Impact of a brief addiction medicine training experience on knowledge self-assessment among medical learners

Shared Medical Appointment: A Novel Model for Incorporating Group Visits Into Residency Training for Substance Use Disorders

BACKGROUND

Shared medical appointments (SMAs) are a novel modality for treating patients with similar conditions, together, by a team of interdisciplinary providers. SMAs benefit patients with substance use disorder (SUD), but no research has focused on the feasibility of implementation of SMAs in a teaching clinic.

METHODS

Primary care residents rotated in a half-day ambulatory addiction clinic for 4 weeks where a third-year resident co-facilitated 4 SMAs. Confidence, knowledge, and attitudes about SUD care were assessed using web-based surveys at weeks 0, 4, and 8. Pre- and post-intervention scores were compared using a t test for paired samples.

RESULTS

Ten residents were included in the analyses. Using a 10-point Likert scale, confidence in SUD knowledge (7.0-8.3, P = .003), confidence in counseling patients with SUD (7.1-8.2, P = .023), and confidence in facilitating an SMA (5.7-8.3, P = .007) showed statistically significant increases from baseline following exposure to the SMAs. Confidence that counseling and other treatments will make a difference for patients with illicit drug use increased (7.1-8.0, P = .142), but did not differ statistically. Furthermore, on a 4-point Likert scale, understanding of behavioral therapies for treating and preventing the relapse of SUD (2.9-3.2, P = .180) showed a similar increase. Attitudes toward patients with SUD (42.4-42.1, P = .303) and physician empathy (119.3-119.2, P = .963) did not change from pre- to post-intervention.

CONCLUSIONS

SMAs are a feasible training tool in the education of primary care residents on an addiction medicine rotation. Residents develop confidence co-facilitating SMAs after 4 weeks. Overall, exposure to SMAs during residency can provide an opportunity to increase confidence in treating patients with SUD, as well as provide a training modality that may shift the way residents interact with patients receiving SUD treatment.

Impact of Nursing Clinical Elective Courses on New Graduate Nurses' Clinical Practice: A Mixed-Methods Descriptive Study

BACKGROUND

Clinical elective courses provide additional specialty knowledge for prelicensure nursing students; however, it is unknown how these courses impact nurses' clinical practice after graduation.

PURPOSE

To describe how clinical nursing electives impact graduates' clinical practice.

METHODS

A mixed-methods descriptive design was used. Students who graduated from a prelicensure nursing program were sent an electronic survey and participated in qualitative interviews.

RESULTS

Thirty-three graduates completed the survey, with 9 participating in interviews. Sixteen graduates worked in the clinical practice areas that were the same, or related to, the clinical elective they took. Many graduates felt that taking the elective course improved their confidence in the clinical setting and provided increased knowledge that put them at an advantage over their peers.

CONCLUSION

Clinical electives may offer a means to meet health care system needs by preparing a more confident, knowledgeable new graduate in specialty areas in which nurses are needed most.

Examining Access to Primary Care for People With Opioid Use Disorder in Ontario, Canada: A Randomized Clinical Trial

IMPORTANCE

People with opioid use disorder are less likely than others to have a primary care physician.

OBJECTIVE

To determine if family physicians are less likely to accept people with opioid use disorder as new patients than people with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial used an audit design to survey new patient intake at randomly selected family physicians in Ontario, Canada. Eligible physicians were independent practitioners allowed to prescribe opioids who were located in an office within 50 km of a population center greater than 20 000 people. A patient actor made unannounced telephone calls to family physicians asking for a new patient appointment. The data were analyzed in September 2021.

INTERVENTION

In the first randomly assigned scenario, the patient actor played a role of patient with diabetes in treatment with an endocrinologist. In the second scenario, the patient actor played a role of a patient with opioid use disorder undergoing methadone treatment with an addiction physician.

MAIN OUTCOMES AND MEASURES

Total offers of a new patient appointment; a secondary analysis compared the proportions of patients offered an appointment stratified by gender, population, model of care, and years in practice.

RESULTS

Of a total 383 family physicians included in analysis, a greater proportion offered a new patient appointment to a patient with diabetes (21 of 185 physicians [11.4%]) than with opioid use disorder (8 of 198 physicians [4.0%]) (absolute difference, 7.4%; 95% CI, 2.0 to 12.6; P = .007). Physicians with more than 20 years in practice were almost 13 times less likely to offer an appointment to a patient with opioid use disorder compared with diabetes (1 of 108 physicians [0.9%] vs 10 of 84 physicians [11.9%]; absolute difference, 11.0; 95% CI, 3.8 to 18.1; P = .001). Women were almost 5 times less likely (3 of 111 physicians [2.7%] vs 14 of 114 physicians [12.3%]; absolute difference, 9.6%; 95% CI, 2.4 to 16.3; P = .007) to offer an appointment to a patient with opioid use disorder than with diabetes.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, family physicians were less likely to offer a new patient appointment to a patient with opioid use disorder compared with a patient with diabetes. Potential health system solutions to this disparity include strengthening policies for accepting new patients, improved compensation, and clinician anti-oppression training.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05484609.

