Primary Care Training and Education in Addiction Medicine Fellowship: expanding the addiction medicine workforce

Abstract

Background

Primary care providers (PCPs) are well-suited to identify candidates for substance use disorder (SUD) treatment and to provide patients with necessary longitudinal services and support. However, training for PCPs on how to diagnose and treat SUD is often lacking. The Primary Care Training and Education in Addiction Medicine (PC-TEAM) program is a one-year in-person and virtual hybrid program that provides more than 50 h of training and focuses on SUD-specific content.

Methods

This article describes the PC-TEAM training program and presents baseline and post-fellowship data on enrolled fellows (n = 88) to evaluate program effectiveness including changes in participant attitudes, knowledge, and comfort level in treating substance use in the primary care setting. Area Deprivation Index (ADI) scores were calculated by practice location of fellows to determine disadvantage across census tract groups.

Results

Large effect sizes in fellows’ comfort levels were observed in caring for patients with SUDs and employing motivational interviewing for SUD (Cohen’s \(d\) = 1.1, 0.78, and 0.91, respectively). The knowledge exam indicated significant improvement across all measures from pre- to post-fellowship. Nearly one in three providers (28.4%) practiced in areas with the highest ADI score of 10 and 50% in areas with an ADI score of 8 or higher.

Conclusion

TNT Fellows experienced an increased overall knowledge and level of comfort in delivering treatment to individuals with SUDs. Fellows typically worked in underserved areas serving vulnerable populations. The PC-TEAM training program provides the opportunity to further develop skills related to evidence-based screening, assessment, and treatment of SUDs.

Introduction

The United States (U.S.) is experiencing a growing epidemic secondary to substance use disorders (SUDs) and their associated morbidity and mortality. Nearly one in three individuals will meet criteria for an SUD in their lifetime [1, 2]. Substance use is a leading cause of preventable death in the U.S. In 2021, more than 100,000 individuals died due to drug overdoses, representing a 14% increase in the age-adjusted rate from 2020 [3]. While preliminary CDC data for the 12 months ending in September 2024 indicates a predicted decline of approximately 26.5% in overall drug overdose deaths compared to the previous year, resulting in roughly 82,059 predicted deaths, it is crucial to acknowledge that these figures still represent an alarmingly high number of preventable deaths [4]. Furthermore, the data reveal that while many states are experiencing declines, some are still seeing increases, and fluctuations in these rates underscore the ongoing and complex nature of the substance use crisis. In addition, more than 140,000 people die from excessive alcohol use in the U.S. each year, making it the fourth-leading preventable cause of death [5]. Despite declines in the prevalence of current smoking, the annual burden of smoking-attributable mortality in the U.S. has remained greater than 400,000 lives lost per year for more than a decade, with millions more living with smoking-related diseases [6].

Fewer than one in ten individuals who require SUD treatment receive care at a specialty facility each year [7]. Primary care settings are well-suited to identify candidates for SUD treatment, as well as to provide necessary longitudinal services and support [8]. Delivering SUD-oriented services within the existing patient trust and infrastructure established for long-term care can enhance engagement and yield more positive outcomes [9]. Integrating SUD treatment into primary care has the potential to engage a greater number of individuals [9], has higher rates of treatment adherence and retention [10], and is a cost-effective solution to the lack of available specialty providers [11]. SUD treatment within primary care has also been associated with enhanced life expectancy [11] and SUD remission [12, 13]. Even time limited and brief interventions in the primary care setting have been found to decrease adverse outcomes linked to substance use [14, 15].

Unfortunately, family medicine physicians often express low levels of preparedness to identify and assist patients with SUDs [16]. Lack of clinical knowledge and training are two of the most common barriers to implementing substance use screening and treatment [17, 18]. To address these barriers, the University of California Irvine Train New Trainers (TNT) Primary Care, Training and Education in Addiction Medicine (PC-TEAM) was created in 2023. The program was modeled from the original University of California Irvine Train New Trainers (TNT) Primary Care Psychiatry (PCP) fellowship. Started in 2016, the original one-year program was designed for primary care physicians, emergency medicine physicians, nurse practitioners (NPs), and physician assistants (PAs) – collectively considered PCPs – seeking additional training in primary care-based psychiatry, with the overarching goal of enhancing the prevention, recognition, and treatment of psychiatric conditions [19]. The TNT PCP Fellowship is a year-long clinical education certificate program for primary care-oriented trainees and providers who want to receive advanced training in primary care psychiatry. This training is provided by national experts at the interface of integrated psychiatric and general medical practice. There is a strong focus on learning with translation to delivery of behavioral healthcare for mainly underserved populations. TNT PCP fellowship training has demonstrated noteworthy effects on attitudes related to behavioral health care delivery, stigma, and professional competence [19]. This article describes the PC-TEAM training program and presents preliminary baseline and post-fellowship survey and questionnaire data to evaluate program effectiveness, including changes in participant attitudes, knowledge, and comfort level in treating substance use in the primary care setting.

