‘No wrong door’: Improving care for people with addiction

Founded in 2017, the Yale Program in Addiction Medicine focuses on prevention, treatment, and harm reduction for those with — or at risk of developing — unhealthy substance use or addiction. Dr. David Fiellin, professor of medicine, emergency medicine, and public health at Yale School of Medicine, serves as the program director and works at the intersection of primary care, general health care settings, and addiction. He was also recently named the next editor-in-chief of the Journal of Addiction Medicine.

Fiellin sat down with Yale News to talk about the program, his new editorial role, and his hopes for the field in the coming years.

What got you interested in the study of addiction medicine?

David Fiellin: It was a combination of three things — the patient population, an opportunity to improve the science, and a rapidly evolving area of medicine. I always wanted to work with underserved populations. Then when I participated in the National Clinician Scholars Program here at Yale, I received high quality training in clinical epidemiology and health services research. Simultaneously, I was working on a project where I was evaluating research on the treatment of alcohol withdrawal, and I noted that the science in addiction medicine was not taking advantage of many state-of-the-art methodological techniques. And lastly, it was clear that this field was changing rapidly, with treatments becoming more readily available in general medical settings. My mentors at Yale were at the forefront of these changes so it felt like being in the right place at the right time.

What are some of the challenges in assessing and treating substance use and addiction?

Fiellin: I think one of the biggest challenges is a lack of understanding among patients, family members, and non-specialty providers about the core concepts in addiction medicine, the genetic predisposition, the neuroscience, and the rationale for the treatments that we provide. And I think that unfortunately leads to misunderstanding at best and stigma at worst.

Take, for example, the condition of opioid use disorder. That is something where the basic neuroscience has been understood since the late ’60s to mid-’70s. And we have effective medications that address the underlying neurobiology. However, most clinicians, family members, and patients seek out non-medication-based treatments because of what historically has been considered a weakness of the will as the underlying cause of the disorder. Unlike other medical conditions where patients are encouraged to use the most effective treatments, patients with addiction are often discouraged or stigmatized for taking life-saving medications.

What is the mission of the Yale Program in Addiction Medicine?

Fiellin: The mission of the program is to expand access to and improve the effectiveness of prevention, treatment, and harm reduction services for people with unhealthy substance use and those with addiction.

We are lucky at Yale to have expertise in addiction and related disciplines across a wide variety of departments and schools. I found, however, that oftentimes faculty and students were not aware of what their colleagues were doing across campus. When the program was founded, we sought to bring together physicians and faculty at the School of Medicine, School of Public Health, School of Nursing, Law School, and elsewhere to serve as a convening structure for individuals around Yale campuses that were involved in substance use, harm reduction, and addiction medicine.

What are some of your goals as director of the program?

Fiellin: My primary focus has been on building our work in the core four pillars, which are clinical services, education, research, and policy. Following our recent strategic planning process, we want to add community engagement to the pillars.

On the clinical side, our primary focus is to advance the concept that there should be no wrong door for individuals who may need help to address their substance use. One of our visions is that patients who come into our health care systems at any portal have the opportunity to receive high quality care and/or referrals for unhealthy substance use and addiction.

From the educational side, we provide subspecialty training through our addiction medicine fellowship. In addition, Jeanette Tetrault, Srinivas Muvvala, and others have created an addiction medicine thread that goes through the education that the medical students, the physicians associate students, and the APRN [Advanced Practice Registered Nurses] students receive. And we are dedicated to trying to increase the number of those underrepresented in medicine in the addiction medicine workforce.

For research, we continue to create and evaluate the most effective treatments — especially for alcohol, opioid, and tobacco use disorders — and the most effect strategies for implementing them in general medicine settings.

Regarding policy, we are actively engaged in local, state, national, and international efforts to implement the most effective evidence-based policies for substance use and addiction. For instance, with the opioid settlement funds — which are being distributed to states through settlement agreements with pharmaceutical companies and other entities involved in distributing opioids — we’ve been working with national entities to try to support the use of those funds in ways that provide the greatest return on investment. We’re also addressing the ways in which stigma is represented in legislative and regulatory practices. Our legal colleagues have identified that some of these practices are in violation of the Americans with Disabilities Act and are working with us to try to address that discrimination.

What community groups does the program currently partner with?

Fiellin: We work very closely with and many of our clinical services are provided through community organizations like Yale New Haven Hospital, Cornell Scott Hill Health Center, and Fair Haven Community Health Center. We also work with the APT Foundation and community organizations focused on harm reduction, including the New Haven Harm Reduction Task Force and the Connecticut Harm Reduction Alliance.

What are you looking forward to in your role as editor-in-chief of the Journal of Addiction Medicine?

Fiellin: To continually pushing the field to produce the best science possible to guide the treatment of patients and those at risk. I also hope to support the implementation of this science into practice and improve public discourse and policies around substance use and addiction.

What are your hopes for the field of addiction medicine in the coming years?

Fiellin: This is a key time for addiction medicine. I’m hopeful that the field will start to more accurately reflect the diversity of the patient populations we see. I’m immensely pleased to see health professional students and trainees gravitating to this area in record numbers; I think that bodes very well for the field. And I hope that stigma is reduced. We didn’t talk about cancer diagnoses in the previous century and individuals were cautious about speaking about depression and other mental health diagnoses prior to the advent of effective treatments. So I hope that individuals will start to realize that addiction is a condition that has biological and environmental contributions, that evidence-based treatments exist whose efficacy is on par with other areas of medicine, and that addiction medicine specialists can play a critical role in clinical care, public health, and policy.