Landscape for Addiction Psych

[vanfanal]

A bit about me. Completed addiction psych fellowship last year, but moved to Canada for personal reasons. Been doing mainly general adult psych, inpt and opt. It feels like it’s just all reactive mood disorders and personality disorders. I enjoy doing pure additions so much more.

So I’m wondering what kind of practice settings and jobs people with the addictions background are doing? What are opportunities and pay like? If your fellowship trained, can you choose to focus on just addictions and not general psych?

Input appreciated.

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[SubzDoc]

I am on the faculty for an addiction psychiatry fellowship. Of our recent graduates, about half of them went into full-time addiction jobs and the other half went into outpatient jobs where they were promised a significant portion of their time would be addiction work. That second category I think has the potential to be a bait and switch, where they promise you are going to spend more time on addiction than you really will. I myself had an outpatient moonlighting job in residency that worked out this way. I said I would only do addiction work but, more and more, they tricked me into taking on gen psych. Of those fellows that took the hybrid jobs, I will also say I think they would have preferred full-time addiction, but there were other aspects of the job that led them to think they could tolerate a certain amount of gen psych (compensation, time off, whatever). I really think most fellows intend on working in addictions. If that were not the case I wouldn't recommend they do the fellowship in the first place.

 

[nexus73]

One kinds of full-time addictions job exist?

 

[littlefred]

One kinds of full-time addictions job exist?

I do addiction work only. They are out there but hard to find.

 

[dl2dp2]

A bit about me. Completed addiction psych fellowship last year, but moved to Canada for personal reasons. Been doing mainly general adult psych, inpt and opt. It feels like it’s just all reactive mood disorders and personality disorders. I enjoy doing pure additions so much more.

So I’m wondering what kind of practice settings and jobs people with the addictions background are doing? What are opportunities and pay like? If your fellowship trained, can you choose to focus on just addictions and not general psych?

Input appreciated.

You should start an addiction-focused private practice. These are much easier in my experience to build than general practices.

Inpatient addiction practices are getting less prevalent, as they are associated with detox-rehab facilities, which are being consolidated. However, it's still relatively easy to get a job as a staff MD at these facilities. Best bet for inpatient is a community dual-diagnosis/MICA unit, but I'm not sure this is the type of populations you are interested in.

 

[nexus73]

You should start an addiction-focused private practice. These are much easier in my experience to build than general practices.

Inpatient addiction practices are getting less prevalent, as they are associated with detox-rehab facilities, which are being consolidated. However, it's still relatively easy to get a job as a staff MD at these facilities. Best bet for inpatient is a community dual-diagnosis/MICA unit, but I'm not sure this is the type of populations you are interested in.

Does this predominantly end up as an OUD practice using Suboxone? Or are there fair number of people wanting to get off alcohol, nicotine?

 

[Sushirolls]

You should start an addiction-focused private practice. These are much easier in my experience to build than general practices.

Inpatient addiction practices are getting less prevalent, as they are associated with detox-rehab facilities, which are being consolidated. However, it's still relatively easy to get a job as a staff MD at these facilities. Best bet for inpatient is a community dual-diagnosis/MICA unit, but I'm not sure this is the type of populations you are interested in.

No, no, don't do an outpatient PP emphasizing addiction.

Simply opening up an office to do broad spectrum addiction will be tough, some regional variability. But you will notice a higher skewing in patient population towards the medicaid - which doesn't exactly pay the bills. Then the other issue, is the Alcohol UD folks are bad at follow up.

I advertise my practice as Psychiatry and Addiction, but I just don't get much addiction on the front end, usually comes up as secondary issues from patient perspective. Alcohol UD have horrible follow up rates. Suboxone for OUD do follow up, but now the market it saturated with "providers" and most of the population is medicaid.