Methods

Program description

The PC-TEAM fellowship was created as a separate program in addition to the University of California, Irvine TNT PCP fellowship. PC-TEAM launched in March 2023 with a specialized focus in SUDs, other co-occurring mental disorders, and complicating pain-related conditions. The one-year PC-TEAM program provides more than 50 h of training focusing on SUD-specific content including evidence-based screening, assessment, treatment, and utilization of recovery supports in the primary care setting. Although the fellowship is not an affiliated Accreditation Council for Graduate Medical Education (ACGME) approved program, the PC-TEAM program is structured to comprehensively address the core competencies outlined by the ACGME for addiction medicine training [20]. The program provides a robust foundation in the medical model of addiction, covering neurobiology and the pharmacology of various substances. The curriculum also emphasizes the epidemiology of SUDs, and the impact of substance use across diverse populations. Consistent with ACGME standards, PC-TEAM incorporates training in prevention, screening, brief intervention, comprehensive assessment, and the management of co-occurring conditions. Furthermore, it provides instruction in matching patients to appropriate care levels, utilizing pharmacotherapy and psychosocial interventions and managing intoxication and withdrawal. In essence, PC-TEAM mirrors the essential elements defined by the ACGME to ensure trainees develop the necessary expertise in addiction medicine. The program also highlights common practice challenges, including risk mitigation when prescribing opioids and managing pain in the setting of an SUD. Topics including managing pain in the setting of concerning substance use (such as cannabis, alcohol, and sedative/hypnotics) as well as safely prescribing opioids to those who may be at higher risk of opioid misuse, or already developed an opioid use disorder, were included following feedback from TNT alumni in other tracks as well as existing PC-TEAM fellows.

Programming consists of two weekend-intensive in-person conferences, bi-monthly Zoom lectures, monthly mentorship with board-certified addiction medicine/addiction psychiatry faculty, as well as career-long training. Bi-monthly Zoom lectures are live, interactive, and combine didactics and case-based learning. Additional recorded lectures are available for fellows on ancillary specialty topics through the Canva platform. Monthly 60-min mentorship sections are delivered in a group format of up to eight learners and 1–2 mentors who have specialties in addiction psychiatry or addiction medicine. Mentorship sessions consist of case-based discussion and application of content from the lectures. The curriculum includes a skills-based component on motivational interviewing techniques and ways to deliver brief, evidence-informed interventions. The training is open to clinicians including PAs, NPs, and physicians (MD and DO). Recruitment strategies include marketing by exhibiting at primary-care related conferences and referrals from past participants (alumni). The TNT Fellowships receive funding to support scholarships from the Department of Health Care Access and Information (HCAI) in California, which covers the full cost of the tuition. The criteria for these scholarships are to be a licensed clinician that works in primary care, work at a site that qualifies as an Federally Qualified Health Center (FQHC)/Lookalike, Primary Care Shortage Area, or Health Professional Shortage Area in Primary Care, serve a patient population that is at least 50% underserved or un insured, and serve or plan to serve patients 25 years of age or younger. With these criteria, recruitment is largely focused on clinicians in underserved areas of California, although the training program is open to learners from across the U.S. and includes representation from various states. In addition, the curriculum focuses on teaching strategies so that graduates from the program will be readily equipped to train colleagues in addiction medicine approaches.

Measures/program development evaluation

Attitude surveys

To measure participants’ perceptions of the utility of the program, fellows’ attitudes and self-identified practice patterns pertaining to the learned materials were assessed before and after the fellowship program. Estimates of the percentage of patients in their daily practice with SUDs and mental health disorders were collected. Their confidence in treating specific SUDs, prescribing medication for addiction treatment, and employing therapeutic techniques was recorded on a scale of 0 to 7, ranging from not comfortable at all to very comfortable. Levels of comfort with medication for addiction treatment was also assessed. In addition to the ratings of individual items, four domain scores were created by calculating an average rating of comfort level within each of these categories: Psychiatric Conditions, Substance Use and Addiction, Prescribing and Managing Medications, and Therapeutic Techniques. Fellows were also asked to identify if specific screening/assessment tools were used in their current practice.

