My name is Sandra D. Young and I am a clinician educator. I am not an addiction specialist, but one day I was driving into work and I was listening to a story on NPR and it was about my local cafe, 1369 Cambridge Street, known familiarly to our fellows and residents as the 1369. It's the cafe where they all pick up their lattes and cappuccinos on their way to work and NPR was interviewing the barista and he was talking about how they had put up a sharp box at the bathroom and he had trained all of his employees in naloxone administration. And I just started to cry and I thought, oh my gosh this guy is doing more to help with this addictions crisis than I'm doing or any of my fellows is doing. And it motivated me to look at what psychiatry was doing in terms of addiction education and I came to the conclusion that we weren't doing much. And so when I became the president of the American Association of Directors of Psychiatry Residency Training, that's a mouthful, my presidential initiative was around trying to improve addiction education in psychiatry and so part of what you'll hear today is a result of that work. I have no other real conflicts relevant to this presentation. So what I thought I would talk about today is a little bit about the current landscape and in terms of what's happening out there and then some very specific ways in which I think we could improve addiction training and that's based on work that I did with a group of both educators and addiction specialists. And then we'll talk a little bit about how you can integrate addiction training into general psychiatry residencies. So how that might look like sort of from a training director standpoint. And then I wanted to touch on the pain addiction and mental health triad which ACGME has sort of raised in part because they've heightened the requirements around pain and addiction, excuse me around pain. And then I want to talk very importantly about the role of stigma and finally I just want to end with things that I think we all can do to try to improve the situation that we're in. So I may not need to tell you all this but and there are many ways of telling this story but just some statistics that 50% of Americans over the age of 12 and older use tobacco, alcohol or an illicit drug in the past months. That's 50%. And of the 18 million Americans who suffer from both a mental illness and a substance use disorder only 16% receive treatment for both. So I cite that statistic because it seems to me if there is any group of clinicians trained to teach to treat that population it's us. And currently only 16% of them are getting help. And then of course we know that the overdose rate keeps climbing and NPR has put it I think very succinctly that there's a drug death every four and a half minutes in this country and so far no quick fixes. I also just wanted to underscore that if this isn't just about substances we know behavioral addictions are a problem and so in young people 13 to 17, 95% report being on a social media platform and more than a third say that they are on it quote-unquote almost constantly. So that's what's happening out there in a public health way. Meanwhile what's happening in a training way. Well the current training requirement and it has been this for years in general psychiatry training is for one month FTE of addiction training. So in a four-year residency of general psychiatry 2% of the time has to be devoted to addictions. So those my colleagues and I like to call this one of the worst educational inequities that is out there right now. Back when I was starting my work as the around addictions as president of the of our task force and now committee on addictions at ADPERT we did a survey of training directors and we were told that 40% of those who responded said that they did buprenorphine waiver training. So 60% were not teaching their residents how to use buprenorphine. Only about half said that it had any kind of formal didactics on addiction and they said that the problem they had was finding faculty to teach. And as we know we do not have enough addiction specialists right so in 2022 we had you know 33.7 K physicians board-certified in addiction medicine and certified in addiction psychiatry never going to be enough right. And even the positions that we have aren't filling so only roughly about half of positions fill each year in addiction psychiatry fellowship. So this is a huge workforce issue that we are never going to meet unless folks like general psychiatrists integrate addictions expertise into what they do. So let me say a little bit about how I think this could be improved and I'm going to acknowledge by name at the end the folks who helped me develop this list but it really was a group effort over almost a couple of years in developing what we thought were reasonable improvements. So the first is to use the term substance-related and addictive disorders which is the current DSM-5 terminology. It turns out not to be often used a lot of you know people still say SUD and all the rest of it. The reason I think and we think it's important is that it isn't only about substances as I alluded to earlier but also I believe this term really emphasizes the idea that it's an addictive disorder that it is a problem of addiction. Yes there are unique differences between cannabis and cocaine and fentanyl etc but that the fundamental problem is an addiction problem. The second thing is that the the education really needs to be longitudinal and developmental from the first year of training to the PGY4 year and it needs to be integrated it can't be siloed right it needs to be integrated into every experience that they have because as we know addictions are there right but if you don't screen for them you don't find them and so this what I'm constantly pushing for people to be screening in all settings because I think that's how we're going to be finding the problems and there is evidence in I'm an educator and there's really good evidence that's what we call spiraled learning which is the idea that you introduce a topic early and then you keep coming back to it at increasing levels of complexity and depth is really the best way to teach. Wherever you're going to practice I think people need to know non-stigmatizing language right so and we know there was actually just a very moving story in my Harvard Gazette about the impact that stigmatizing language can have on people and we know that it really interferes with people's engagement. And then stigma so I think it's crucial we understand and prevent stigma towards these disorders and I'm going to come back to that in a little bit. Addiction training needs to really take place in all of these different settings so if you ask most training directors these days what they do for their one month required FTE of addiction training they'll tell you things like the residents spend a month on a detox unit or the fellows you know spend a month you know in the emergency room handling all the patients who come in who are intoxicated and not surprisingly that gives them a rather skewed sense