Without having the complete clinic for addiction, the PHP, the IOP, the detox unit, (maybe even the residential?) it's truly hard to capture the population. I've found that many of the clinics that do get the patients entering at their Detox/residential/PHP level, step down to the other and then follow up with the same clinic for their outpatient care.

Possibly, possibly, if you open an IOP/PHP from the start and even advertise the ability to do outpatient alcohol/benzo tapers, you *might* be able to make it work.

 

[vanfanal]

I am on the faculty for an addiction psychiatry fellowship. Of our recent graduates, about half of them went into full-time addiction jobs and the other half went into outpatient jobs where they were promised a significant portion of their time would be addiction work. That second category I think has the potential to be a bait and switch, where they promise you are going to spend more time on addiction than you really will. I myself had an outpatient moonlighting job in residency that worked out this way. I said I would only do addiction work but, more and more, they tricked me into taking on gen psych. Of those fellows that took the hybrid jobs, I will also say I think they would have preferred full-time addiction, but there were other aspects of the job that led them to think they could tolerate a certain amount of gen psych (compensation, time off, whatever). I really think most fellows intend on working in addictions. If that were not the case I wouldn't recommend they do the fellowship in the first place.

What does full time addictions look like, mainly and outpatient methadone and suboxone clinic?

 

[vanfanal]

No, no, don't do an outpatient PP emphasizing addiction.

Simply opening up an office to do broad spectrum addiction will be tough, some regional variability. But you will notice a higher skewing in patient population towards the medicaid - which doesn't exactly pay the bills. Then the other issue, is the Alcohol UD folks are bad at follow up.

I advertise my practice as Psychiatry and Addiction, but I just don't get much addiction on the front end, usually comes up as secondary issues from patient perspective. Alcohol UD have horrible follow up rates. Suboxone for OUD do follow up, but now the market it saturated with "providers" and most of the population is medicaid.

Without having the complete clinic for addiction, the PHP, the IOP, the detox unit, (maybe even the residential?) it's truly hard to capture the population. I've found that many of the clinics that do get the patients entering at their Detox/residential/PHP level, step down to the other and then follow up with the same clinic for their outpatient care.

Possibly, possibly, if you open an IOP/PHP from the start and even advertise the ability to do outpatient alcohol/benzo tapers, you *might* be able to make it work.

Yikes. I’m not sure if I’m in a position to start something like that on my own yet.

From my training, I remember it was valuable to be able to follow and manage pts from detox, to rehab, to IOP and eventually outpatient. I valued the relationship and they generally did better with the continuity of care. But that requires being part of a big system.

I’m looking into the VA.

 

[SubzDoc]

What does full time addictions look like, mainly and outpatient methadone and suboxone clinic?

It could be a methadone clinic or a full-time outpatient addiction clinic (VA, private, hospital-based, etc). It could be a residential job, typically either a detox facility or a 28-day rehab. There are more unusual ones, like an inpatient unit of some kind. Forensic kinds of jobs for patients in certain professions or treatment programs for court-ordered individuals, although these are less likely to be full-time. Plus more. Unfortunately, I usually don't see addiction positions well-advertised. It helps if you network well. If you know even one or two people in the local treatment community they may be able to steer you in the right direction.

 

[Merovinge]

Yikes. I’m not sure if I’m in a position to start something like that on my own yet.

From my training, I remember it was valuable to be able to follow and manage pts from detox, to rehab, to IOP and eventually outpatient. I valued the relationship and they generally did better with the continuity of care. But that requires being part of a big system.

I’m looking into the VA.

There's plenty of this work in the private space as well. I work for a company that does RTC/PHP/IOP services and tightly collaborates with IP/detox units when that's needed to kickstart treatment. Full spectrum of addiction work plus all mental health/trauma and getting to the bottom of what was causing the substance use in the first place. We have one fellowship trained psychiatrist (in addictions), the other folks just get the training on the job.

 

[Sushirolls]

If some one has the passion/drive, time, and even a pinch of money; here is a recipe.

