Core Rotations
Inpatient Addiction Medicine Consults
The fellows will cover inpatient substance use disorder consults on a weekly basis at both the Boise VA Medical Center and at St. Luke's Boise Medical Center. Common inpatient consultations include complex alcohol withdrawal including delirium tremens, complications of methamphetamine use, and initiation of medications for addiction treatment. Fellows work closely with inpatient medical and psychiatry teams, the emergency room, and medical social work to assist in inpatient management of substance use disorders and smooth transitions to outpatient services or residential care.
Outpatient Addiction Medicine Consults
Fellows receive robust experience in the outpatient management of patients with substance use disorders and often significant comorbid medical and psychiatric diseases in a variety of outpatient settings.
At the Boise VA, fellows provide a wide variety of addiction medicine care in the outpatient setting, both within psychiatry and primary care-based addiction medicine clinics. They see patients shortly after hospital discharge serving as a "bridge" to ongoing care with their primary care team, offer ambulatory withdrawal management for patients with alcohol use disorder who do not need admission, and provide longitudinal care to veterans with severe substance use disorders needing ongoing addiction medicine care. Fellows become comfortable starting buprenorphine for opioid use disorder (including fentanyl, prescription opioids and kratom), using traditional, slow and high dose protocols, and prescribing all forms of medications for alcohol use disorder. Fellows engage with a multidisciplinary team ensuring that patients have access to other services as needed, including individual case management, various levels of outpatient behavioral substance use disorder treatment, contingency management, psychiatry and primary care.
At the Boise VA, the fellows develop their skills providing virtual addiction medicine care by video and phone to veterans living in rural and frontier areas across Idaho without easy access to specialty addiction care. The fellows complete full virtual substance use disorder assessments for veterans with different levels of disease severity and multiple medical and psychiatric comorbidities and become comfortable engaging in motivational interviewing and prescribing MAT virtually.
The fellows also have a longitudinal addiction medicine experience at Full Circle Health Center, a federally qualified health center in the Treasure Valley that cares for patients regardless of insurance status or ability to pay. Through this continuity clinic, fellows develop their skills prescribing medications for opioid use disorder to a diverse patient population.
Opioid Treatment Program
Fellows evaluate and manage patients receiving addiction treatment at the local Opioid Treatment Program (OTP) Raise the Bottom. They rotate through both the Nampa and Boise sites, which serve distinct patient populations with different cultural and socioeconomic backgrounds. Fellows have the opportunity to perform OTP intakes and initiate buprenorphine and methadone treatment. They work on an interdisciplinary team to comprehensively manage complex patients with severe opioid use disorder.
Residential Substance Use Treatment
The fellows care for patients admitted to the 28-day substance use disorder treatment in the Boise VA's 18-bed domiciliary. The program focuses on psychosocial treatment and relapse prevention. Fellows participate in admission evaluations (including withdrawal management, initiation of MAT, and stabilization of medical and psychiatric comorbidities), case management, co-leading of groups, and interdisciplinary team meetings. Fellows help coordinate discharges to facilitate continuation of treatment on completion of the program.
Comprehensive Pain Management
Fellows see patients in the Boise VA Opioid Safety Clinic, alongside an addiction medicine physician, a physical medicine/rehab physician, a pain psychologist, a physical therapist, a health and wellness coach, and multiple clinical pharmacists. They develop their skills in caring for patients with chronic pain and addiction (including complex persistent opioid dependence), assessing the risks/benefits of different treatments for pain in the context of their patients' unique needs, focusing on specific functional goals as well as risk mitigation. The fellows participate in all aspects of pain care, including evaluation of substance use disorders, procedures (joint injections, Battlefield acupuncture), CBT for pain groups, rehabilitative treatment including physical therapy, non-opioid pharmacologic treatment, and risk mitigation/safer prescribing if opioids are indeed needed. Fellows participate in multidisciplinary case reviews and assist with the development of treatment plans.
Elective Rotations
Advocacy Elective
Fellows have the opportunity to develop their skills in advocacy and community engagement as part of their elective time. Fellowship faculty have robust local connections to Idaho state agency leadership, educational institutions, and community-based organizations to facilitate advocacy experiences. Prior fellows have used this time to work with the Idaho Department of Health & Welfare on various projects, including a needs assessment related to case management for pregnant persons with SUD and developing a benzodiazepine taper strategy for Idaho Medicaid's pharmacy program. As well, fellows have the opportunity to participate in an after-hours Advocacy Elective run by local faculty during the legislative session, to develop their skills in writing op-eds, working with the media, speaking with legislators, and testifying.
Criminal Justice: Treatment Courts and Veteran’s Justice Outreach
Fellows have the opportunity to work alongside the Veteran’s Justice Outreach (VJO) program at the Boise VA, to support veterans caught up in the criminal justice system as a result of their substance use. The Boise VA VJO team works veterans enrolled in Veteran's Court, a problem-solving court (alternative to incarceration) for veterans with drug-related legal charges. They also connect regularly with veterans incarcerated at the local county jail or in state prison. Fellows will join the VJO team in assisting veterans in accessing treatment services and recovery supports, will provide medical and addiction medicine expertise to the Veteran's Treatment Court team, and will have the opportunity to sit in on Treatment Court and tour a local jail and state prison, to better understand their patients' experiences as they cycle in and out of the criminal justice system.
Pain Procedures
Fellows will have the opportunity to pursue additional training in procedure-based pain management at the Boise VA. Through this elective they have the opportunity to learn more about epidural steroid injections, Battlefield/auricular acupuncture, nerve blocks, and trigger point injections as well as ketamine and lidocaine infusions for severe, refractory pain.
Research Elective
Fellows can choose to use elective time to delve further into substance use-related research or quality-improvement work. They could do this work alongside a local mentor or potentially continue research they started prior to the fellowship.
Tobacco Cessation Clinic
Fellows have the opportunity to rotate through the Boise VA Tobacco Cessation Clinic, which is largely staffed by clinical pharmacists. Veterans interested in tobacco or nicotine cessation are offered medication assistance, including bupropion, varenicline, and various forms of nicotine replacement therapy. The veterans have frequent follow up and clinicians use motivational interviewing techniques to help achieve and sustain remission.
UW Seattle Electives
Fellows can choose to spend up to a month in Seattle for a more urban addiction medicine experience, rotating alongside UW-Seattle Addiction Medicine fellows at Harborview, a large publicly-owned county medical center with a busy inpatient and outpatient addiction medicine service, or VA Puget Sound, a larger federal facility with significant inpatient and outpatient addiction medicine resources.