of what treating addictions is like and we know that actually over the course of training residents become less inclined to be interested in teaching in working with patients struggling with addictions because their experience has been almost always negative they have a view that patients can't get better they're rude to you they kick you you know it's not fun and and I think we've really done the whole field of disservice. So important that we cover all stages of this disorder including relapse prevention and recovery so important bless you and of course we need to be teaching prevention models and early intervention strategies super important a harm reduction model. I am a child psychiatrist so I'm a developmentalist by training but I we know that some of the most problematic issues and addictions right now are happening in our senior population right and I know as a child psychiatrist that that kids who are going to get into trouble as young adults with substances do so you know are starting in their teen years so we really need to be covering the full spectrum of the developmental lifespan and we need to be including the full range of socioeconomic demographic and racial ethnic backgrounds. This is addictions as you know is a very democratic disorder it affects everybody and then supervision so people need to be taught by people who are experts in the area that they are supervising in so you know if it's psychopharm then you need people who are psychopharm experts if it is family-based interventions then you need experts who are in family work and so on and then finally there are so many resources now available online so when programs tell us that they they really can't think of anything to do in their program they don't have any faculty etc etc etc I say oh well look you know check out this resource and this resource because honestly that the quality and range of good content out there is is terrific and I'll mention some of them later a little later. So how can we integrate addiction training into general psychiatry training? So here are some things I'm going to focus first of all on what to teach. We teach interviewing skills to our incoming psychiatry residents but too often we really don't teach them adequately how to interview for SRADs and that should include learning the use of critical screening instruments. So in child psychiatry I want every child psychiatry fellow who graduates to be very familiar with the S2BI and then to know where to go from there for a more narrow band screen. Motivational interviewing you know it's hard not to argue that that is just a basic skill across psychiatry and everybody should know it but again that needs to be really emphasized and and the stages of change model still is it such a useful concept. They should know residents should know how to order interpret and appropriately use laboratory measures and that's another area that we in my experience don't do a great job on. They need to learn how to identify and manage co-occurring psychiatric disorders so as I was saying earlier I can't imagine who else in medicine would be expert at treating SRADs that co-occur with DSM-5 you know psychiatric diagnoses and that interface is a unique clinical problem I would say that psychiatrists are uniquely equipped to treat and then of course they need to be able to manage intoxication overdose and withdrawal. We need to teach them hard reduction strategies and very importantly to teach them some things in the moment that they can do right so knowing about self-help organizations and referrals right that's people should know the lay of the land and how to access these. They should know some basic behavioral interventions that they can mobilize in the moment to help their patients. They certainly should know medications for addiction treatment. I would say every resident should know how to prescribe buprenorphine and then they should know the ASAM criteria right I think that's a really useful model that that residents can keep in their head for determining the appropriate level of care and it's a bit of an antidote to this notion that they're essentially taught in a kind of hidden curriculum way that if they feel uncomfortable with substances and other addictions they should just refer out right it's like oh that's not my bailiwick I'm really not an expert so I do think that those criteria are very useful for that and then super important they need to learn how to engage families and the patient's organic support system. Where can all of this be taught? Well I would say it can be taught across the board so one of the things that people say again is that they just don't have the in-house expertise and I say but you know there must be in your community places where patients are being treated so whether they're sober housing places or mutual aid and self-help group programs or physicians health services right there's got to be a place that you can access that to give your residents an experience in this and so one of the things that we try to do at the Add Per Addictions Committee is to help training directors and others get creative in their thinking about about how to integrate and where they can use different sites so for example we use school-based sites in child psychiatry right that's a huge need. One of the hot issues is faculty development for these programs that say they just don't have the in-house expertise and so this is sort of a list of things that I typically like to refer people to. One of them is this meeting and I hope you've noticed at this meeting that there's an I mean the theme this year is addictions but there's always a lot of really good content including learning how to prescribe buprenorphine so you know that if people want to learn they can certainly come to this meeting but these other meetings are also very helpful the AAP and the Adpert meeting we always have content on that. There is the National Neuroscience Curriculum Initiative is was developed by leadership at Adpert and it is a focuses on neuroscience but it has great addiction content and it's intended for people to be able to learn very quickly from and then ASAM has great stuff but then of course there's also PCSS through SAMHSA and so if people are nervous I say call up PCSS if you're not sure how to start a program or if you need ongoing clinical help you know these are the folks who can help you. SAMHSA has a great opioid overdose prevention toolkit. NIAAA has a great combined behavioral intervention manual and then there are a number of different terrific books that are put out by APA Publishing for example Art Woloszek just published a book on addictions in the geriatric population that's terrific. I also like to plug this is a course that is was developed by folks at Yale but this is a Coursera online course called Addiction Treatment for Healthcare Providers. If you have a faculty member or someone in your in your group practice who was interested in learning more about addiction this is often my go-to for them. It's a really wonderful sort of start for people to get comfortable with