Bestow yourself title of med director, get a large enough space, open up a PHP/IOP/ and outpatient office. Jump thru the hoops to get the SAP designations, and hire the therapists with right alphabets, and reach out to the courts and also do the court mandated evaluations. Eventually the role will be less clinical, but more admin/owner.

 

[nexus73]

There's plenty of this work in the private space as well. I work for a company that does RTC/PHP/IOP services and tightly collaborates with IP/detox units when that's needed to kickstart treatment. Full spectrum of addiction work plus all mental health/trauma and getting to the bottom of what was causing the substance use in the first place. We have one fellowship trained psychiatrist (in addictions), the other folks just get the training on the job.

What does the day to day of an RTC/PHP/IOP psychiatrist look like? Is this a M-F job. 8-5? 8-noon? 4 day week?

 

[Merovinge]

What does the day to day of an RTC/PHP/IOP psychiatrist look like? Is this a M-F job. 8-5? 8-noon? 4 day week?

At my company it looks awesome. Patients are seen weekly so there is a lot of flexibility in daytime structure beyond weekly staffing times. It's roughly 17 hours clinical and the rest of your time is spent collaborating with OP teams, your team, working with families, extra time with patients who need it, etc. Most of our docs keep a pretty light Friday, you still are expected to return any emails/calls between 9-5 but can leave once all your work is done.

 

[whopper]

There's a lot of addiction out there and a lot of need for addiction treatment. I'm in the midwest where there's a shortage of mental health providers. While this has increased the demand and hence the job security and pay it creates other risks. For example, some clinics are taking in patients that I consider too hot to handle and should be better done in a hospital such as detoxing pregnant patients. While some may agree with me there's hospitals that will not detox pregnant patients thinking this shouldn't be handled in the hospital.

This parallels a lot of what happens in rural psychiatry. You could do financially well being one of the few providers in a rural community but in doing so you're often times on your own. Don't expect to be in a situation where the local hospital has a good psych unit, where the police have good mental health training, and you can refer to another psychiatry easily if you feel the patient violated a boundary.

 

[vanfanal]

Thoughts on what the DATA 2000 changes will mean for addictionologists?

 

[SubzDoc]

If you are referring to the eliminated need for a DATA waiver to prescribe buprenorphine, I think this is a good change. This needed to happen years ago. Even so, I think buprenorphine prescribing will continue to come mostly from specialists. The issue was not that doctors would not prescribe buprenorphine because they had to get a waiver, it was that they didn't want to prescribe it in the first place. I hope this will expand the availability of buprenorphine in rural areas but I think most suboxone scripts will still come from specialty care.

 

[Sushirolls]

Nothing.
The fact that ARNPs an PA's were granted waivers years ago already changed the landscape.
Secondly, the PE / Big Box shop expansion of firms that hired any and every doc/specialty with a pulse and license to prescribe already changed the landscape.

Perhaps these large groups that have a bunch of EM and IM and FM and psych and OB doing suboxone, will be consolidated to a few full time people instead of a bunch of people doing part time?

It'll make it easier for EM docs to start sending people out with prescriptions and same for UCs.

Patients will be less inclined to participate with more stringent contract based programs and things will descend into a more pronounced "harm reduction" attitude. "Legit clinic won't prescribe because I keep popping THC positive or coke or benzo or whatever, showing up late, not doing meetings or therapy or whatever"... they'll just keep going to EM and UC and be like "I'm in withdrawal... give me subs" and they will.

 

[TexasPhysician]

I think it will actually hurt the patients, because most have no idea how to dose it. Fewer places will require therapy or higher levels of care.

The current medical trend is about access. We are moving toward a Walmart approach to care.

 

[Sushirolls]

But will still get mailed REMS documents every other week! LOL

 

[allantois]

Thoughts on what the DATA 2000 changes will mean for addictionologists?

