Addiction Medicine Practice Pathway vs Fellowship

[deleted1025203]

FM PGY3 here,

I have interest in addiction medicine however I will be working a nocturnist gig next year. I see my home institution is starting an addiction medicine fellowship and will most definitely give them a holler however, how in the world would you go about getting boarded in addiction medicine through the practice pathway now that it is extended to 2025. Would I simply study up, do a few electives, then apply to jobs with caveat that they will need to give me some on the job training? Does anyone have any insight or experience in this realm?

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[Psychiatry1]

Psych PGY3 here also interested in addictions. From the website the impression I got was that as long as you can track meeting the required hours (which can include non patient care activities and general practice, that certainly helps) and be board certified, you can apply. I'm interested as well in seeing what the actual approval process will be like though

 

[deleted1089378]

I can address this. I am the CMO for a medium sized FQHC (Federally Qualified Health Center) serving the medically disadvantaged, re entry citizens (i.e. newly released prisoners and jail incarcerated) who often were in for drug related issues, the homeless population, undocumented residents, and indigent. We have a large population of those addicted to multiple substances including mainly methamphetamine and heroin. To better serve this growing population we instituted an MAT (Medication Assisted Treatment) program almost 3 years ago including buprenorphine and vivitrol as well as working with our behavioral health providers and LCSW providers for counseling. This program ramped up quickly and represented 5% of our daily census and moved up to over 30% within the next several years. We partnered with a national expert Addiction Medicine doctor.
I took the x waiver course and started suboxone treatments for patients. The patients are very, very appreciative as they are miserable being addicted and don't want to ever go back. Compliance is amazing, better than any patient group I have served.
The practice pathway process is extensive and please read the terms very closely. Few hours outside of direct MAT work qualify for the requirement of hours needed. They won't count weaning someone addicted to narcotics, pain management, or primary care hours of any significance. Almost 2 years into our MAT program I applied for the practice pathway and was rejected to sit for the exam.
I practiced another year as the program grew and was accepted last year to sit for the exam. I found out I passed on Monday and am dual boarded in ABPM Addiction Medicine and also ABFM.
The exam was much more difficult to study for than my recent recertification for ABFM likely because I didn't do a residency/fellowship in it. Not only did it include opioid use, methamphetamine, club drugs, gambling addiction, hallucinogens, and very detailed specific brain addiction pathways you probably don't remember since neuroanatomy (ventral tegmentum, nucleus acumbens, locus ceruleus, habenula, prefrontal cortex ventral aspect and lateral, etc and detailed info about neurotransmitters of each individual drug of which they are often multiple) - it is heavy on statistics and epidemiology because it is administered by the ABPM now. So break out those statistics books from freshman year in college.
Am I glad I did it? Yes. But it was a lot of studying since I didn't do a residency in it. But if you have a lot of MAT patients in your practice it is possible to gain similar experience.

 

[hallowmann]

I can address this. I am the CMO for a medium sized FQHC (Federally Qualified Health Center) serving the medically disadvantaged, re entry citizens (i.e. newly released prisoners and jail incarcerated) who often were in for drug related issues, the homeless population, undocumented residents, and indigent. We have a large population of those addicted to multiple substances including mainly methamphetamine and heroin. To better serve this growing population we instituted an MAT (Medication Assisted Treatment) program almost 3 years ago including buprenorphine and vivitrol as well as working with our behavioral health providers and LCSW providers for counseling. This program ramped up quickly and represented 5% of our daily census and moved up to over 30% within the next several years. We partnered with a national expert Addiction Medicine doctor.
I took the x waiver course and started suboxone treatments for patients. The patients are very, very appreciative as they are miserable being addicted and don't want to ever go back. Compliance is amazing, better than any patient group I have served.
The practice pathway process is extensive and please read the terms very closely. Few hours outside of direct MAT work qualify for the requirement of hours needed. They won't count weaning someone addicted to narcotics, pain management, or primary care hours of any significance. Almost 2 years into our MAT program I applied for the practice pathway and was rejected to sit for the exam.
I practiced another year as the program grew and was accepted last year to sit for the exam. I found out I passed on Monday and am dual boarded in ABPM Addiction Medicine and also ABFM.
The exam was much more difficult to study for than my recent recertification for ABFM likely because I didn't do a residency/fellowship in it. Not only did it include opioid use, methamphetamine, club drugs, gambling addiction, hallucinogens, and very detailed specific brain addiction pathways you probably don't remember since neuroanatomy (ventral tegmentum, nucleus acumbens, locus ceruleus, habenula, prefrontal cortex ventral aspect and lateral, etc and detailed info about neurotransmitters of each individual drug of which they are often multiple) - it is heavy on statistics and epidemiology because it is administered by the ABPM now. So break out those statistics books from freshman year in college.
Am I glad I did it? Yes. But it was a lot of studying since I didn't do a residency in it. But if you have a lot of MAT patients in your practice it is possible to gain similar experience.

