MMT/Buprenorphine training in psych residency

[Mark7954]

Hello

I am a rising MS4 interested in pursuing psychiatry. For all the psych residents out there, do you feel you have received adequate training in opioid replacement therapy or would there be a need for an addiction fellowship? Just curious.

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[Bartelby]

I am an attending, but can say I felt comfortable prescribing Suboxone right out of residency. My program provided the "half and half" training for the X-waiver, and I had the opportunity to rotate through several addiction treatment settings. I think Suboxone should be a part of the basic toolkit for psychiatrists at this point, and prescribing it should not require a fellowship year (I still prescribe it regularly).

 

[wolfvgang22]

You don't need to do a fellowship unless you like deferring your income. I run a MAT clinic and frequently prescribe suboxone.
The online course you need to complete to obtain an X waiver to prescribe suboxone is not difficult. All the information you might need is provided online by SAMSHA. If you seek out experience in residency, which is easy to get, you will be more than fine.
Sadly, this is the last year one can just challenge the addiction boards without doing a fellowship.

 

[clausewitz2]

OP, probably the majority of suboxone in my area is prescribed by FM docs in community health centers. You'll be just fine without a fellowship. There are nuances to suboxone, legal, pharmacological and otherwise, but at the end of the day it's not rocket surgery.

 

[reca]

Don't need a fellowship but a rotation during residency would help (thought not needed). We don't get any suboxone training at my program unless you do it as an elective in PGY-4 year. With that said, plenty of residents just do the weekend training and get the waiver on their own to moonlight starting PGY-2.

 

[Mark7954]

Thanks so much everyone!

 

[michaelrack]

The online training for the waiver is only $150 or less, free in some cases

 

[whopper]

There's a lot of curveballs with Buprenorphine that isn't taught in the required training to get the license for the X-DEA number. E.g. they don't inform you that the withdrawal can go on for weeks, that even if you reduced the dosage to less than 1 mg a day the person can still have bad withdrawal when they stop it, that the studies on how long a person should be on Buprenorphine don't usually go past 1 year so it's not set in stone exactly how long someone should be on it, and what alternatives could be done on patients who are non-compliant with rules other than simply just terminating their treatment.

Another issue I see are several doctors are prescribing Buprenorphine but not providing therapy. They just have the patients show up, take their money, then give them a UDS (if even that) and the medication and bye bye. This is minimal and poor care. Some doctors here even defended the practice completely ignoring that there's a doctor-patient responsibility to this patient and not even screening the person for other disorders such as ADHD or depression.

The above curveballs aren't as mentioned above rocket-science but if you start doing Buprenorphine, don't expect the training for the license to cover these needed areas.

 

[Coupd'Cat]

The 8-hour online training is available here: PCSS Learning: 8 Hour Online MAT Waiver Training.

 

[calvnandhobbs68]

There's a lot of curveballs with Buprenorphine that isn't taught in the required training to get the license for the X-DEA number. E.g. they don't inform you that the withdrawal can go on for weeks, that even if you reduced the dosage to less than 1 mg a day the person can still have bad withdrawal when they stop it, that the studies on how long a person should be on Buprenorphine don't usually go past 1 year so it's not set in stone exactly how long someone should be on it, and what alternatives could be done on patients who are non-compliant with rules other than simply just terminating their treatment.

Another issue I see are several doctors are prescribing Buprenorphine but not providing therapy. They just have the patients show up, take their money, then give them a UDS (if even that) and the medication and bye bye. This is minimal and poor care. Some doctors here even defended the practice completely ignoring that there's a doctor-patient responsibility to this patient and not even screening the person for other disorders such as ADHD or depression.

The above curveballs aren't as mentioned above rocket-science but if you start doing Buprenorphine, don't expect the training for the license to cover these needed areas.

To play the other side of this though, there’s conflicting evidence that therapy changes outcomes significantly in MAT. Certainly it’s ideal to do a some motivational interviewing, inquire about social supports, what’s keeping people sober, etc. but when you have people who have been stable for years on suboxone, it’s really debatable how much therapy you really need to be doing at these followup visits.

States that have therapy “requirements” that you have to document (without any limit on how long you have to keep telling the patient they need to be going to therapy...) are also really overly onerous. Do we force patients with diabetes or obesity or hypertension to go see a dietician or physical therapy/do some exercise program to get their meds refilled? Do we force adult patients with ADHD to go to therapy to keep refilling their prescriptions every 3 months if everything else seems stable? We prescribe other controlled substances all the time and although I encourage my patients to attend therapy and use MI techniques, I don’t REQUIRE them to go to therapy to get their medications if it doesn’t seem like they are using these medications inappropriately.

I just think it’s bizarre that anyone with a DEA number can write people for 90 oxy from day 1 but we put up barriers for people to access suboxone.

I dont defend the 5 minute cash on the table, script in your hand visits though. People should have a basic ROS and relevant info obtained which could affect sobriety at every visit just like any other followup psych visit.

 

[whopper]

To play the other side of this though, there’s conflicting evidence that therapy changes outcomes significantly in MAT. Certainly it’s ideal to do a some motivational interviewing, inquire about social supports, what’s keeping people sober, etc. but when you have people who have been stable for years on suboxone, it’s really debatable how much therapy you really need to be doing at these followup visits.

Anyone stable on it for years likely doesn't need the added stuff, but I'm talking about someone who comes in for brand new treatment. Just give them the induction, them the med and only take their money once a month and that's the entire treatment experience? That's poor care when the overwhelming amount of data shows that addiction doesn't exist in and of itself with nothing else psychologically going on.

I just think it’s bizarre that anyone with a DEA number can write people for 90 oxy from day 1 but we put up barriers for people to access suboxone.

Completely agree there.