Educational Studies Examining Knowledge of Substance Use Disorders and Career Aspirations Among Medical Trainees in an Inner-City Hospital

OBJECTIVES

Gaps in addiction medicine training are a reason for poor substance use care in North America. Hospital addiction medicine consult services (AMCS) provide critical medical services, including screening and treatment of substance use disorders. Although these programs often feature an educational component for medical learners, the impact of AMCS teaching on objective knowledge and career aspirations in addiction medicine has not been well described.

METHODS

The authors report findings from two sequential studies conducted at a large academic hospital in Vancouver, Canada. The first study assessed the impact of an AMCS clinical rotation on medical trainee addiction medicine objective knowledge using an online survey of 6 true/false questions before and after the rotation. The second study examined the impact of an AMCS rotation on career aspirations using 4 seven-point Likert-type questions. One-sample t tests on mean differences (MD) with Benjamini-Hochberg adjustment for multiple comparisons were employed for statistical analyses.

RESULTS

Between May 2017 and June 2018, knowledge scores were significantly higher postrotation (MD = 4.78, standard deviation [SD] = 19.5, P = 0.034) among 115 medical trainees. Between July 2018 and July 2019, aspirations to practice addiction medicine were significantly more favorable postrotation (MD = 3.48, SD = 3.15, P < 0.001) among 101 medical trainees.

CONCLUSIONS

AMCS rotations appear to improve addiction medicine knowledge and aspirations to practice addiction medicine among medical trainees. Larger-scale evaluations and outcomes research on integrating substance use disorders teaching in these settings will help move the discipline forward.

Medical Student Screening for Naloxone Eligibility in the Emergency Department: A Value-Added Role to Fight the Opioid Epidemic

INTRODUCTION

Opioid overdose education and naloxone distribution (OEND) for use by laypersons are safe and effective at preventing deaths from opioid overdose, but emergency department (ED) implementation is challenging. Curricula addressing OEND could enable students to serve in value-added roles on the clinical team, overcome challenges of naloxone distribution, and improve patient care.

METHODS

We created a 1-hour didactic session on opioid use disorder and OEND for first-year medical students in the emergency medicine elective. During two clinical shifts, students used this knowledge to perform screenings to identify patients at high risk of overdose. If a patient screened positive, students performed patient education and then notified the physician, who ordered a naloxone kit.

RESULTS

Thirty students received the didactic and conducted screening shifts. Of 147 patients screened, 40% (n = 59) were positive for naloxone eligibility, 21% (n = 31) reported that someone close to them used opioids, 18% (n = 26) had witnessed an opioid overdose, 12% (n = 17) had previously overdosed themselves, and 12% (n = 18) previously knew what naloxone was. Fifty-nine naloxone kits were distributed over the 3-month pilot versus 13 naloxone prescriptions for patients discharged from the ED the prior year.

DISCUSSION

Through didactic training and structured patient engagement, medical students gained knowledge of and hands-on experience with addiction medicine, discussed sensitive topics with patients, and identified a high volume of patients eligible to receive naloxone. Medical student screening for OEND in ED patients is feasible and adds significant value to the clinical team.

Do People Trust in Robot-Assisted Surgery? Evidence from Europe

(1) Background: The goal of the paper was to establish the factors that influence how people feel about having a medical operation performed on them by a robot. (2) Methods: Data were obtained from a 2017 Flash Eurobarometer (number 460) of the European Commission with 27,901 citizens aged 15 years and over in the 28 countries of the European Union. Logistic regression (odds ratios, OR) to model the predictors of trust in robot-assisted surgery was calculated through motivational factors, using experience and sociodemographic independent variables. (3) Results: The results obtained indicate that, as the experience of using robots increases, the predictive coefficients related to information, attitude, and perception of robots become more negative. Furthermore, sociodemographic variables played an important predictive role. The effect of experience on trust in robots for surgical interventions was greater among men, people between 40 and 54 years old, and those with higher educational levels. (4) Conclusions: The results show that trust in robots goes beyond rational decision-making, since the final decision about whether it should be a robot that performs a complex procedure like a surgical intervention depends almost exclusively on the patient’s wishes.