Just out of curiosity, how did you track and submit the hours? How detailed did they require that tracking to be - i.e. did you have to identify every encounter, date, length, etc. where you did addiction? Trying to get a sense for what you would need to keep track of for the actual submission.

I would have thought 30% addiction of fulltime FM practice for 2 years would easily reach the hour threshold, but obviously you had to do another year. What was the barrier?

 

[deleted1089378]

I have been practicing for 30 years. So I have many hours of primary care experience and weaning patients from opioids, benzos, stimulants like Concerta/Ritalin, etc. I had thought those would be included but apparently not the first time I applied. I counted the hours to meet their requirements and appeared to meet them with primary care and addiction patient encounters. They apparently did not. They weren't specific why I was rejected the first time but hinted that I didn't have enough direct experience with addiction specific patient encounters. I also supervise multiple NP's, which should be teaching hours, who also do addiction medicine which appears to count as well but they are very specific in their requirements - per their webpage -
"Addiction Medicine practice outside of direct patient care, such as research, administration, and teaching activities, MAY count for a combined maximum of 75% (or 1440 hours).Only 25% (480 hours) of general practice can count towards the required hours for the Practice Pathway, and the remaining 75% must be specific Addiction Medicine practice."

I would recommend go over this and doing the FULL 1440 hours exclusively in direct addiction medicine one-on-one encounter hours to be allowed to sit for the exam. To be honest, I would also do the other required 480 hours in direct addiction medicine encounters too and not rely on primary care encounters only. I had changed from another job 18 months before becoming CMO of my current job and even though my previous medical director wrote a LOR, it appears my time there was dismissed since it was only primary care or weaning from narcotics patient experience and not actual one on one addiction medicine patient encounters. They need 2 contiguous years of patient encounters so even if you meet the requirement in one year it still won't allow you to sit for the exam. You need 2 years of specific practice in addiction medicine. It is likely since I didn't do the full 2 year cycle under the umbrella of addiction medicine I was rejected the first time.
And finally, they are on the honor system, and very fair, so they don't require specific patient encounters, diagnosis or any PHI which is unlike when I did my training in the early 90's for Family Medicine where I had a 3 X 5 index card with patient name and DOB for every procedure I did for Boards and hospital privileges. HIPPA has changed things. You will need a colleague, however, to write a LOR verifying, in general terms, that you really did do the addiction medicine encounter hours.

 

[Sardonix]

I have been practicing for 30 years. So I have many hours of primary care experience and weaning patients from opioids, benzos, stimulants like Concerta/Ritalin, etc. I had thought those would be included but apparently not the first time I applied. I counted the hours to meet their requirements and appeared to meet them with primary care and addiction patient encounters. They apparently did not. They weren't specific why I was rejected the first time but hinted that I didn't have enough direct experience with addiction specific patient encounters. I also supervise multiple NP's, which should be teaching hours, who also do addiction medicine which appears to count as well but they are very specific in their requirements - per their webpage -
"Addiction Medicine practice outside of direct patient care, such as research, administration, and teaching activities, MAY count for a combined maximum of 75% (or 1440 hours).Only 25% (480 hours) of general practice can count towards the required hours for the Practice Pathway, and the remaining 75% must be specific Addiction Medicine practice."

