By Yassmin Hegazy, MD (PGY-2)

Pictured L to R: Dr. Davis Bradford and Dr. Leah Leisch

With the opioid epidemic and the subsequent rise of cases of substance use and mental illness caused by the COVID pandemic, addiction medicine has increasingly become an integral part of medical practice. To reflect this, the residency program, along with GIM faculty Dr. Davis Bradford and Dr. Leah Leisch, have recently conceptualized a new Addiction Medicine rotation for trainees. 

Dr. Bradford, a UAB medical school alumni who returned following residency at Boston University, and Dr. Leisch, an academic internist who manages veterans and patients with chronic opioid use disorders at the VA and Beacon clinic, have become major leaders in Addiction Medicine and will now become mentors for residents rotating through the recently added rotation this past July. I had a chance to sit down and interview them on some of the recent changes.

What made you interested in addiction medicine?

LL: With an initial interest in primary care, I was an attending at UAB for four years and helped start the Red Opioid Safety clinic with Dr. Teresa Bryan at the VA. I developed an interest in motivational interviewing and addiction and realized that the problem wasn't the patients, it was our lack of training and I became very passionate on educating our residents on how to manage patients with chronic opioid use disorders and pain.

DB: My interest started in primary care, and I realized that addiction has impacted patient's lives and that it's something to be equipped with as internists to address our patient's needs. I was able to focus on this through my internal medicine residency and saw a need for it here at UAB. I came back hoping our residents would eventually feel empowered and take skills back into their own practice.

How did the addiction medicine rotation come to be?

LL: Dr. Bradford and I joined forces when we came back. We knew it was something we wanted to have available for residents. The reason it came to be as a rotation was resident driven. It initially started as a rotation as one of the clinics of block month and through resident feedback, we saw they wanted to know more about substance use disorders.

DB: Very resident driven. UAB is a great general internal medicine program and trains excellent generalists and I was lucky to have huge internal medicine mentors in residency and feel lucky to be a mentor to residents and thinking of this as a general internal medicine skill to have.

What are the goals for the addiction medicine curriculum?

LL: As part of the outpatient block, residents will be rotating at three clinical sites including the Beacon Recovery, the Opioid Reassessment Clinic (ORC) at the VA, and on addiction medicine consults. At ORC, residents are oriented on how to best approach patients for whom there is a concern for a co-occurring opioid use disorder or where it's unclear whether the patient has opioid use disorder in addition to their chronic pain. We focus on the best approaches to diagnosis and treatment. Residents get to work with an addiction psychiatrist and a pain psychologist and learn how best to talk to patients about their pain and possible addiction. In Beacon clinic, there's a lot of management of opioid and alcohol use disorders and addressing co-occurring mental illness and health consequences of substance use. There is a counselor that will sit in on a visit with residents and give feedback on motivational interviewing, especially regarding the presence of any stigmatizing language. There's also an opportunity to interact with patients in long term recovery, who are now fully employed. We hope this allows residents to breakdown negative experiences that often occur with these same patients in the hospital.

DB: In addition to screening our patients with substance use disorders, we try to meet them where they are—even if they're not ready to engage in active treatment. It's important for them to know we have other things to offer, such as counseling on making injection practices safer, Narcan training (with handy Narcan kits) for both patients and their loved ones in order to turn the tide of the overdose epidemic, and even thinking later on about Hepatitis C screening and treatment.

How has addiction medicine changed recently?

LL: I think people are starting to see that it is a treatable illness which I think is a very good thing for patients. There's still plenty of stigma, but people are now starting to come around that it is a disease and its treatable. It's a huge step in a positive direction.

DB: I think it's amazing for residents to see that although so much of internal medicine training in regard to addiction is based in the hospital where we meet our patients at their darkest moments, that it is possible to get out of that cycle. In this elective, you're able to join us in consults, start Suboxone among other treatments and see patients go back to living their own lives, going back to work and back to being loving mothers and fathers.

What advice do you have for residents navigating addiction medicine?

LL: I would encourage residents to view substance use disorder as you would any other chronic medical information. It's a piece of information, it doesn't define the person. I encourage providers to remember (one of Dr. Bradford's phrases: "as clinicians, we should use clinical language." So even if patients refer to themselves as "addicts" or "clean", we make sure we are using non-stigmatizing clinical language. I was also introduced to the phrase "documentation is a form of advocacy." So, we do our best and make sure that our documentation is not advocating against our patients. Rather we recognize that it advocates for them.

DB: It helps to start at a place with zero assumptions and approach patients just like you would another who doesn't have the label of addiction. It's important to acknowledge and know that you already have a bias with addiction going in. It can be stigmatizing to our patients, and unless we acknowledge it, we can't treat our patients well.

Closing thoughts?

LL: Dr. Bradford and I are open to feedback. We want to hear what residents want to learn. We want to prepare residents to manage patients who have substance use disorders as you would manage anyone else, and we want to hear if we are doing that.

DB: Extremely open to feedback. We are in the primary care world, but we also want this to be a skill that cardiologists or gastroenterologists can take with them in their practice to help their patients when they're in specialty care as well.