this content. So what about the pain addiction and mental health triad? So in 2021 the Accreditation Council of Graduate Medical Education which is the overseeing body for all residency training programs held a conference called the Stakeholders Conference on Preparing Residents and Fellows to Manage Pain and Substance Use Disorder and I was invited to this conference and part of what they wanted was to think about recommendations and they issued and if you go to their website you can see they issued a white paper on recommendations. A group of us psychiatrists who participated in this were concerned because they talked a great deal about pain and when I say they this was all the participating physicians from all different specialties. They talked about pain and they talked about substances. They did not talk about mental health and so as I'm sure you know those with significant trauma, depression, I could go on and on are at higher risk of substance use disorders and also have a different experience of pain and thresholds for pain. So we actually wrote a letter to ACGME and said this is what we think is a much better model of thinking about this. And you're really doing a disservice to patients if you don't consider mental health disorders. And those surgeons who were talking about pain and opioid use, for example, probably should be getting psychiatric consultations, for example, on many of their cases. And they basically pushed it back to us, ACGME, and said, OK, you guys go ahead. And you can propose this model. And it's your field. You make the recommendations. So in this group that I got together about specific recommendations, I invited CL psychiatrists who were experts in pain. And I asked them to come up with what they thought were the core skills that psychiatrists need to know about pain. And this is their list. So they thought residents should understand neurological, psychological, and social aspects of pain, that they ought to be able to do a biopsychosocial assessment of both acute and chronic pain, including using some of these evidence-based tools. And very importantly, they should know a range of non-pharmacological and pharmacological treatment options and their respective risks and benefits and how to prioritize the safest treatments first. And then finally, this idea of being familiar with pain management services and when and how to refer. But again, I want to emphasize that they really felt that there is a lot psychiatrists can do before they refer out and that we need to sort of elevate the expectation about what psychiatrists are doing with these patients. Sorry, this is a continuation. They need to be familiar with addiction specialty services, the non-medical community report, CBT, the relationship between pain and social determinants of health, especially in the resident's community, understanding why chronic pain co-occurs with psychiatric disorders, and be able to do a real assessment of that, and then knowing something about complementary and alternative treatment strategies. So this is James Kimball was the lead on this. And this was his suggestion of the very specific skills that graduating residents should have. So this idea of getting into the informed consent and shared decision-making process about pain and co-occurring mental disorders, and really developing a collaborative treatment plan that is team-based, conducting a general pain assessment, and then doing that risk-benefit profile I was just describing, and being able to do this in a variety of setting. So stigma is just such an important topic. And one of the things that we did at Adpert to try to combat stigma among ourselves, because we are as guilty of stigma as anybody else, is to bring in psychiatrists and other physicians working with psychiatrists. And they gave a plenary, actually. These were people in recovery. And they told their stories. And as it turned out, it happened during COVID, which I was initially a little disappointed about. But it ended up being on Zoom, which meant that you could see the presenters' faces up close and personal. And you could see the audience and their faces. And there was a running chat. And every single presenter was so moving. And they were weeping on screen. They were looking down in shame. And it was just one of the most powerful presentations on this topic I have seen. And the chat just went crazy. People were just so moved and so grateful. These were people they had been passing at meetings for years. And they had no idea that these people were in recovery. And the amount of loss and shame that these physicians had suffered as they, in a very isolated way, had to contend with their own addictions. So I am a big believer in reminding us that we medical professionals are not immune from addictions, that almost 6% struggle with illicit drug use, and that at some point in their career, between 10% and 20% of physicians will struggle. And then there are many wonderful personal narratives that have been published. I particularly like this one. But I think exposing our trainees to this and discussing honestly. One of the folks who presented, actually not at our plenary, but at another Adpert workshop, was a young physician who described going through her residency training with her water bottle, just like one of these. And she would bring it into didactics and be sipping away. And she said, and nobody realized it was vodka in that bottle. Nobody realized. And she went through. Fortunately, she had a very empathic training director. And her problem was picked up eventually. And she has gotten help and is developing a fine career. But it's right in front of us every day. And we need to get past our own stigma. So I wanted just to say a little bit more about stigma. There's some really interesting research on stigma. But basically, there are three kinds of stigma. There's this individual stigma, which is about the processes that the stigmatized person goes through to conceal, the self-stigma, the internalization of the negative perceptions. And so that's one kind of stigma. But the other is clearly interpersonal. And that's the one that we see between doctors and patients playing out with all kinds of biases in place. But there's also this structural one. It's sometimes called social stigma, which has been defined as societal level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized. And I would argue that we really are facing this problem, both within medicine itself, that we have discriminatory practices within our systems of care, but also more broadly in our society. And not surprisingly, this kind of stigma is associated with negative health outcomes. So this is, I think, we need to really confront stigma on all these different levels. There is a terrific piece that John Bornstein wrote. He's the former editor of Psych News. And he wrote a piece that I would highly recommend on the APA website that goes into this further. Stigma itself is an old Greek term. And it was actually a tattoo that people had this mark burned into their skin in ancient Greece. And it indicated