Provider Attitudes and Practices for Alcohol Screening, Treatment, and Education in Patients With Liver Disease: A Survey From the American Association for the Study of Liver Diseases Alcohol-Associated Liver Disease Special Interest Group

BACKGROUND & AIMS

While abstinence-promoting behavioral and pharmacotherapies are part of the therapeutic foundation for alcohol use disorder (AUD) and alcohol-associated liver disease (ALD), these therapies, along with alcohol screening and education, are often underutilized. Our aim was to examine provider attitudes and practices for alcohol screening, treatment and education in patients with liver disease.

METHODS

We conducted a survey of primarily (89%) hepatology and gastroenterology providers within (80%) and outside the United States (20%). Surveys were sent to 921 providers with 408 complete responses (44%), of whom 343 (80%) work in a tertiary liver transplant center.

RESULTS

While alcohol screening rates in liver disease patients was nearly universal, less than half of providers reported practicing with integrated addiction providers, using alcohol biomarkers and screening tools. Safe alcohol use by liver disease patients was felt to exist by 40% of providers. While 60% of providers reported referring AUD patients for behavioral therapy, 71% never prescribed AUD pharmacotherapy due to low comfort (84%). Most providers (77%) reported low addiction education and 90% desired more during GI/hepatology fellowship training. Amongst prescribers, baclofen was preferred, but with gaps in pharmacotherapy knowledge. Overall, there was low adherence to the 2019 AASLD practice guidance for ALD, although higher in hepatologists and experienced providers.

CONCLUSIONS

While our survey of hepatology and gastroenterology providers demonstrated higher rates of alcohol screening and referrals for behavioral therapy, we found low rates of prescribing AUD pharmacotherapy due to knowledge gaps from insufficient education. Further studies are needed to assess interventions to improve provider alignment with best practices for treating patients with AUD and ALD.

Towards a framework for implementing physician education in substance use disorders

•Substance use education is inadequate despite the urgent need to equip health care professionals to effectively treat substance use disorders.•Ineffective timing of substance use education within the timeline of medical training contributes to a lack of knowledge and negative attitudes.•The imminent implementation or scaling up of the various training initiatives calls for an urgent examination of their methods from a contextual perspective.

Predicting longitudinal service use for individuals with substance use disorders: A latent profile analysis

INTRODUCTION

Substance use disorders (SUD) are chronic conditions that often warrant coordinated medical care throughout a relapsing and remitting course. However, SUD treatment is frequently measured as a binary outcome, where individuals either receive or do not receive care following the immediate treatment seeking event. This study aimed to describe longitudinal treatment seeking behaviors by assessing service use patterns among individuals with diagnosed SUDs in a safety net hospital that offers a "no wrong door" care model. This study also examined whether certain patient subgroups were more likely to transition to service use patterns that support recovery or treatment disengagement over time.

METHODS

The team conducted a retrospective cohort study using electronic health record data from adult patients diagnosed with SUDs (n = 1157) who regularly accessed services at a safety net hospital over a five-year period. The study used latent class analysis (LCA) and latent profile analysis to empirically identify distinct treatment utilization profiles of individuals with SUDs. We used multinomial logistic regression to evaluate predictors of class membership and transitions over a five-year period.

RESULTS

The research team identified five distinct service use classes, including patients who disengaged from services (42.4%), or those who predominantly used outpatient substance use services (7.0%), mental health services (13.0%), primary care services (24.7%), or other specialty care services (13.1%). Being female and an older adult were statistically significant predictors for membership in any service use-driven status. Black patients had increased odds for "substance use service" and "primary care" service statuses over time.

CONCLUSION

LCA and latent transition analysis (LTA) methods are novel approaches for identifying profiles of patients with higher risk for health services disengagement. SUD treatment engagement strategies are needed to reach males, young adults, and individuals with non-opioid SUDs.

Towards competency-based medical education in addictions psychiatry: a systematic review

BACKGROUND

Current curriculum guidelines for addiction training in psychiatry need to be adapted to the competency by design framework to integrate clinical skills in addiction.

OBJECTIVE

We conducted a systematic review to identify curricular and educational interventions to build competency among psychiatry residents and fellows in addiction psychiatry.

METHODS

We followed the PRISMA guidelines, searching five databases from inception to August 2020 for relevant evaluation-type studies exploring addiction psychiatry competency among psychiatry residents and fellows. We appraised study quality using the Joanna Briggs Institute's risk of bias tool for observational designs.