Knowledge exam

A 36-item knowledge exam was administered at three points during the fellowship. The questions were the same at each time point, but the order of the items was random. A percent-correct score was calculated based on the total number of questions attempted. Subscale scores (measured as percent correct) were calculated based on a priori themes used when creating the survey: Medication Management (6 items), Pain Management (6 items), Substance Use Disorders (9 items), and Skills/Practice (16 items), with one item appearing in two categories. Additionally, a theme-weighted total score was calculated as a weighted average of the subscale scores. The weights used were equivalent to the proportion of the exam represented by each theme: Medication Management (16.2%), Pain Management (16.2%), Substance Use Disorders (24.3%), and Skills/Practice (43.3%). Within the larger Skills/Practice and Substance Use Disorders themes, the average percent correct for item clusters aligned with curriculum topic areas was also explored.

The Area Deprivation Index (ADI)

This index measure was utilized to assess the level of disadvantage at the primary work location of TEAM fellows. Developed by researchers at the University of Wisconsin-Madison, the ADI is available through the Neighborhood Atlas tool [21,22,23]. Based on a provided clinic street address, ADI integrates social-demographic information such as income, education, employment, and housing quality to determine disadvantage across census tract groups. Both a state-level score (1–10) and federal-level score (1–100) are provided with higher scores indicating more disadvantage. The address validation process and inclusion criteria identifying a fellow’s primary practice location are described in a previous publication [24]. Only verified practice locations in California and the state-level decile score were used in the current analysis.

Statistical analyses

Descriptive statistics characterizing the cohort of fellows were calculated at baseline for all enrolled fellows (n = 88). For the Attitude Survey, averages and percentages of fellows’ self-ratings were compared between the baseline and post-assessments for each survey item and the four domain scores. Effect sizes for dependent sample mean differences (Cohen’s d) and proportion differences (Cohen’s h) were calculated as indices of magnitude of change. For the Knowledge Exam, random effects mixed models were used to evaluate changes in the overall exam scores (both percent correct and theme-weighted total score) as well as the percent correct for each subscale. Paired comparisons of model-generated least squares means were performed for baseline to midpoint, midpoint to post, and baseline-post changes. Sensitivity analyses were performed to determine impact on total score if partially complete exams were included in the analysis. The frequency distribution of California ADI decile scores was obtained and plotted.

This study was exempted by institutional review board at the University of California Irvine. For all data collection, unique ID numbers were assigned upon acceptance to the program and mapped to the email address used to administer the surveys/exams at each assessment. For statistical significance testing this ID number was used to link the multiple assessments. Only specified staff members had access to the mapping in accordance with privacy policies. Participants were required to complete the post-fellowship survey to receive their certificate of program completion. Fellows were mass-emailed the post survey after the final lecture of the fellowship, with reminder emails every two days for up to two weeks. Individuals who still did not complete their surveys received an individual email and phone call two months post-fellowship.

Results

Participants

A total of 88 fellows started the program in 2023. Participant characteristics for the 2023 cohort are summarized in Table 1. The majority of participants were female (59.6%) between 45 to 54 years of age. Of the sample, 28.1% identified as White, 23.6% Hispanic/Latinx, 21.4% as Asian, and 11.2% as Black or African American. Professionally, 43.8% were physicians, 41.6% were nurse practitioners, and 14.6% were physician assistants. Additionally, 82.02% specialized in family medicine or primary care. Other specialties reported included pediatrics, internal medicine, and psychiatry.

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Attitudes and level of comfort

Response rates for the attitude surveys for each of the three collection points were relatively high, with 98% responding at baseline, 87% at midpoint, and 90% for post-survey completion. Prior to the start of the fellowship program, fellows estimated that an average of 57.18% of their patients had mental health disorders, whereas 31.61% had SUDs (Table 2). The average comfort level in caring for patients with SUDs was 4.2 out of 7, while the average comfort level in managing patients with mental health disorders was 5.03. Fellows indicated an average comfort level of 4.31 in employing supportive psychotherapy/counseling, 4.69 in employing motivational interviewing, and 3.44 in utilizing CBT techniques for SUD. The majority (70.1%) of fellows stated that they regularly utilized a standardized substance use screener/assessment tool in their practice. Only 3.5% of fellows mentioned that they did not incorporate any behavioral health scales in their practice.