I would recommend go over this and doing the FULL 1440 hours exclusively in direct addiction medicine one-on-one encounter hours to be allowed to sit for the exam. To be honest, I would also do the other required 480 hours in direct addiction medicine encounters too and not rely on primary care encounters only. I had changed from another job 18 months before becoming CMO of my current job and even though my previous medical director wrote a LOR, it appears my time there was dismissed since it was only primary care or weaning from narcotics patient experience and not actual one on one addiction medicine patient encounters. They need 2 contiguous years of patient encounters so even if you meet the requirement in one year it still won't allow you to sit for the exam. You need 2 years of specific practice in addiction medicine. It is likely since I didn't do the full 2 year cycle under the umbrella of addiction medicine I was rejected the first time.
And finally, they are on the honor system, and very fair, so they don't require specific patient encounters, diagnosis or any PHI which is unlike when I did my training in the early 90's for Family Medicine where I had a 3 X 5 index card with patient name and DOB for every procedure I did for Boards and hospital privileges. HIPPA has changed things. You will need a colleague, however, to write a LOR verifying, in general terms, that you really did do the addiction medicine encounter hours.

Sounds like as a PGY1 it will be impossible for me to meet the 2025 practice pathway deadline if I wanted to.

 

[deleted1089378]

You could definitely make the practice pathway by 2025, but I'd partner with an addiction medicine specialist to see patients to get the hours. You can find providers in your area on the ASAM website. And you can do the X waiver course for free online so if you haven't done it I would start. For doctors it is only 8 hours but for NP's it is 24 hours of training. Weblink: Home - American Academy of Addiction Psychiatry (aaap.org)
I think they extended the deadline to 2025, because they really want want more doctors doing MAT work (COVID quarantine contributed to skyrocketing opioid abuse and overdoses as well as alcoholism) and are trying to make things easier and more accessible. It definitely can't hurt to apply and see where things go. You have 4 years until 2025.

 

[deleted1089378]

PGY1 makes it tougher to get hours due to required basic rotations but as you move into PGY2 and 3 you can do electives. Have you spoken to your PD about possible options if you want to do more electives in addiction medicine? Are you in a University based residency or community based? University makes it easier as more likely to have an addiction medicine dept or psychiatry/PCP based addiction medicine program already in place.

 

[hallowmann]

PGY1 makes it tougher to get hours due to required basic rotations but as you move into PGY2 and 3 you can do electives. Have you spoken to your PD about possible options if you want to do more electives in addiction medicine? Are you in a University based residency or community based? University makes it easier as more likely to have an addiction medicine dept or psychiatry/PCP based addiction medicine program already in place.

My understanding is that no time in training counts towards practice pathway numbers. I'm already doing MAT one day a week in residency, but I don't think it'll be counted until I graduate.

Sounds like as a PGY1 it will be impossible for me to meet the 2025 practice pathway deadline if I wanted to.

Yeah, as a PGY1 it will not be possible. Even with a graduate date next year, I think it will be tough for me to do it unless I'm doing at least 2 days a week for 2 years right after graduation. I do wonder if they'll extend it again. The Addiction Medicine attendings and fellowship faculty I've talked to are worried about that happening and will probably suggest against further extension because fellowships aren't filling and they're expanding quite a bit.

I'm still going back and forth about practice pathway vs. fellowship.

 

[Sardonix]

My understanding is that no time in training counts towards practice pathway numbers. I'm already doing MAT one day a week in residency, but I don't think it'll be counted until I graduate.


Yeah, as a PGY1 it will not be possible. Even with a graduate date next year, I think it will be tough for me to do it unless I'm doing at least 2 days a week for 2 years right after graduation. I do wonder if they'll extend it again. The Addiction Medicine attendings and fellowship faculty I've talked to are worried about that happening and will probably suggest against further extension because fellowships aren't filling and they're expanding quite a bit.