RESULTS

From 1600 records, 17 studies met inclusion criteria. Addiction psychiatry competencies spanned themes involving core knowledge development; attitudinal, communication and leadership skills; screening, assessment, diagnosis; management; and special populations. Examples of effective educational interventions to enhance addiction competency include specific modules for substance use disorders and integrated clinical rotations that simultaneously combine multiple types of skills. Lived experience improved trainee attitudes towards addiction psychiatry.

CONCLUSIONS

While there is current evidence supporting strategies for developing competency in addiction psychiatry, the lack of studies measuring sustained competence over a longer-term follow-up period and the absence of randomized controlled trials limit the overall strength of evidence in this review. Current psychiatry entrustable professional activities (EPAs) involving addiction only partly overlap with curriculum training guidelines and studies identified in this review. These EPAs need to be better identified for training programs, competence in those EPAs better delineated for residents and preceptors, and evaluations should be done to ensure that adequate competence in addictions is attained and sustained.

Treating Withdrawal and Pain in Inpatients With Opioid Use Disorder: A Brief Educational Intervention for Internal Medicine Residents

INTRODUCTION

Despite the effectiveness of opioid agonist therapy (OAT) for treating patients with opioid use disorder (OUD), insufficient education remains a barrier to prescribing. Internal medicine (IM) residents are optimally positioned to facilitate use of OAT, especially in the inpatient setting. We implemented an educational intervention aimed at increasing IM residents' knowledge and confidence regarding prescribing OAT to inpatients with OUD.

METHODS

We created a 35-minute, case-based presentation highlighting the management of opioid withdrawal using OAT and treating pain in inpatients on maintenance OAT. It was presented to IM residents beginning their general medicine ward rotations from November 2019 through January 2020. We developed a survey to measure participants' knowledge (mean number of questions correct out of five) and confidence (mean Likert-scale score, 1 = Not at all confident, 5 = Extremely confident, on each of five items) regarding prescribing OAT in the inpatient setting. We compared knowledge and confidence before versus 1 month after the intervention using paired Student t tests, with p < .05 indicating significance.

RESULTS

Of 103 unique residents completing ward rotations, 29 (28%) completed both the pre- and 1-month postsurveys and were included in the analysis. The mean number of knowledge questions correct increased from 3.1 pre- to 4.3 postintervention, and mean confidence scores increased from below 2 pre- to over 3 postintervention in four of five items (ps < .001).

DISCUSSION

A brief, generalizable, educational intervention significantly increased residents' knowledge of and confidence in prescribing OAT in inpatients with OUD.

Infectious Complications of Addiction: A Call for a New Subspecialty Within Infectious Diseases

Infectious diseases (ID) physicians are increasingly responsible for the management of infectious consequences of substance use disorders (SUD). While we are often consulted for diagnosis and treatment of the infectious disease, it is clear that successful management of these infections requires a holistic approach, including acknowledgement and treatment of the underlying SUD. As we have learned through years of treating human immunodeficiency virus and hepatitis C virus infections, ID physicians have unique expertise in addressing both the infection and the complex biopsychosocial factors that underpin the infection. Many ID physicians have incorporated the management of addiction as part of their scope of practice, and here we seek to give a name and define the role of these ID/addiction dual specialists. We define the potential role of ID/addiction physicians in clinical care, health administration, and research, as well as provide recommendations to bolster the supply and reach of this burgeoning subspecialty.

Development and Evaluation of the Online Addiction Medicine Certificate: Free Novel Program in a Canadian Setting

BACKGROUND

Despite the enormous bur-den of disease attributable to drug and alcohol addiction, there remain major challenges in implementing evi-dence-based addiction care and treatment modalities. This is partly because of a persistent lack of accessible, specialized training in addiction medicine. In response, a new online certificate in addiction medicine has been established in Vancouver, Canada, free of charge to participants globally.

OBJECTIVE

The objective of this study was to evaluate and examine changes in knowledge acquisition among health care professionals before and after the completion of an online certificate in addiction medicine.

METHODS

Learners enrolled in a 17-module certificate program and completed pre- and postknowledge tests using online multiple-choice questionnaires. Knowledge acquisition was then evaluated using a repeated measures t test of mean test scores before and after the online course. Following the certificate completion, a subset of learners completed the online course evaluation form.