that they were kind of like lepers who should be shunned. And researchers in stigma have said that actually there's no country, society, or culture where people with mental illness have the same societal value as people without mental illness. So we know the mentally ill are already stigmatized. And those who have mental illness with co-occurring SRADs are further stigmatized. So I think one of the things that we probably don't think about enough is what is the function of stigma, the sort of psychological function. And those of you who have read Isabel Wilkerson's book, Cast, will have heard her talk about how if you go around the world, all societies or many societies seem to have some kind of hierarchical system in which there are those who are better than and those who are lesser than. And that this seems to be a need, a human need, that we have to put people in these kinds of categories. And it's the people in power who do it. And presumably, they do it to assure themselves of their own value, goodness, and sense of control. So I always say when people are talking about stigma, let's think for a little bit, what's the function of stigma here? What is this stigma doing that people may unconsciously want it to be doing? And let's really think about that in more depth. So what can you do? So I think that if you're in private practice, you can bring the issue of enhancing your expertise to SRADs to peer learning sessions like group supervision. So I think this should be a lifelong learning activity for all of us. We enter the field. I happen to be a director on the AVPN board. And so I'm very engaged in lifelong learning. And one of the reasons I entered this field was that it's a field that's always changing. And so I think we need to sort of structurally bring it in, do in-services, commit to at least one continuing education session per year, either online or in person. Just tell yourself that my CMEs this year are going to include something on addiction. There are some terrific addiction newsletters out there which you can subscribe to. And then talking with your group or in your own practice, thinking about integrating, deciding on which broadband screens and narrowband screens you're going to use in your practice. And if you have trouble, get an addiction mentor. There are people out there. My experience as someone who came to this really not having much expertise in addictions, I have found that the experts are extremely willing to help. And so if you can find an addiction mentor in your community to help you, that can be great as well. If you have a group practice, you can bring in an expert in your practice to do in-services, hold monthly meetings, and to talk about your cases. I think case discussions are really useful as you're learning and building confidence in managing these kinds of cases. And then, as I said, bring in in-service consultants and teachers. If you're in education like I am, then I think it can be helpful to go to the training director, the program director, and say, I want to improve my expertise in SRADs. And I would like to be your faculty ambassador to improving the treatment of addictions in this program. And then work with them to think about how the program can improve. Go to Adpert workshops. Take the Coursera course. Look at what other programs are doing. Think about creative ways to mobilize addiction teaching opportunities in your communities. And I think talking about stigma, bringing in people, ideally physicians, ideally psychiatrists, who are in recovery, and have them tell their story of how hard it was to access care, how nobody asked them, nobody asked them whether they were struggling with any kind of addiction. If you're an administrator or leader, I think it's critical to prioritize SRADs in your mission, vision, and values. So we can't keep ignoring it. I work with kids who are often peripheralized and not on people's radar screens. So I have sort of had a career of trying to advocate for kids. But the same is true of SRADs, right? All of these groups that are not front and center. Same idea in terms of identifying experts and potential ambassadors within your system and protecting time for them to teach and mentor. So programs, departments cannot grow in this area if there isn't time set aside for them, paid time to be able to develop their expertise, teach about it, get consultation, and so forth. I think initiating stigma reduction campaigns can be really helpful. So I always loved the model of the handwashing campaign, which was hugely successful in medicine, right? We really went out and had these posters in all the washrooms about how you had to wash your hands after using the facilities. And to me, those kinds of things can be very helpful. So if it's a decision you take as a leader, then think about doing these kinds of things to help people recognize stigma and keep it conscious in their minds so that they can make different decisions in the room with patients. And then critically important are research initiatives in clinical care and education. We need to know more about how best to do all of this. And I happen to work in educational scholarship, and there's funding available through the ABPN for innovative research projects in education. Substance abuse education and training is, to me, calling out for people to do interesting projects and try to develop things that other people in the field can use. OK. So I wanted to acknowledge, these are the people who have been on this path with me. So the folks at ADPERT, they're the past and current members of the formerly Addiction Task Force. Now I'm happy to say Addiction Committee. It's a permanent standing committee. We have worked very closely with APA's Council on Addictions and its wonderful staff. We've also worked very closely with the AAAP and are grateful to all of their support. And then this list of people here, these 12 people, are the ones that I recruited who worked with me to develop the recommendations on addictions and pain. I just wanted to say that we did send those recommendations to the RRC, the Psychiatry RRC, which is the body that develops the specific recommendations for training. I'm very happy to say that the general psychiatry requirements are about to start the process of revision. And so my fervent hope is that some of our recommendations will be apparent in the next iteration of the requirements. I actually sit on the RRC now. And so I'm hoping that things can improve. I will say that my experience is that the current generation of training directors across the country has a much greater sense of the importance of teaching addictions. And so I do think there has been a cultural shift. Medical students and residents are asking for it. They want more training in addictions because they see the public health crisis that we're in. So I am hopeful that things will change. But it's really, it's like everything else, it's going to take a village. And I think it needs to be, it's not going to help if residents learn about it and then go into a practice where nobody's screening