More cases from inappropriate prescribing by FM/EM

 

[vanfanal]

I think it will actually hurt the patients, because most have no idea how to dose it. Fewer places will require therapy or higher levels of care.

The current medical trend is about access. We are moving toward a Walmart approach to care.

More cases from inappropriate prescribing by FM/EM

Agree. There’s a balance between increasing access for harm reduction and what I suspect will be the proliferation suboxone only practices, some cash only, now seeing greater numbers of patients with inappropriate prescribing patterns imo. In fellowship, I’d say one of the most important things I learned wasn’t how to prescribe a med, but set boundaries and work with the other issues around patients with addictions.

 

[allantois]

Also I’m not sure I agree with removing 275 limit. That’s a hell ton of patients even if someone ONLY sees patients with OUD. They are basically no different from a drug dealer at those volumes.. but I hope the DEA will keep a close eye on their new experiment. I’m quite disappointed that this is the solution proposed by administration instead of expanding funding for comprehensive addiction treatment centers/programs. I bet you one of those online pill mills funneled money into some Congress members’ re-election campaigns

 

[vanfanal]

I do addiction work only. They are out there but hard to find.

How does one find them?

 

[littlefred]

How does one find them?

Given the X waiver changes the landmark will change a bit, but job security for addiction work are methadone clinics (working at more than 1 being ideal) as per regulations they need to have an MD/DO at the helm.

 

[Sushirolls]

Also I’m not sure I agree with removing 275 limit. That’s a hell ton of patients even if someone ONLY sees patients with OUD. They are basically no different from a drug dealer at those volumes.. but I hope the DEA will keep a close eye on their new experiment. I’m quite disappointed that this is the solution proposed by administration instead of expanding funding for comprehensive addiction treatment centers/programs. I bet you one of those online pill mills funneled money into some Congress members’ re-election campaigns

This has been a project of ASAM for years now. I wouldn't chock this one up to nefarious. Just good ol' fashioned kumbaya thinking.

The cash arena for suboxone has been dead since PA/ARNPs got X numbers. Probably for the best. But not access will swing too far to have greater ramifications.

But what do we know? We only went to medical school. Its not like we have the expert training of DC, ND, DNPs - who really know their stuff! Society wants fast, quit, immediate and what they want. They want a true service industry, not a profession. Perhaps we should just give unrestricted license - same license - to any pulse that completes a degree, be it MD/DO/MBBS/DNP/ND/DC etc. Just let people have at it.

Just recently I had a consult of someone who basically wanted psychedelics only. Could have had great response with standard of care. Nope, wants psychedelics.
Everyone wants weed and thinks it helps them.
10 supplements are okay, but its agonizing to take one FDA approve med.
My poor focus must be ADHD.

 

[yoloswagpoop42069]

If some one has the passion/drive, time, and even a pinch of money; here is a recipe.

Bestow yourself title of med director, get a large enough space, open up a PHP/IOP/ and outpatient office. Jump thru the hoops to get the SAP designations, and hire the therapists with right alphabets, and reach out to the courts and also do the court mandated evaluations. Eventually the role will be less clinical, but more admin/owner.

Sounds like a plan. Although it would seem to be tough from an overhead perspective to start a PHP/IOP, with whatever regulatory fees, as well as hiring that many salaried employees initially.

I'm going to start an addiction psychiatry fellowship come July 2023, wasting time and money, but it's what I enjoy, and look forward to honing my skills over a dedicated year.

Regarding psychedelics, I do believe that there is significant potential for psychedelic treatments for SUDs. Bill W of AA attributed some of his "spiritual awakenings" to his use of LSD, and there was reportedly some consideration to include such experiences in the Big Book. Some studies with ketamine coming out for AUD as well. Given the impact on the glutamatergic system, it makes some sense.

Overall, it will take a significant amount of time for regulatory hurdles and studies for psilocybin et all in the SUD sphere, but we will see.