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Post-fellowship program assessments indicated that an average of 53.48% of fellows’ patients had mental health disorders, whereas 30.38% had SUDs (Table 2). The average comfort level in caring for patients with SUDs was 5.68, while the average comfort level in managing patients with mental health disorders was 5.63. After completing the fellowship program, fellows indicated an average comfort level of 5.39 in employing supportive psychotherapy/counseling, 5.80 in employing motivational interviewing, and 5.06 in utilizing CBT techniques for SUD. Post-fellowship program assessments demonstrated that the majority (86.3%) of fellows regularly utilized a standardized substance use screener or assessment tool in their practice.

Large effect sizes of the fellowship program in fellows’ comfort levels were observed in several areas: caring for patients with SUDs, using supportive psychotherapy and counseling, employing motivational interviewing, and utilizing CBT techniques for SUD (\(d\) = 1.1, 0.78, 0.91, and 1.10, respectively) (Table 2). A medium effect size was observed for comfort level in caring for patients with mental health disorders (i.e., \(d\) = 0.6). A small effect size was observed for routinely employing a standardized substance use screener/assessment tool (\(d\) = 0.40) and there was no difference in utilizing any behavioral health scales (\(d\) = 0.07) before and after the fellowship program.

Table 3 presents summary statistics for the variables indicating fellows’ comfort level in assessing and treating specific conditions, as well as in prescribing or managing specific medications, both before and after the program. Large effect sizes were observed for comfort level in assessing and treating all of the SUD-related diagnoses. Additionally, large effects were found for comfort levels in prescribing commonly used medications for addiction including disulfiram, naltrexone, acamprosate, buprenorphine, and utilization of non-opioid pain medication. Finally, medium effects were noted for comfort levels in prescribing benzodiazepines, opioids, gabapentin, sedative-hypnotic medications, nicotine replacement, varenicline, and methadone.

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Knowledge exam

Figure 1 presents the results for the total exam score and theme subscales. Due to a time restriction in the administration of the exam, some participants failed to complete all 36 items. Exams submitted with less than half of the 36 items were omitted, resulting in analyzed sample sizes of n = 82 at baseline, 73 at mid-point, and 72 at post. At each assessment point the sample had more than 80% completing all 36 items, and more than 90% completing 30 items or more. Sensitivity analyses performed to determine impact on the percent correct score if partially complete exams were included yielded no significant differences in the sample averages (complete/partial: baseline 50.04% vs 50.41%, midpoint 57.83% vs 58.30%, and post 63.29% vs 62.65%). Items appearing at the end of exams were more likely to be missing but since the item-order was randomized this did not result in the same items always being unanswered based on placement.

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Table 4 contains the descriptive statistics for all scores and the results of the longitudinal analyses. All measures demonstrated a significant increase in the cohort’s average score from baseline to post-training across both observed and theme-weighted measures (p < 0.05). The observed total percent correct increased from a mean of 50.4% (SD = 11.3%) at baseline to 62.7% (SD = 12.3%) post-training, representing an overall increase of 12.25% (p < 0.0001). The Substance Disorder theme yielded the greatest increase during the fellowship.

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The theme-subscales also demonstrated improvements across all categories (Table 4). In the Medication Management theme, percent correct increased from 47.1% (SD = 23.2%) at baseline to 58.1% (SD = 25.4%) post-training, for a total increase of 11.01% (p < 0.05). In the Pain Management theme, the percent correct increased from 51.1% (SD = 21.5%) at baseline to 62.8% (SD = 18.2%) post-training, resulting in an overall increase of 11.68% (p < 0.005). The Skills/Practice theme saw a percent correct increase from 55.1% (SD = 13.8%) at baseline to 66.0% (SD = 13.6%) post-training, a total increase of 10.84% (p < 0.0001). Finally, in the Substance Disorder theme, the percent correct increased from 40.8% (SD = 18.0%) at baseline to 61.1% (SD = 19.6%) post-training, leading to the largest total increase of 20.35% (p < 0.0001). The Substance Use subscale and total score demonstrated significant improvement from mid-post assessment. The others (Med, Pain, Skills) demonstrated small increases (additional 1.9%—2.9%).

ADI of primary practice location

Of the 88 fellows enrolled, 82 had verified practice locations in the state of California. ADI scores could not be calculated for 8 addresses, leaving an analyzed set of n = 74. Figure 2 presents a histogram of the state decile scores. The largest proportion of practices were located in areas with the highest ADI score of 10, representing the decile of greatest disparity. Fifty percent of the cohort practiced in locations with an ADI score of 8 or higher, while 8.1% practiced in locations with an ADI score of 3 or lower.