I'm still going back and forth about practice pathway vs. fellowship.

I'm interested to hear what your take and the above faculties' take is on what the average addiction medicine fellowship grad chooses to do with their training. I personally have no interest in starting a treatment center or running one that already exists. I just want to be a PCP with really, really good addiction med skills because I think it's important and interesting material/patients. I'd be very sad if I lost my other generalist skills and knowledge by doing so, though.

 

[deleted1089378]

The thing is that you can do addiction medicine with primary care without doing a fellowship or getting board certified in addiction medicine. Once you take the X waiver online course and pass their test (relatively much easier compared to the ABPM board test) you are authorized to prescribe buprenorphine. You would not need addiction board certification at all and your daily practice would be identical. I practice both primary care and addiction medicine but nothing has changed in my daily practice since I became board certified by ABPM. I did the board certification route for addiction medicine because our company received a large grant for integration of MAT work and behavioral health and primary care and as CMO I needed "street cred", for lack of better terminology. But all you need to do primary care and MAT work is taking the 8 hour course.

 

[deleted1089378]

And now the DEA and SAMHSA has waived the requirement to even need to use an X waiver (which is a glorified way of saying you have a second DEA number with an "X" in front instead of the other letters) to prescribe buprenorphine due to the opioid crisis. I still recommend doing the course, though. It is an excellent review of the psychology of addiction and patient care goals.

 

[Sardonix]

And now the DEA and SAMHSA has waived the requirement to even need to use an X waiver (which is a glorified way of saying you have a second DEA number with an "X" in front instead of the other letters) to prescribe buprenorphine due to the opioid crisis. I still recommend doing the course, though. It is an excellent review of the psychology of addiction and patient care goals.

Eine minute, bitte: https://www.washingtonpost.com/health/2021/02/09/lawmakers-urge-biden-back-opioid-treatment-measure/

Otherwise I appreciate the input. We actually already have our X-waiver at my program, both due to just being smart and also due to my program being sympathetic to the patient population, which I love. Unfortunately I won't be able to see suboxone patients until 2nd year though.

 

[deleted1089378]

OK, anything I can do to help. If you are in the Los Angeles area I can sponsor an externship.

 

[hallowmann]

I'm interested to hear what your take and the above faculties' take is on what the average addiction medicine fellowship grad chooses to do with their training. I personally have no interest in starting a treatment center or running one that already exists. I just want to be a PCP with really, really good addiction med skills because I think it's important and interesting material/patients. I'd be very sad if I lost my other generalist skills and knowledge by doing so, though.

All of the current Addiction faculty at my institution are either IM-Psych trained, FM-Psych trained, Psych trained, or EM trained. We have a number of people in other specialties that have X-waivers, but it's mostly in FM, IM, and Anesthesia. They all do both addiction and their primary specialty (e.g. Psych, EM shifts, etc.). None have done a fellowship, but many have qualified through the practice pathway. Our first fellow does not plan to open up an addiction treatment center, but is doing it to get better training.

What I was told when I voiced interest earlier in the year, was that their goal was to have fellows continue to spend at least some time in their primary clinics and find ways to incorporate addiction training into it. For example spending time in the Peds, FM, or OB/Gyn clinic and being the "go-to" person for substance use. Weekends are also usually off, so moonlighting in a primary clinic would be very doable.

You can definitely do what you describe with just waiver training, and don't necessarily need a fellowship for it. Unless you had a strong reason for a fellowship, e.g. needing board certification for your job or wanting to get more training in other areas of addiction, I'm not sure that you wouldn't be able to learn most things on your own. Afterall, it's what people doing practice pathway do anyway.

And now the DEA and SAMHSA has waived the requirement to even need to use an X waiver (which is a glorified way of saying you have a second DEA number with an "X" in front instead of the other letters) to prescribe buprenorphine due to the opioid crisis. I still recommend doing the course, though. It is an excellent review of the psychology of addiction and patient care goals.