After an addiction fellowship, I plan to do a psychedelic fellowship. Roast me if you want. I think with mid-level creep, and venture capital business conglomerates taking over, that there needs to be something to separate us from the rest, if you want to be truly successful. If you want to see a **** NP be my guest.

 

[vanfanal]

This has been a project of ASAM for years now. I wouldn't chock this one up to nefarious. Just good ol' fashioned kumbaya thinking.

The cash arena for suboxone has been dead since PA/ARNPs got X numbers. Probably for the best. But not access will swing too far to have greater ramifications.

But what do we know? We only went to medical school. Its not like we have the expert training of DC, ND, DNPs - who really know their stuff! Society wants fast, quit, immediate and what they want. They want a true service industry, not a profession. Perhaps we should just give unrestricted license - same license - to any pulse that completes a degree, be it MD/DO/MBBS/DNP/ND/DC etc. Just let people have at it.

Just recently I had a consult of someone who basically wanted psychedelics only. Could have had great response with standard of care. Nope, wants psychedelics.
Everyone wants weed and thinks it helps them.
10 supplements are okay, but its agonizing to take one FDA approve med.
My poor focus must be ADHD.

This makes me so sad because it feels so true.
To be honest I’ve been struggling with this the last few nights. Is no one else feeling this existential angst? It started for me with this waiver change. I upskilled with an addictions fellowship, but I find myself thinking what value does it add when anyone else can do this work now, whether they do it properly or not. I know my training has value, but it doesn’t feel like society, systems or governments see us as any different from a midlevel, just more expensive, which is discouraging given 10 years of training. We try carving out more niche ground and mid levels and other physician specialties encroach. Doesn’t seem like anyone is interested in a tempered and nuanced professional opinion anymore.
We’ve been devalued. Other guilds haven’t had this level of encroachment, my accountant increased fees by $500 this year for no extra work. But between mid levels and a push for lower reimbursement, we’re pushing against a race to the bottom.
Sorry…. I don’t know 😞….I’m spiralling with my thoughts. I’ll just call it a night.

 

[yoloswagpoop42069]

This makes me so sad because it feels so true.
To be honest I’ve been struggling with this the last few nights. Is no one else feeling this existential angst? It started for me with this waiver change. I upskilled with an addictions fellowship, but I find myself thinking what value does it add when anyone else can do this work now, whether they do it properly or not. I know my training has value, but it doesn’t feel like society, systems or governments see us as any different from a midlevel, just more expensive, which is discouraging given 10 years of training. We try carving out more niche ground and mid levels and other physician specialties encroach. Doesn’t seem like anyone is interested in a tempered and nuanced professional opinion anymore.
We’ve been devalued. Other guilds haven’t had this level of encroachment, my accountant increased fees by $500 this year for no extra work. But between mid levels and a push for lower reimbursement, we’re pushing against a race to the bottom.
Sorry…. I don’t know 😞….I’m spiralling with my thoughts. I’ll just call it a night.

Don’t be so depressed man.

Have you seen the quality of an NPs work? They barely know how to diagnose properly or manage medications.

I don’t think many know how to differentiate BAD from BPD. Sure they can take the simple MDD and GAD cases from the worried well who respond well to one standard antidepressant, but any complexity to the case and the NP loses their **** and any competent physician would question their decision making.

The problem, like you said, is that systems like insurance companies, and businesses have a difficult time quantifying these nuances. Ie insurances get billed, patients get seen, admitted or discharged, so it’s hard to tell.

I think on some level, the savvy health literate patients understand this. At my outpatient clinic the CMO (who’s a MD btw) told me “but patients insist on wanting to see a doctor… eye roll.” Typical boomer ****… type of doc who sold us out to mid levels in the first place.

So I think there will be increasing awareness. Overall I think the NP school mills will further dilute the mid level profession and taint reputation, which works in our favor.

It remains to see what happens with the shake out though. Innovate to survive. Find a way to separate yourself.