for addictions. We need to be doing it across the board. So let me stop there and ask if anybody has any questions. I'm really interested in your thoughts. They do ask you to use the microphone. Thank you. Thank you for the talk very much. I appreciate it. I'm so happy to see the addition of pain. My mentor, Brian Johnson, had started a half a day pain clinic years ago. And that's been some of the best learning as an addiction psychiatrist for me, that how do you treat opioid use disorder if you don't know how to treat pain? We would find our patients just kept relapsing, whether we were treating with buprenorphine or trying to do, you know, opioid use disorder. Or trying to do, you know, whatever kind of treatment we were using. And for me, that learning for pain was really helpful. And then having, we had some research as well on pain. So, you know, what happens with patients after they've been stabilized on buprenorphine or methadone for years? And then, you know, we know that some of the latest public retention rates for buprenorphine, 50% after six months, or 20%, really low rates. What happens with all these other patients? And so we actually started using low-dose naltrexone and then following the numbers with patients. And for me, it was really eye-opening. Because, you know, really, what I was trained was, you just give people buprenorphine or methadone, and that's, when do they ever stop taking it, right? But a lot of them do. Most, I would say, you know, according to the literature, do. So this pain treatment was really helpful for me in addition to the addiction piece. Just one other comment was that I do think there's a lot of interest. We have, and I think you highlighted some of this, like we're a part of a system in resident and fellow training that the residents and fellows kind of go where what generates the most money for the hospital at times, I feel like. And, you know, so I get this, there are all these competing interests for resident time. And right now, I have no residents on my service, actually. I know, for years, we were doing a lot of teaching, but slowly, there have been less and less and now none. Now the only residents I have are a day and a half a week, once in a while, with family medicine residents, which is great. But I'm an addiction psychiatrist and I miss that. So if you have any thoughts or strategies on how those of us who do want to teach and are even doing some research can navigate all the competing interests, I guess, for resident time. You have reminded me, and I'm gonna commit to today to teaching a course on substance use disorders. I'm already teaching other interprofessional trainees and we just need to keep inviting the psychiatry residents to come back. But I found it difficult to navigate the system because- It can be difficult to navigate the system. There's the problem of residency time and then kind of like child mental health, some of the work in addictions is time intensive and not necessarily well reimbursed. And so these are systemic issues. I think one of the important things about trying to integrate is that it can get around some of those issues. So for example, if you have a case conference series in which residents bring cases to present, could someone, you or someone, zoom in as a consultant in addictions? Because all you have to do is say, did you screen for anything in this patient? Oh, no, I didn't. Huh, what do you think are the odds of them having a co-occurring SRAD? I don't know. Well, let's look that up, right? And because it's not rocket science to know that it's very likely that they are treating patients with addictions that they're not recognizing. And part of it, of course, is that they're afraid. They don't wanna pick up an addictive disorder that they don't know how to treat, right? And feel incompetent and unconfident. And of course, faculty can be the same way. So they don't ask about it because they don't wanna expose their own ignorance, right? We're all human. So if you can find ways to bring in an addiction angle on cases, incredibly important. If somebody is, for example, if there's a series on trauma or whoever's teaching PTSD or developmental trauma to the residents, I don't see how you can talk about trauma and not talk about addictions, right? Those two are so highly co-occurring. And trying to understand how it is that people with trauma seek addictions, what that relationship is, how it affects your treatment approach, and all of that. So, and similarly with, for example, the consult liaison service, right? I mean, we see people who come in and go out, and they get a quick site consult. But how often does that site consult include proper screening for addictions, right? And how many people are we letting walk out the door with an unrecognized addictive SRAD? So if I were you, I would have a conversation with your program director about integrating substance use, not creating yet another course or yet another rotation or some add-on experience, because training directors will tell you the program's jam-packed, I can't do it. So it really has to be in this much more integrated fashion. I also like to bring in media. So for example, as I mentioned, there was just this incredibly moving story about a patient who felt so stigmatized by the language that was used on her presentation to the medical system, that she felt that she couldn't say that she had an addiction problem, and it ended up in her death. And the, you know, I think that we need to realize how powerful we are in these encounters and how just everything about how we present ourselves, our language, our nonverbal communication, will have an impact. And sometimes it's easier for residents to feel moved by stories that are not on their patient list, you know, stories that are out there. I also like to use media in teaching. So for example, at ACAP, when I'm talking about this, we used the movie Beautiful Boy because it's the story of a young man who develops an addiction and his relationship with his father and how the family is really devastated by this but doesn't give up on him. And so it's wonderful to understand addictive behaviors, it's wonderful to understand family dynamics, system-based care, all of that. And again, I often find that it's through those kinds of things that you can have the residents become less defended and more emotionally accessible to some of this content. And oftentimes that's what excites them is to recognize that part of doing good as a psychiatrist, part of helping people is to also help them with their addictions. I'm wondering if other people in the room have ideas. Anybody else use ways to teach about addictions in their, go ahead. Yeah, the microphone would be great. Hi, nice to see you. Nice to see you. I was session hopping, so I'm sorry I'm late. I probably missed the meat of it. My name is Sarah Daniel, and I just ran into Dr. DeJong after some other session. But I think the problem is, I always ask about addictions and I always did as a resident, but it's like, what's the next step? So if you don't have actually, even if