Addiction Psychiatry Training Within the State of Delaware

Humans across cultures have been consuming addictive substances for centuries, and the health, social, and economic consequences associated with use of these substances, whether legal or illicit, are certainly not new phenomena. Despite increasing knowledge regarding neurobiological changes that occur with substance use disorders (SUDs) and policy changes aimed at reducing the consequences of substance use in varying ways (ranging from criminalizing use of certain drugs to promoting harm reduction), SUDs remain a significant public health problem throughout the United States. According to the 2023 National Survey on Drug Use and Health (NSDUH), 48.5 million people aged 12 or older, over 17% of this population, met criteria for a substance use disorder in the past year.¹ SUDs range from mild to severe (addiction), and recent decades have been marred by increasing rates of death due to overdose (OD), often associated with opioids.² The U.S. Congress Joint Economic Committee estimated that opioid misuse and OUD cost the country close to $1.5 trillion in 2020, and that is not including the economic burden stemming from alcohol use disorder and other substance use disorders. Costs of health care, the criminal justice system, public safety, lost productivity, decreased quality of life and lives lost (such as due to overdose) all contribute to the economic toll of addiction.³ Despite increasing awareness that addiction touches individuals from all backgrounds and growing acceptance that compulsive use represents an aspect of a biological illness rather than a moral failing, many affected individuals do not receive potentially life-saving treatment. While there are a number of barriers to treatment – including but not limited to availability and accessibility of treatment, cost concerns, insurance coverage of services, and stigma – studies suggest that physicians’ limited knowledge and skills in the realm of addiction treatment contribute to limited use of evidence-based practices to identify, assess, and effectively treat patient with SUDs.⁴ Ensuring that all US medical schools provide sufficient training on recognizing, evaluating, and providing compassionate care to individuals with SUDs is a crucial step in providing our workforce with the knowledge and skills needed to address this public health crisis.

Delaware has not been spared from rising rates of SUDs and overdose deaths. In recent years Delaware has surpassed the national average in terms of SUD prevalence and overdose rates.^2,5 In 2017-2019, the annual average prevalence (among people aged 12 and older) of past-year substance use disorder was 9.6% in Delaware compared to a national average of 7.4% during that same time period.⁵ Our state has also suffered a higher rate of drug overdose deaths (many secondary to opioids) than the national average between 2011 and 2021. In 2021, there were 54.0 drug overdose deaths per 100,000 population in Delaware compared to 34.4 per 100,000 in the United States.⁵ While Delaware's strategic state-level policies are showing a positive impact on reducing overdose deaths in recent years, the success of these efforts is being tested by a critical shortage of healthcare providers.⁶ This scarcity of qualified professionals means that despite the state's commitment, many Delawareans struggling with substance use disorders (SUDs) continue to face significant barriers to accessing the care they need. In this opinion article we will explore some of the areas where medical training can be expanded to include treatment of substance use disorders and to improve access of care for the patients in the state of Delaware. We propose a multilayered approach to incorporate exposure to train future physicians who are empathetic, confident, and follow evidence-based care to treat SUD population.

1. Including a required addiction rotation as a core component for medical students. Integrating in depth knowledge and skill-based training for medical students will serve as a strong foundation for the future healthcare workforce. The curriculum should include evidence-based practices for the identification, intervention, and treatment of SUDs, including but not limited to approaches such as Screening, Brief Intervention, and Referral to Treatment (SBIRT) and motivational interviewing. The neurobiological basis of addiction and pharmacology of Medication Assisted Treatment should also be topics of discussion. This education will provide early career physicians, regardless of their specialties, with the basic tools to identify at risk patients and early withdrawal symptoms and to incorporate preventative strategies. Equipping physicians with these basic skills can facilitate brief intervention and timely referral from any medical office, which can potentially prevent overdose. Furthermore, the more healthcare settings that adopt these approaches, the greater the extent to which harm reduction can be achieved at a broader scale in the community.

2. Offering an Addiction rotation as a required block to training programs. Advocating for training programs, particularly primary care training residencies (Pediatrics, Family Medicine and Internal Medicine) to add a required Addiction rotation can have a significant impact in reducing the barriers to access to care. Hands on training during these rotations can substantially reduce the hesitancy to prescribe many life-saving medicines for this population at the primary care level (such as Buprenorphine, which evidence has shown can decrease risks of OD and relapse).⁷

3. Creating an addiction psychiatry training program. This is the last, but perhaps most critical, step to feedback into the cycle of training. The establishment of an addiction psychiatry fellowship in Delaware would be instrumental in recruiting and ideally retaining psychiatrists passionate about the specialty. In addition to serving as an opportunity for Delaware physicians to receive further addiction training, a fellowship could recruit other physicians to the area to provide care to our community throughout residency, and these trainees may choose to continue serving this population after completing fellowship. With more addiction specialists in Delaware, a critical mass could be achieved, which could open up the bottle neck of supply and demand. It would also naturally create a space of collaboration between medical centers, community treatments centers, health agencies, and even policy makers; the fellows could rotate through various care settings and, with the support of their faculty mentors, could learn how to effectively advocate for their patients by discussing barriers to treatment and exploring potential solutions with the state government agencies and policy makers. Furthermore, a training program could foster a culture of research and lead to more tailored and effective interventions specifically for the state.

The establishment of an Addiction Psychiatry fellowship in Delaware would be a meaningful step towards providing Delawareans with access to physicians equipped with the skills to treat SUDs and the comorbid psychiatric conditions that commonly accompany addiction. By proactively addressing the gaps in medical school and residency training, and by establishing a dedicated Addiction Psychiatry Fellowship program in Delaware, we can empower our future physicians with the knowledge, skills, and compassion necessary to effectively combat this public health epidemic.