People are skeptical whether waiving the requirement will be a real thing. Even if it does happen as it says, by the wording it sounds like you still need an X-waiver to have a panel of more than 30 patients.

Eine minute, bitte: https://www.washingtonpost.com/health/2021/02/09/lawmakers-urge-biden-back-opioid-treatment-measure/

Otherwise I appreciate the input. We actually already have our X-waiver at my program, both due to just being smart and also due to my program being sympathetic to the patient population, which I love. Unfortunately I won't be able to see suboxone patients until 2nd year though.

You can still see suboxone patients, you just wouldn't be able to prescribe for them. As long as you are staffing with someone who has their waiver, that shouldn't be an issue.

 

[Sardonix]

You can still see suboxone patients, you just wouldn't be able to prescribe for them. As long as you are staffing with someone who has their waiver, that shouldn't be an issue.

True of course, but it's additional layer of logistics that doesn't make things all that practical. Still seeing plenty of SUD patients though and I'm happy with that.

 

[Drellismd]

I can address this. I am the CMO for a medium sized FQHC (Federally Qualified Health Center) serving the medically disadvantaged, re entry citizens (i.e. newly released prisoners and jail incarcerated) who often were in for drug related issues, the homeless population, undocumented residents, and indigent. We have a large population of those addicted to multiple substances including mainly methamphetamine and heroin. To better serve this growing population we instituted an MAT (Medication Assisted Treatment) program almost 3 years ago including buprenorphine and vivitrol as well as working with our behavioral health providers and LCSW providers for counseling. This program ramped up quickly and represented 5% of our daily census and moved up to over 30% within the next several years. We partnered with a national expert Addiction Medicine doctor.
I took the x waiver course and started suboxone treatments for patients. The patients are very, very appreciative as they are miserable being addicted and don't want to ever go back. Compliance is amazing, better than any patient group I have served.
The practice pathway process is extensive and please read the terms very closely. Few hours outside of direct MAT work qualify for the requirement of hours needed. They won't count weaning someone addicted to narcotics, pain management, or primary care hours of any significance. Almost 2 years into our MAT program I applied for the practice pathway and was rejected to sit for the exam.
I practiced another year as the program grew and was accepted last year to sit for the exam. I found out I passed on Monday and am dual boarded in ABPM Addiction Medicine and also ABFM.
The exam was much more difficult to study for than my recent recertification for ABFM likely because I didn't do a residency/fellowship in it. Not only did it include opioid use, methamphetamine, club drugs, gambling addiction, hallucinogens, and very detailed specific brain addiction pathways you probably don't remember since neuroanatomy (ventral tegmentum, nucleus acumbens, locus ceruleus, habenula, prefrontal cortex ventral aspect and lateral, etc and detailed info about neurotransmitters of each individual drug of which they are often multiple) - it is heavy on statistics and epidemiology because it is administered by the ABPM now. So break out those statistics books from freshman year in college.
Am I glad I did it? Yes. But it was a lot of studying since I didn't do a residency in it. But if you have a lot of MAT patients in your practice it is possible to gain similar experience.

This is helpful. When you say you were rejected - did you apply for it initially with less than the required 1920 hours? Or you had the 1920 hours and it was the depth/quality of the addiction work you did they did not accept?

 

[deleted1089378]

They didn't disclose exactly why I was rejected the first year - very vague. I just continued for another year with seeing more addiction medicine only patients and submitted those hours in entirety the second year. I think they wanted more direct addiction medicine hours and less emphasis on just primary care (even if weaning from opioids, pain management type patients, etc.) even though their website said they took some of those hours. YMMV

 

[deleted1089378]

Also keep in mind, as already brought up previously, the X waiver requirement is now waived for those seeing up to 30 buprenorphine patients. Your DEA number suffices to see them although I still recommend the X waiver online course offered through AAAP (free) to acquaint yourself with addiction medicine.

