Residents’ Voices

Career Choices:

Saeed Ahmed, MD, and Cornel Stanciu, MD

Editor’s note: Career Choices features a psychia- interested in cessation. Through mentorship try resident/fellow interviewing a from addiction-trained faculty about why he or she has chosen a specific career members, I was able to get a taste of the neu- path. The goal is to inform trainees about the vari- robiologic complexities of the disease, some- ous psychiatric career options, and to give them thing that left me with a desire to develop a a feel for the pros and cons of the various paths. deeper understanding of the disease process. Witnessing strikingly positive outcomes with Saeed Ahmed, MD n this Career Choices, Saeed Ahmed, implementation of evidence-based treatment MD, talked with Cornel Stanciu, MD. modalities further solidified my path to sub- IDr. Stanciu is an addiction psychiatrist specialty training. Even during that early at Dartmouth’s Geisel School of , phase, because I expressed interest in manag- where he is an Assistant Professor, and serves ing these conditions, I was immediately put as the Director of Addiction Services at New in a position to share and disseminate any Hampshire . He provides support newly acquired knowledge to other special- to clinicians managing patients with addic- ties as well as the public. Cornel Stanciu, MD tive disorders in a multitude of settings, and also assists with policy making and delivery Dr. Ahmed: Could one manage addictive Dr. Ahmed is a PGY-4 Psychiatry Resident, Nassau University Medical of addiction care at the state level. He is also disorders with just general psychiatry train- Center, East Meadow, New York. the author of Deciphering the Addicted Brain, a ing, and what are the differences between Dr. Stanciu is Assistant Professor of Psychiatry, Dartmouth’s Geisel guide to help families and the general public the different paths to certification that a School of Medicine, Hanover, better understand addictive disorders. resident could undertake? New Hampshire, and Director of Addiction Services, New Hampshire Hospital, Concord, New Hampshire. Dr. Ahmed: What attracted you to pur- Dr. Stanciu: Addictive disorders fall under Disclosures sue training in addictive the general umbrella of psychiatric care. The authors report no financial disorders? Most individuals with these disorders relationships with any companies whose products are mentioned in exhibit some degree of mental illness. this article, or with manufacturers of Dr. Stanciu: In the early stages of my train- curriculum offers on aver- competing products. ing, I frequently encountered individuals age 2 hours of addiction-related didactics with medical and disorders during 4 years. General psychiatry train- whose treatment was impacted by underly- ing programs vary significantly in the type ing substance use. I soon came to realize any attempts at (for example) managing hyper- tension in someone with cocaine use disorder, LET YOUR VOICE BE HEARD or managing schizophrenia in someone with Current Psychiatry invites psychiatry residents ongoing cannabis use, were futile. Almost to share their views on professional or clinical all of my patients receiving treatment for topics for publication in Residents’ Voices. E-mail [email protected] for author mental health disorders were dependent on guidelines. Current Psychiatry tobacco or other substances, and most were Vol. 18, No. 3 33 Residents’ Voices

of exposure to addiction—some residencies Dr. Stanciu: I completed my fellowship train- have an affiliated addiction fellowship, oth- ing through Dartmouth’s Geisel School of ers have addiction-trained on Medicine, and the experience was tremen- staff, but most have none. Ultimately, there dously valuable. In evaluating programs, is great variability in the degree of comfort one of the starting points is whether you have in working with individuals with addic- interest in a formal research track, because tive disorders post-residency. Being able to several programs include an optional year prescribe for the treatment of for that. Most programs tend to provide addictive disorders is very different from exposure to the Veterans Affairs system. being familiar with the latest evidence-based The 1 year should provide you with broad recommendations and guidelines; the lat- exposure to all possible settings, all addictive ter is unlikely to be gleaned simply though disorders and patient populations, and all Clinical Point residency training. There are 2 routes to spe- treatment modalities, in addition to rigorous Training should cialization after residency: addiction psychi- didactic sessions. The ideal program should atry, and . The American include rotations through treat- include rotations Board of Psychiatry and (ABPN) ment centers, intensive outpatient programs, through methadone recognized as a sub- pain and interdisciplinary , detoxifica- centers, outpatient specialty in 1993. Since 1998, completion tion units, and centers for treatment of ado- programs, detox units, of a fellowship recognized through the lescent and young adults, as well as general Accreditation Council for Graduate Medical medical settings and infectious disease clin- pain clinics, and more Education has been required for board cer- ics. There should also be close collaboration tification. There are almost 50 programs with psychologists who can provide training nationwide with approximately 150 spots. in evidence-based therapeutic modalities. There is no match process for admissions; During this year, it is vital to expand your acceptance is based on a review of applica- knowledge of the ethical and legal regula- tion documents and a personal interview. tions of treatment programs, state and fed- Upon completion of this 1 year of training, eral requirements, insurance complexities, candidates sit for the certification exam, and requirements for privacy and protec- which is offered every other year. tion of health information. The size of these Addiction medicine is a fairly new route programs can vary significantly, which may initially intended to allow non-psychiatric limit the one-on-one time devoted to your specialties access to addictive disorders training, which is something I personally training and certification. This is offered valued. My faculty was very supportive of through the American Board of Preventive academic endeavors, providing guidance, Medicine. There are currently 2 routes to funding, and encouragement for attend- sitting for the exam: through completion of ing and presenting at conferences, publish- a 1-year addiction medicine fellowship, or ing papers, and other academic pursuits. through the “practice pathway” still avail- Additionally, faculty should be current with able until 2020. To be eligible for the latter, emerging literature and willing to develop individuals must provide documentation of or implement new protocols and evaluate clinical experience post-residency, which is new pharmacologic . Discuss this article at quantified as number of hours spent treating www.facebook.com/ patients with , plus any additional Dr. Ahmed: What are some of the career MDedgePsychiatry courses or training, and must be endorsed options and work settings for addiction by a certified addictionologist. psychiatrists?