it's just a taste, like a week of it or whatever, I think the problem is feeling confident to go the next step. So for example, when I was a resident, I went to University of Toronto and they had opportunities to do outreach in Northern Ontario communities. So I went to what is now Nunavut, to Baffin Island, Cape Dorset, Timmins, all these places. When I was a medical student, I went to what they call a reserve in Alberta for Canadian Native people. So if I didn't have that kind of experience, even though I didn't feel confident, I would never have done it. I went to a place called People in Need House, which was like a shelter. So I think the problem is that if you don't actually see one, do one, teach one, you don't feel confident. So now I've just signed up to be like a homeless patient or homeless person psychiatrist. And I'm also gonna like get a refresher on primary care because a lot of them don't, they have presenting problems, but a lot of psychiatrists don't feel confident to do that. So I used to be like doing a little bit of primary care because they had open licenses in those days. So I really feel that I hear what you're saying about program directors don't wanna put yet in another component, but even like a week of either inpatient, outpatient, or dual diagnosis would really help. And then the other point I had is I just recently, I'm in a book club, a few book clubs, but one book club, there's a guy called Vincent Lam. I don't know if you've heard of him. He's a Canadian East Asian, I believe Vietnamese background, and he's a merge doc, and he won a big prize when he wrote off his first book about experiences being in a merge doc. I think it's called On Bloodletting and Other Cures, but he recently, relatively recently wrote a book called On the Ravine, and I really recommend it. It's about a guy who's a doctor working in an outpatient kind of methadone or some sort of substance use disorder clinic. And there's one main character who's a violinist who ends up becoming opioid addicted due to some sort of injury and then a legal prescription. So to me, it was a real eye-opener, even though I've been a psychiatrist for 25 years, it really gave me a perspective on what it must be like, and a lot of doctors don't have empathy for just smarten up. I mean, you don't consciously think that, but it's an implicit bias I think many of us hold. Like, why don't you just stop? Why don't you just go to a drug treatment program? Why don't you just do this? And it gave me such an eye-opener. So if you want to use that in teaching, it's On the Ravine by Vincent Lam. And it also brings in the pharma angle, which is really interesting, because this doctor's also involved in a drug trial. So it kind of touches on a lot of issues. Thank you, that sounds like a wonderful book. And let me just clarify, I'm not advocating that residents and fellows not have a chunk of time in training devoted to addictions. So there is this one month minimum. I'm just, I'm saying that when education happens in these kinds of separate chunks, I worry that it promotes the notion that addictions is this separate thing. It's that thing you go on to do a fellowship in that general psychiatrists just need to get some exposure to. And I think that's the wrong message. I think we need to be, it was sort of farmed out, and I think we need to integrate it back into psychiatry and view it as just part and parcel of what we do. There will always be those who are more expert, and there will be times you need to refer, but there is so much more that general psychiatrists could be doing in their own therapeutic spaces, and that's really what I think we need to be modeling, emphasizing that integration in how we teach it, how we practice it, and so forth. We did, the ADPERT group that I was referring to earlier, we've published a number of papers in academic psychiatry that go into much greater length about different kinds of educational experiences in addiction, where and how to teach them, how to assess them, and so if you Google my name or do a PubMed search under my name and academic psychiatry, you should find those. And we're always developing good, I mean a homeless shelter is another example of a, I think a terrific opportunity for community-based exposure to addictions. You do, one of the requirements in training is that you have to have a supervisor for each experience, so there needs to be somebody who will review the experience with the resident, and ideally, somebody who will facilitate the experience and go with them to the shelter and help them understand what they're seeing, because of course, if they just go themselves, they won't know what they're seeing, and they won't know how to ask. So there's this wonderful old Russian neuropsychologist named Vygotsky who had this concept of the zone of proximal development, and we use it a lot in child work. The idea is that you want people to be constantly growing and being challenged and kind of moving out of their comfort zone, so you want them to stretch, but you don't want what they're stretching for to be beyond their reach. You want it to be within their reach with a good stretch, and that's sort of a nice metaphor, I think, for what I'm suggesting here today, that we really need to get our psychiatry training programs to upping the expectation and to asking our residents to reach a little bit more and to come out of training with greater confidence, because of course, I fear that if we don't do that, they will go off into practice and never have the confidence and just avoid dealing with it, which I think is what happened largely to the current generation of training directors who grew up in a world where they weren't mostly adequately trained in addictions, and so now they avoid it in their training programs. It's just a human thing to do. I'm not judging anybody, but we need to counteract that and sort of really embrace it. Sorry, I'm not in academic psychiatry because I live in the boonies in Niagara, but is it required now in American psych residencies, and do you know anything about whether Canadian psych residencies? Yeah, no, so I know you missed the start of the talk, so yes, there's a one-month full-time equivalent requirement in four years of psychiatry residency training. That's 2% of total training time, and unfortunately, I would argue that's quite inadequate. And is that in Canada too? You know, it's a great question. I do not know the Canadian standard, yeah. And what about family? Because a lot of family doctors have to juggle regular psychiatric illness. Yeah, it's another great question. I think they also feel like they need to beef up, and again, I was describing this conference I went to that was sponsored by the Accrediting Organization for Training Programs that brought together doctors from all different specialties, and it was interesting. In a way, it was the surgeons and the ER docs who were the most invested, but their concept of addictions was almost exclusively opioids, and so the primary care folks didn't give as much voice, and I'm not sure what that