RESULTS

Of the total 6985 participants who registered for the online course between May 15, 2017 and February 22, 2018, 3466 (49.62%) completed the online pretest questionnaire. A total of 1010 participants completed the full course, achieving the required 70% scores. TThe participants self-reported working in a broad range of health-related fields, including nursing (n=371), medicine (n=92), counseling or social work (n=69), community health (n=44), and pharmacy (n=34). The median graduation year was 2010 (n=363, interquartile range 2002-2015). Knowledge of the addiction medicine increased significantly postcertificate (mean difference 28.21; 95% CI 27.32 to 29.10; P<.001). Physicians scored significantly higher on the pretest than any other health discipline, whereas the greatest improvement in scores was seen in the counseling professions and community outreach.

CONCLUSIONS

This free, online, open-access certificate in addiction medicine appeared to improve knowledge of learners from a variety of disciplines and backgrounds. Scaling up low threshold learning opportunities may further advance addiction medicine training, thereby helping to narrow the evidence-to-practice gap.

In-hospital training in addiction medicine: A mixed-methods study of health care provider benefits and differences

Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.

Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems

Substance use disorders are highly prevalent and are a large driver of costly inpatient medical care; however, historically the substance use disorder has gone unaddressed during an inpatient stay. Inpatient addiction consult services are an important intervention to use the reachable moment of hospitalization to engage patients and initiate addiction treatment. Addiction consultation involves taking an addiction-specific history, motivational interviewing, withdrawal symptom management, and initiation of long-term pharmacotherapy. Addiction consult services have the potential to decrease readmissions and utilization costs for medical systems and improve substance-related outcomes for patients.

An opioid overdose curriculum for medical residents: Impact on naloxone prescribing, knowledge, and attitudes

BACKGROUND

Despite escalating opioid overdose death rates, addiction medicine is underrepresented in residency curricula. Providing naloxone to at-risk patients, relatives, and first responders reduces overdose deaths, but rates of naloxone prescribing remain low. The goal of this study is to examine the impact of a brief curricular intervention for internal medicine residents on naloxone prescribing rates, knowledge, and attitudes.

METHODS

Internal medicine residents (N = 160) at an urban, tertiary care medical center received two 1-hour didactic sessions addressing overdose prevention, including intranasal naloxone. The number of naloxone prescriptions generated by residents was compared to faculty, who received no similar intervention, in the 3-month periods before and after the curriculum. Resident knowledge and attitudes, as assessed by pre- and post-intervention surveys, were compared.

RESULTS

The resident naloxone prescribing rate increased from 420 to 1270 per 100,000 inpatient discharges (P = .01) and from 0 to 370 per 100,000 ambulatory visits (P < .001) post-intervention. Similar increases were not observed among inpatient faculty, whose prescribing rate decreased from 1150 to 880 per 100,000 discharges (P = .08), or among outpatient faculty, whose rate increased from 30 to 180 per 100,000 ambulatory visits (P < .001) but was lower than the post-intervention resident rate (P = .01). Residents demonstrated high baseline knowledge about naloxone, but just 13% agreed that they were adequately trained to prescribe pre-intervention. Post-intervention, residents were more likely to agree that they were adequately trained to prescribe (Likert mean 2.5 vs. 3.9, P < .001), to agree that treating addiction is rewarding (Likert mean 2.9 vs. 3.3, P = .03), and to attain a perfect score on the knowledge composite (57% vs. 33%, P = .05).

CONCLUSIONS

A brief curricular intervention improved resident knowledge and attitudes regarding intranasal naloxone for opioid overdose reversal and significantly increased prescribing rates.

Adolescent Addiction Curriculum: Impact on Knowledge Self-Assessment in Pediatric Learners

Introduction

Addiction is developmentally a pediatric-onset disease. Adolescent addiction recently gained the nation's attention due to the steep increase in opioid-related drug overdose deaths. Educating future adolescent health providers on adolescent addiction is a strategic initiative to mitigate the impact of this challenging public health concern.

Methods

We used a logic model worksheet to identify key target areas informing the curriculum content development. The curriculum was written to be delivered in three successive parts-the Science of Addiction, Adolescence and Addiction, and Diagnosis and Treatment-each within a 2-hour interactive lecture session using PowerPoint presentations, brief videos, and learner activities. We collected data using pre- and postsession self-evaluation questionnaires. We calculated mean differences in scores and obtained qualitative data from learner comments.

Results

Sessions were well received by attendees. A total of 31 participants attended at least one session. Knowledge of adolescent addiction increased in each session, with the greatest increase in the Science of Addiction (1.6, p = .0011), followed by Diagnosis and Treatment (1.1, p < .0001) and Adolescence and Addiction (0.9, p < .0001).

Discussion

Attendance at one or more sessions improved participants' addiction-related knowledge. Graduate medical training programs can provide adolescent addiction education using systematic curricula such as this. Furthermore, this curriculum can be adapted to suit different groups of learners.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.