone and buprenorphine for opioid use disorders, and psychotherapeutic techniques. Fellows also gain knowledge in important ethical and legal regulations specific to addictions, including regulation of opioid treatment programs (OTP; ie, “methadone clinics”), relevant state/federal regulations, documentation requirements and insurance complexities, and the Code of Federal Regulations 42 rules regarding privacy and protected health information for substance abuse treatment. In addition, fellows gain experience in working with interdisciplinary teams composed of chemical dependency counselors, social workers, nurses, and psychologists. Programs vary in their available resources and settings but typically include inpatient units, detoxification centers, residential units, outpatient substance abuse clinics, outpatient buprenorphine clinics, OTPs with methadone and/or buprenorphine, inpatient or outpatient women's or adolescent addiction units, exposure to pain management, HIV/hepatitis C treatment, addictions consultation, research, and psychotherapy.9 All fellowships will include formal didactic experience. ACGME requires fellows to complete two scholarly projects during their year of training. These scholarly projects include participation in grand rounds, posters, workshops, articles, publications, or book chapters.10
Fellowship graduates typically pursue certification in addiction psychiatry through the ABPN. Graduates from an ACGME-accredited addiction psychiatry fellowship training program are eligible to sit for the subspecialty examination in addiction psychiatry after they have passed their general psychiatry boards.9 The addiction psychiatry examination is offered every other year.
Developing an Addiction Psychiatry Fellowship Program
Most of the requirements for an addiction psychiatry fellowship are similar to those for other ACGME-recognized training programs and are detailed in the ACGME Common Program Requirements (Fellowship);11 a brief overview of the requirements is provided here. Notably, the fellowship program must have appropriate faculty for training fellows, including at least two faculty members with subspecialty certification in addiction psychiatry, one of whom must be the program director. The addiction psychiatry fellowship program must be sponsored by an ACGME-accredited sponsoring institution. The sponsoring institution is the organization or entity that assumes the ultimate financial and academic responsibility for the fellowship program consistent with the ACGME institutional requirements. Together, the program and the institution must ensure an appropriate and safe environment for training: access to food while on duty; safe, quiet, clean, and private sleep/rest facilities available and accessible for fellows with proximity appropriate for safe patient care; clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care; security and safety measures appropriate to the participating site; and accommodations for fellows with disabilities consistent with the sponsoring institution's policy. The sponsoring institution and program must also provide ready access to subspecialty-specific and other appropriate reference material in print or electronic format. This must include access to electronic medical literature databases with full-text capabilities. The fellowship program, in partnership with its sponsoring institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents (if present), fellows, faculty members, senior administrative staff members, and other relevant members of its academic community.
The fellowship program is responsible for identifying and establishing relationships with appropriate training sites. The program, with approval of its sponsoring institution, must designate a primary clinical site. When the sponsoring institution is not a rotation site for the program, the most commonly used site of clinical activity for the program is the primary clinical site. A participating site is an organization providing educational experiences or educational assignments/rotations for fellows. Participating sites should reflect the health care needs of the community and the educational needs of the fellows. A wide variety of organizations may provide a robust educational experience and, thus, sponsoring institutions and participating sites may encompass inpatient and outpatient settings including a university, a medical school, a teaching hospital, a nursing home, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner's office, an educational consortium, a teaching health center, a physician group practice, a federally qualified health center, or an educational foundation. There must be a program letter of agreement (PLA) between the addiction psychiatry fellowship program and each participating site that governs their relationship. The PLA must be renewed at least every 10 years and be approved by the designated institutional official (DIO). The program must monitor the clinical learning and working environment at all participating sites. At each participating site there must be one faculty member, designated by the program director, who is accountable for fellow education for that site, in collaboration with the fellowship program director. The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all fellows, of 1-month full-time equivalent or more through the ACGME's Accreditation Data System. The program's educational and clinical resources must be adequate to support the number of fellows appointed to the program. The clinical learning environment has become increasingly complex and often includes care providers, students, and post-graduate residents and fellows from multiple disciplines. Ideally, the presence of these practitioners and their learners enriches the learning environment. Programs have a responsibility to monitor the learning environment to ensure that fellows' education is not compromised by the presence of other providers and learners, and that fellows' education does not compromise core residents' education.