 

[allantois]

Sounds like a plan. Although it would seem to be tough from an overhead perspective to start a PHP/IOP, with whatever regulatory fees, as well as hiring that many salaried employees initially.

I'm going to start an addiction psychiatry fellowship come July 2023, wasting time and money, but it's what I enjoy, and look forward to honing my skills over a dedicated year.

Regarding psychedelics, I do believe that there is significant potential for psychedelic treatments for SUDs. Bill W of AA attributed some of his "spiritual awakenings" to his use of LSD, and there was reportedly some consideration to include such experiences in the Big Book. Some studies with ketamine coming out for AUD as well. Given the impact on the glutamatergic system, it makes some sense.

Overall, it will take a significant amount of time for regulatory hurdles and studies for psilocybin et all in the SUD sphere, but we will see.

After an addiction fellowship, I plan to do a psychedelic fellowship. Roast me if you want. I think with mid-level creep, and venture capital business conglomerates taking over, that there needs to be something to separate us from the rest, if you want to be truly successful. If you want to see a **** NP be my guest.

What makes you think an NP won't be able to prescribe ketamine or psychedelics? There are NPs already involved in this area.

Also, there is still not enough addiction care for everyone living with addiction issues. Surely a psychiatrist with addiction interest/training will always stand out even from other non-psych addictionologists

 

[hallowmann]

The doom and gloom here regarding the elimination of the X-waiver is way more than most addiction and physician groups I'm a part of. There was no reason to treat Suboxone (or Methadone for that matter) with such rigid enforcement, when anyone and their mother with a DEA can prescribe Dilaudid and fentanyl whenever they wanted. It didn't make sense and is built upon discrimination towards people with OUD.

Most people don't see anywhere close to the 275 cutoff, and with this change, I assure you barely anyone will see above it. As for the dropping requirement for therapy, its already been the recommendation for a while for that NOT to be a barrier for care. Sure, ideally they would do both, but it shouldn't determine whether or not they get access to necessary and potentially live-saving medication. Can you imagine requiring everyone with DM2 to see a nutritionist weekly before prescribing them insulin? Its ridiculous.

As for the psychedelics, sure, its a mess, but it already was. Where I trained we had CRNAs opening up ketamine infusion clinics themselves and doing a crap job of counseling patients, screening for diagnoses, and screening overall risk.

 

[Sushirolls]

Addiction fellowships won't be value added.
The only reason to day a fellowship is for the pure love of the field.

The fellowship does open some doors for addiction specific units in hospitals, or Methadone clinics to be a preferred candidate.

Or, if very full of gusto, push to open your own full fledged everything clinic. PHP/IOP/OP, etc. Then maybe hit the local community up to find grants, or donors, etc to then get a detox unit. No guarantees it will be big money maker, but will pay dividens in community respect and life transformations for many patients.

Want money, there are a few high cost residential clinics that every so often have openings. But don't assume you'll find them or be hired for one.

 

[yoloswagpoop42069]

What makes you think an NP won't be able to prescribe ketamine or psychedelics? There are NPs already involved in this area.

Also, there is still not enough addiction care for everyone living with addiction issues. Surely a psychiatrist with addiction interest/training will always stand out even from other non-psych addictionologists

Thread is a bit of a mish-mash, but there are two themes

1. People thinking a reduction of X-waiver requirements will lead to more scope creep / worsening future for addictionlogists (I don't think so, like others have stated).

2. NPs diluting the field in general

Regarding:
1. I stated the appropriate future use of psychedelics may be used to separate yourself from more general practices in the future, and currently the field is still just starting (and no, I'm not talking about ketamine, I'm talking more like psilocybin). Its going to take a few years for FDA approvals and regulatory hurdles to get settled for actual clinical practice though.

2. Yeah sure NPs can prescribe whatever they want, including ketamine, it doesn't mean their actual clinical practice is any good.

Kind of separate things I was referencing, and not mashing together like you alluded.