means, but it's a great question. In this country, we have the American Society of Addiction Medicine, which is open, in which you can get training in addictions with any background as a doctor, with any specialty, and then we have Addiction Fellowship, which is a one-year fellowship after the four years of general psychiatry training. So those are sort of more specialized ways of getting training. But what I'm really suggesting here is that our general training needs to be beefed up in this regard so that everybody who is a psychiatrist is comfortable treating these disorders. I think you're, I just don't want it to be a conversation between you, but my husband is a surgeon, and he always says, because I took a detour to have three kids and I went to law school, but he says, oh, I do more psychiatry than you, and you're the psychiatrist. Because exactly what you say, all these patients come in with psychiatric problems, and they also have opioid addictions. And I remember when we graduated in 98, and then we started practice after fellowships in 01, and that was when those guys were coming from Purdue and started detailing OxyContin to him for post-surgical pain, and it was really interesting because the guy's a very young, nice guy who had a BA or a BSC, and that was like his entry-level job. And so then my husband, instead of Tylenol 3s, which was his go-to, he started doing this OxyContin. And then after all this crisis came up, and then I had a carpal tunnel surgery, and I took one Tylenol number three and almost collapsed because I was opioid naive, I guess. And then after that, I was just on Advil and plain Tylenol, and then he realized, well, if my wife can survive a little carpal tunnel with just NSAIDs and Tylenol, he stopped, there were no more, he'd already stopped OxyContin, but there were no more Tylenol number threes because he used to have a standard pre-written prescription pad that he would just sign, and he'd give a month's supply. Well, I was fine in four days, and I'm not like exceptionally pain tolerant or anything. So I think maybe you need to also, like being in the position you are, maybe you should go through more family doctor and more surgical and ER training, and then link the, like you said, link the psychiatry residents with those things so then there's like a conduit where there's a multidisciplinary collaboration where they ID these patients, and then they send them to whoever is a little bit more specialized. Yeah, no, I completely agree. I guess I'm starting where I have the most influence, but I agree that we need to really expand the project. Your comment about family medicine made me think of another movie that I really think is a terrific teaching tool is called Dopesick, and we actually honored the author of that book at last year's APA meeting and the family doctor that the book is about, and he was a family physician in West Virginia who, just as you were describing, was sort of approached by all of these Purdue pharma reps, and he started at, you know, doling out OxyContin and it follows what happens to some of his patients, but he himself has an injury and then he too gets addicted to OxyContin. And it's the story of how he fought to really be a whistleblower and bring this attention, this issue to the attention of the regulators with the help of some other folks. But that, I do think the teaching, you know, as we know, residents' historical perspective can be quite short because they were very young, not that long ago, right? And so one of the things that can be very useful is to show them this as history because they don't know that whole thing about pain being the fourth vital sign and, you know, all of that stuff and how the reps were really being so pushy about and feeding the docs with misinformation about OxyContin was not addictive. And so just letting them know that the entire medical establishment got really hoodwinked in a very negative way into prescribing a substance that was not gonna be safe and that, you know, to me, that heightens our responsibility, right? That we really helped create a public health crisis, it's part of our responsibility to help address it. Kind of a related topic is when I was in law school, like I got a big eye opener about pharmaceutical regulation which I did not have in medical school or residency. And I think another approach would be to, I don't know what is being taught, but you are extremely naive with respect to pharma. So when I took this course, International Regulation of Pharmaceuticals, I went to U of T Law as well. And the professor is Trudeau Lemons. He's really excellent, he's a health law professor. He's also a big advocate for slowing down what they call medical assistance in dying for psychiatric patients and also disabled people. Anyway, he showed on the first class this video of some sort of US town. I don't know if it was from 60 Minutes or one of those front line. The whole town is addicted to opioids. And then that was a segue into how these guys are just totally unethical in terms of big pharma. And the one article he gave is a lay article, it's called Big Pharma's Crime Spree. And it's a great kind of, I guess, eye-opener that you could use to introduce substance abuse. You could use it to introduce pharmaceutical regulation. You can use it to introduce law and medicine. You can use it to introduce ethics. So many topics, but basically the point was that the big multi-billion dollar US settlements with Pfizer and other companies were all based on off-label prescribing that was never passed by FDA and that became, these detailers were going and pushing it on doctors. And there was a whistleblower, and some states have whistleblower regulations. So this guy was hired supposedly as a researcher, but he was really supposed to go around and push the drugs. And he realized that it was just really unethical. He blew the whistle. I think he got like $26 million in the end for blowing the whistle, but it was basically showing how these companies are exploitative. And in medicine, I think we often just accept what they say at face value. We don't critically evaluate the research, whether it's valid, whether it's biased. So I think we need to take a step back and also teach residents to be more critical of what they receive from pharma. And U of T developed a course about this. So thank you for that comment. And this I think is another great example of how addiction content can be integrated into curricula, right, because there are so many systems issues, ethical issues. So the trick is to make sure that at least some of what gets discussed, some of the examples that are used, some of the cases pertain to addictions. Yeah, yeah. So a couple of things just clicked for me. This is really helpful. So I just wanted to get everybody's thoughts about this. So the opioid resettlement money, we have an open request for proposals right now. I put in my proposal and I'm realizing it's probably based on what was discussed today, probably not ideal. It's for more, well, we were gonna expand our fellowship, basically have an