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Discussion

A self-selected group of motivated PCPs deriving largely from areas identified as disadvantaged based on the ADI exhibited improved comfort, knowledge, and implementation of screening and treatment for their patients with SUDs after participating in the PC-TEAM fellowship. Participation in the PC-TEAM program was associated with significant improvements in the cohort’s average knowledge exam scores from baseline to post-training across both observed and theme-weighted measures, with the highest increases observed within the Substance Use Disorder theme yielded the highest increases throughout the program. Overall, results suggest effectiveness of the PC-TEAM fellowship program. Our findings are consistent with previous research on the effectiveness of clinician training in improving confidence, knowledge, and skills related to SUD treatment.

The observed increase in provider comfort, knowledge, and use of screening tools has significant implications for the potential for PC-TEAM to play an important role in addressing the national shortage of clinicians trained to treat SUDs. A significant strength of this program is the inclusion of multiple disciplines such as NPs and PAs. Advanced practice providers have historically received limited training in addiction medicine [25], contributing to inadequate prescribing of medications for addiction treatment. The fellow cohort was also racially/ethnically diverse. Additionally, the practice locations of PC-TEAM fellows in predominantly high-disparity areas with socioeconomically disadvantaged patient demographics suggest a role for PC-TEAM to help address well-documented disparities in access to SUD care including by race [26,27,28], socioeconomic status [27, 28], and rural vs. urban environments [29,30,31].

While findings of this study support an increased level of comfort treating patients with SUD, methods were not adequate to demonstrate an actual increased delivery of evidence-based treatment. However, a separate study evaluating the impact of TNT PCP fellowship training on clinician prescription rates for antidepressants has provided evidence of behavior change. Following completion of the TNT training, patients treated by PCPs who had completed the TNT PCP fellowship training received an average of 0.154 more antidepressant prescriptions per quarter-year compared to anticipated levels (p < 0.01) [32]. Future studies are necessary to examine the impact of PC-TEAM on clinical practice related-outcomes including prescribing patterns and implementation of effective behavior change strategies. The TNT Fellowship group is currently designing a new research study that will use an Artificial Intelligence-powered chatbot to assess program effectiveness. This tool is being developed to evaluate trainee knowledge before and after the intervention, and may offer a scalable, automated approach to measuring training outcomes [33, 34].

Although knowledge significantly increased from baseline to midpoint, raising questions about ideal program duration, the curriculum's second half focuses more on skills (e.g., motivational interviewing), which knowledge-based assessments may not adequately capture. Further evaluation of these programs that capture practice-based change and patient outcomes may provide additional information necessary to decide the optimal amount of exposure to content and materials. Other evaluations of training programs, particularly in motivational interviewing, have used standardized rating systems–such as Motivational Interviewing Treatment Integrity (MITI) [35, 36] and the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) [36, 37] to assess clinician knowledge and skills through audio and video recordings, fidelity scoring, and other structured evaluation techniques. Incorporating such methods in future PC-TEAM evaluations could provide more direct evidence of practice-based change. An additional limitation of this study is that the cohort included in PC-TEAM is a self-selected group of providers who willingly engaged in ongoing training for behavioral and mental health. Results may not be as generalizable to general PCPs who might not share the same dedication or interest in addiction medicine.

The majority of behavioral health care is already provided in the primary care setting [38]. Patients often do not realize they need or could benefit from substance-focused treatment and do not seek specialty treatment for SUD [39]. However, even internal medicine residency programs are not mandated by ACGME to include psychiatric training [40]. Recognizing PCPs' paucity of formal training in areas related to the diagnosis and treatment of common psychiatric conditions [41,42,43], increasing hesitation to implement existing treatment guidelines, the PC-TEAM training program was designed to promote PCPs’ development of skills to implement evidence-based screening, assessment, treatment, and utilization of recovery supports to help their patients with SUDs. Ongoing evaluation and adjustment to the training curriculum will be necessary to remain responsive to the evolving landscape of addiction medicine. Continuous feedback from participants can guide enhancements to the program, ultimately fostering a more competent workforce capable of addressing the complex needs of patients with SUDs.

Data availability

The dataset analyzed during the current study is not publicly available due to confidentiality agreements and the sensitive nature of the data.

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