The program director (PD) is a critical component of any addiction fellowship. In recognition of this critical role, the ACGME mandates that a single individual is designated as the PD and that the PD must have subspecialty designation in addiction psychiatry. The PD is appointed by the institution after approval by the institutional graduate medical education committee (GMEC), and final approval of PD resides with the ACGME Residency Review Committee. The fellowship PD is responsible for the design and conduct of the program in a fashion consistent with the needs of the community, the mission of the sponsoring institution, and the mission of the program, with the ultimate goal of training physicians to provide high-quality care to patients with addictions. The PD must have dedicated time for the leadership of the fellowship, and the PD is responsible for communicating with the fellows, faculty members, DIO, GMEC, and the ACGME. The PD, as the leader of the program, must administer and maintain a learning environment conducive to educating the fellows in each of the ACGME competency domains and the ABPN milestones for addiction psychiatry. The PD must also serve as a role model to fellows. The PD should display the traits that are expected of fellows including compassion, integrity, respect for others, outstanding professionalism, high quality patient care, educational excellence, and a scholarly approach to work. The PD is responsible for creating an environment where respectful discussion is welcome, with the goal of continued improvement of the educational experience for fellows and faculty.
The ACGME recently revised the fellowship eligibility requirements that will take effect July 1, 2019. All required clinical education for entry into ACGME-accredited fellowship programs must be completed in an ACGME-accredited residency program, an American Osteopathic Association-approved residency program, a program with ACGME International (ACGME-I) Advanced Specialty Accreditation, a Royal College of Physicians and Surgeons of Canada accredited program, or a College of Family Physicians of Canada accredited residency program. The ACGME Review Committee has also expanded the definition of “scholarly activity” by including nontraditional forms of scholarly work. Under this revision, faculty participation in grand rounds, posters, workshops, quality improvement presentations, podium presentations, grant leadership, nonpeer-reviewed print/electronic resources, articles or publications, book chapters, textbooks, webinars, service on professional committees, or serving as a journal reviewer, journal editorial board member, or an editor for a peer-reviewed publication. In addition, in the new Common Program Requirements, the scholarly activity of programs will be judged as a whole rather than simply counting scholarly activity among core faculty.10
Addiction psychiatry is an expanding field, and currently there is a high demand for this specialty in both the private and public sector. As of Fall 2017, there are 1,098 active certified addiction psychiatrists in the US,8 a small number compared to the estimated 23 million Americans in need of treatment for drug and alcohol addictions. Two recent federal laws have expanded treatment access for addictive disorders. The Affordable Care Act, for the first time in US history, requires all insurers, including Medicaid, to cover the treatment of drug and alcohol addiction.12 For anyone with insurance coverage, the Mental Health Parity and Addiction Equity Act ensures that the duration and dollar amount of coverage for substance use disorders is comparable to coverage for medical and surgical care.13 Together, the two federal laws are expected to make billions of dollars available to the behavioral health care market. The shortage of addiction psychiatrists threatens to stall a national movement to bring the prevention and treatment of substance use disorders into the mainstream of American medicine at a time when millions of people with addictions have a greater ability to pay for treatment thanks to expanded coverage14 and increases the risk of patients receiving substandard, non–evidence-based treatment for addictions.
- National Institute of Drug Abuse. Trends & statistics. https://www.drugabuse.gov/related-topics/trends-statistics. Accessed October 8, 2018.
- Cousins G, Boland F, Courtney B, Barry J, Lyons S, Fahey T. Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study. Addiction. 2016;111:73–82. doi:. doi:10.1111/add.13087 [CrossRef]
- United Nations Office on Drugs and Crime. World drug report 2016. https://www.unodc.org/wdr2016/. Accessed October 8, 2018.
- National Institute of Alcohol Abuse and Alcoholism. Alcohol facts and statistics. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics. Accessed October 22, 2018.
- Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314(7):700–707. doi:. doi:10.1001/jama.2015.8950 [CrossRef]
- Centers for Disease Control and Prevention. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use. Accessed October 22, 2018.
- Substance Abuse and Mental Health Services Administration. Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed October 22, 2018.
- American Academy of Addiction Psychiatry. Fellowship positions. https://www.aaap.org/clinicians/trainee-resources/fellowships/. Accessed October 22, 2018.
- Kumar N. Addiction psychiatry fellowship: how and why to apply. https://www.aadprt.org/application/files/1315/3624/6506/ADDICTION_PSYCHIATRY_FELLOWSHIP_HOW_AND_WHY_TO_APPLY.pdf. Accessed October 22, 2018.
- Accreditation Council for Graduate Medical Education. Common program requirements for one-year fellowships. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/One-Year_CPRs_2017-07-01.pdf. Accessed October 22, 2018.
- Accreditation Council for Graduate Medical Education. ACGME program requirements (fellowship). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf. Accessed October 8, 2018.
- Buck JA. The looming expansion and transformation of public substance abuse treatment under The Affordable Care Act. Health Aff (Millwood). 2011;30(8):1402–1410. doi:. doi:10.1377/hlthaff.2011.0480 [CrossRef]
- Centers for Medicare & Medicaid Services. The Mental Health Parity and Addiction Equity Act (MHPAEA). https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html#Key%20changes%20made%20by%20MHPAEA. Accessed October 22, 2018.
- Vestal C. How severe is the shortage of substance abuse specialists. http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage-of-substance-abuse-specialists. October 8, 2018.