Dr. Ahmed: What was your fellowship expe- Dr. Stanciu: Addiction psychiatrists work rience like, and what should one consider in numerous settings and various capaci- Current Psychiatry 34 March 2019 when choosing a program? ties. They can provide subspecialty care Residents’ Voices

directly by seeing patients in outpatient life through the use of and tobacco clinics or inpatient addiction treatment cen- is significant, and hence this is a large por- ters for detoxification or rehabilitation, or tion of the conditions I encounter. I have they can work with dual-diagnosis popu- also seen an abundance of marijuana use lations in inpatient units. The expansion of due to decreased perception of harm and telemedicine also holds promise for a role increased access. through virtual services. Indirectly, they can serve as a resource for expertise in the field Dr. Ahmed: What are some of the challenges through consultations in medical and psy- in working in this field? chiatric settings, or through policy making by working with the legislature and public Dr. Stanciu: Historically, funding for ser- health departments. Additionally, they can vices has been an issue for clinicians work- help create and integrate new knowledge ing primarily with addictive disorders from Clinical Point into practice and educate future genera- the standpoint of reimbursement, patient Stigma associated tions of and the public. access to evidence-based pharmacotherapy, and ability to collaborate with existing lev- with addiction is a Dr. Ahmed: What are some of the prevalent els of care. In recent years, federal funding significant challenge disorders and reasons for consultation that and policies have changed this, and after you encounter in your daily practice? numerous studies have found increased CLASSIFIEDS cost savings, commercial insurances are MDedge.com/Psychiatry ■ Also available at MedJobNetwork.com Dr. Stanciu: This can vary significantly providing coverage. A significant challenge depending on the setting, geographical region, and demographics of the popula- tion. My main non-administrative responsi- bilities are primarily consultative assisting clinicians at a 200-bed to address co-occurring addictive disor- ders. 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 or other forms of medi- cation-assisted treatment. I work closely with licensed and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment refer- rals. Clinicians in longer term units may consult on issues related to pain manage- ment in individuals who have addictive disorders, the use of evidence-based phar- macologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific of abuse, although opi- oids 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

December 2018 ■ 18 ■ Clinical Psychiatry News Residents’ Voices

also has been public stigma and dealing combined with increased insurance reim- with a condition that is relapsing-remitting, bursement should prompt research and poorly understood by other specialties and new drug development. Some promising the general public, and sometimes labeled as agents are already in the pipeline. Research a defect of character. Several efforts in educa- into molecular and gene as a way to tion have lessened this; however, the impact better individualize care is also underway. still takes a toll on patients, who may feel Going forward, I think we will also ashamed of their disorder and sometimes encounter a different landscape of drugs. are hesitant to take medications because Synthetic agents are emerging and increas- they may believe that they are not “clean” ing in popularity. Alarmingly, public if they depend on a for remis- perception of harm is decreasing. When sion. Lastly, recent changes in marijuana it comes to cannabis use, I see a rise in Clinical Point policies make conversations about this drug pathologic use and the ramifications of this The American quite difficult because patients often view it will have a drastic impact, particularly on as harmless, and the laws governing legal- patients with mental health conditions. Academy of Addiction ity and indications for therapeutic use are We will need to undertake better efforts in Psychiatry has a slightly ahead of the evidence. monitoring, staying updated, and provid- robust mentorship ing public education campaigns. system Dr. Ahmed: In what direction do you believe the subspecialty is headed? Dr. Ahmed: What advice do you have for trainees contemplating subspecialty train- Dr. Stanciu: Currently, there are approxi- ing in addiction psychiatry? mately 1,000 certified addiction psychiatrists for the 45 million Americans who have addic- Dr. Stanciu: I cannot emphasize enough the tive disorders. Smoking and other forms of importance of mentorship. The American tobacco use pose significant threats to the Academy of Addiction Psychiatry has a 2020 Healthy People Tobacco Use objectives. robust system for connecting mentees with There is a significant demand for addictio- mentors at all stages in their careers. This nologists in both public and private sectors. can be extremely helpful, especially in situa- As with mental health, demand exceeds tions where the residency program does not supply, and efforts are underway to expand have addiction-trained faculty or rotations downstream education and increase access through treatment centers. Joining such to specialists. Several federal laws have been an organization also grants you access to put in place to remove barriers and expand resources that can help further your enthu- access to care and have paved the way to a siasm. Those interested should also famil- brighter future. One is the Affordable Care iarize themselves with currently available Act, which requires all insurances includ- pharmacotherapeutic treatments that have ing Medicaid to cover the cost of treatment. evidence supporting efficacy for various Second is the Mental Health Parity and addictive disorders, and begin to incorporate Addiction Equity Act, which ensures that these medications into general mental health the duration and dollar amount of coverage practice, along with attempts at motivational for substance use disorders is comparable to interviewing. For example, begin discussing that of medical and surgical care. with patients who have comor- Another exciting possibility comes from bid alcohol use disorders and are interested the world of pharmaceuticals. Some medi- in reducing their drinking; and cations have modest efficacy for addressing with patients who smoke and are interested addictive disorders; however, historically in quitting. The outcomes should automati- these have been poorly utilized. Enhanced cally elicit an interest in pursuing further Current Psychiatry 36 March 2019 understanding of the neurobiology training in the field!