 

[hallowmann]

Also keep in mind, as already brought up previously, the X waiver requirement is now waived for those seeing up to 30 buprenorphine patients. Your DEA number suffices to see them although I still recommend the X waiver online course offered through AAAP (free) to acquaint yourself with addiction medicine.

For more details of the implementation:

Waiver Elimination (MAT Act)

www.samhsa.gov

Updated 5/4/21. If anyone plans to do this, make sure to submit an NOI application first.

Personally given how easy the process is currently for the X-waiver with all online curriculum, I would just apply for that. I've had the waiver <1 yr, spend <1 day a week in MAT clinic as a resident and already have a panel of 15-20 active patients on my waiver.

The added benefit is that in a year you can upgrade to 100, and then after another year, you can hit 275. Unless you're doing only addiction, I can't imagine hitting that 275 limit.

 

[sotto]

FM PGY3 here,

I have interest in addiction medicine however I will be working a nocturnist gig next year. I see my home institution is starting an addiction medicine fellowship and will most definitely give them a holler however, how in the world would you go about getting boarded in addiction medicine through the practice pathway now that it is extended to 2025. Would I simply study up, do a few electives, then apply to jobs with caveat that they will need to give me some on the job training? Does anyone have any insight or experience in this realm?

Hey! Just trying to get a follow up on if you decided to do the fellowship and what your experience has been if you did. I’m thinking about the fellowship

 

[medhead1990]

So I finish residency June 2023, and my understanding was I would be ineligible to do the practice pathway because I would only have 18 months Post residency to submit time/hours. I definitely have over six months of addiction under my belt from residency, would I be able to use that time towards the 24 month requirement and get in through the practice pathway?

As I have been doing my research My assumption was it was over 2025 but it appears most of the verbiage is saying through 2025 which would then give me enough time for the requisite 24 months. If someone knows this for sure please let me know I will do some more homework and may email abpm.

 

[hallowmann]

So I finish residency June 2023, and my understanding was I would be ineligible to do the practice pathway because I would only have 18 months Post residency to submit time/hours. I definitely have over six months of addiction under my belt from residency, would I be able to use that time towards the 24 month requirement and get in through the practice pathway?

As I have been doing my research My assumption was it was over 2025 but it appears most of the verbiage is saying through 2025 which would then give me enough time for the requisite 24 months. If someone knows this for sure please let me know I will do some more homework and may email abpm.

My understanding is that no time during residency is eligible for practice pathway, however, time spent on a non-accredited or <12 mo fellowship may be applied.

If you graduate in June 2023, theoretically you could work immediately in addiction for 24 consecutive months ending in June 30, 2025 and apply that year. Applications are due by June 30th of the application year, but there is a late application fee for applying by July 15th (at least that is how it is this year). So I guess you could apply in June with the indication that you have completed the hours through that time in order to sit for the Oct 2025 addiction medicine board exam. I would verify this with the board though.

This is all assuming they don't extend it further, like they did last year, but from what I've heard they might not extend it.

Below is other information from the website about the hour requirements. It comes out to about 20 hrs per week over 2 years (assuming 48 wks of working per year) to fulfill the 1920, which is about 15 hrs per week over the 2 years to meet the 1440 direct patient care, and then at least a 5 hrs per week of your primary specialty and/or research, admin, teaching activities, etc.

Applicants must submit documentation of a minimum of 1,920 hours in which they were engaged in the practice of Addiction Medicine at the subspecialty level; this minimum of 1920 hours must occur over at least 24 of the previous 60 months prior to application. The minimum of 24 months of practice time need not be continuous; however, all practice time must have occurred in the five-year period preceding June 30 of the application year. Practice must consist of broad-based professional activity with significant Addiction Medicine responsibility. Applicants must also demonstrate a minimum of 25% (or 480 hours) as Direct Patient Care. Addiction Medicine practice outside of direct patient care, such as research, administration, and teaching activities, may count for a combined maximum of 75% (or 1440 hours).Only 25% (480 hours) of general practice can count towards the required hours for the Practice Pathway, and the remaining 75% must be specific Addiction Medicine practice.