addiction, a public psychiatry and addiction fellowship. But now I'm thinking half of the positions are unfilled. It's just probably gonna be unfilled, right? So what is a way we could use, it's two and a half million dollars over three years with two additional years of potential. So it's essentially five years, $4 million. If you guys had that, what would you suggest I propose? Because I'm just thinking now the public psychiatry fellowship is just not gonna, it's gonna go unfilled. And also the other thing is, we have this competing interest back to what we discussed before. We have this competing interest. I'm told it has to be financially sustainable. So of course, we were gonna hire nurse practitioners or physician assistants because it's really expensive to hire physicians and that kind of thing. So balancing all these things, if you guys had $4 million over the next five years, what would you propose with opioid resettlement money that would be the most helpful to the community, but also educational. And I was thinking maybe it's integrating like in the way you said, maybe what I do is I pay, I offer to pay for a half a day a week as a consultant to everybody in town, because we're the academic addiction psychiatrists, right? And maybe that would be more helpful to all these agencies to just say, look, half a day, you can call Aslam. We'll spend four hours, one hour each for the shelters, et cetera, anyway, I'd love to hear what you guys all think would be a helpful way to spend about $4 million over five years. This is in Syracuse, New York. Well, we all wish we were in your position, of course. I smell my honey too. No, I understand. Everybody can apply for it. Yeah. Just so I remember to say it, ADPERT, this American Association of Directors of Psychiatric Residency Training, has a visiting scholar program. So programs from across Canada and the U.S. can apply to have a visiting scholar come to be a consultant to you for a year. And there's an application process for exactly what you wanna use that person for, what your goals are. But it's a terrific potential resource for you. In your case, in Syracuse, it sounds like you have actually very good addiction expertise. What you need help is in the educational and training aspects to integrate addictions into your educational experience. And so that's something that you could articulate in your proposal. There are other sort of ways and entities that are interested in helping with that. The person I would reach out to about both of those things is Scott Oakman, and I'll give you his information after the session. So that's certainly one thing I would think about. Scott Oakman. He's based in Minnesota. He's a community psychiatrist, and he has been co-chair of the Addictions Committee and has helped with the application process of the Visiting Scholar Program. But he's very well plugged in to some of these other resources as well. The other thing, I guess, in terms of money is time, right? So I think your idea of using some of your money to get time to do this work is gonna be critical. And as you said, you don't want one-shot deals, right? You want to make this sustainable. And so I think you're gonna need to identify a team of people, certainly at least one educational expert and training expert who can help you develop the program and meet goals that serve both the community and the educational goals of the program. The other thing I just, I'm gonna make a plug for, I don't know if you know Lisa Marsh. Does that name ring a bell? She's a psychologist. She runs the Dartmouth Center for Technology and Mental Health. It's M-A-R-S-C-H. She has been working for years, for 20 years about, in the digital therapeutics space. And one of the things about upstate New York is that it's a pretty rural population, right? So in communities like that where it's gonna be a hardship for many of these patients to actually get to a clinic, I really would advocate training your community members in some of these remote technologies. There's really powerful data. Lisa herself edited a book, wrote a book, co-wrote a book. But if you, she's available. Part of their, they're a center for excellence and they, part of their mission is to help programs develop expertise in this area. She has partnered with communities and groups of mental health centers and all kinds of entities across the country, including here in New York City, to do both clinical interventions but study it as a clinical research project. And I think that, again, getting to the workforce issue, we're never gonna have enough warm bodies to do this. And so we need to be thinking creatively about ways to leverage our expertise and think about treating on a population-based model. And some of these, just there's a whole, there are wearables, there are apps, there are, there's a whole range. If you go to her talk yesterday, the slides, I think, are on it as well. So that's, I think, just in terms of leveraging for the future, I think that's an incredibly important direction to go in. Sorry, I don't know your name, sir, but I don't know if you went to the talk on the program that they have in L.A. for the homeless population, many of whom have substance use disorders as well. It was amazing. It was about four presenters and what they've done in terms of integrating this homeless or under-housed, as the new terms would be supposed to be, population with linkages with emerged departments that are not averse to treating these people. They have integrated nurse practitioners. They've got medical students and residents being part of this program. They're going to their different encampments. And they showed these before and after pictures of these patients. And the main thing they were saying, it's not psychiatry or medicine, but they also integrated a bunch of family doctors that would then treat their medical problems. But they were saying it was housing. So if you have so much money, which seems like a lot of money, to make this model, and they're willing to do these presentations out either in person or remotely, as Dr. DeJong said, from a virtual platform and show how to integrate this into your community, I'm sure there's homeless people in Syracuse as well. So I look that up and give you the name of these people because I wanted to bring them up to, the organization that I've joined is called Reach Niagara, and they have a, TELUS is a telecommunications provider and also has branched into things like alarm systems and things, and they have provided a little cargo van that they've outfitted as a mobile outpatient clinic. And they have these people called system navigators, which this LA program also has, which are not social workers, but they also have a social worker. And then they hook up these people with different resources. But this, the scope of this LA program is unbelievable. And they only have like, I think, 15 psychiatrists that are part of it. I forgot how many family doctors, but the key that I took away from that is like the integration and the kind of empathy that they had for these people. And they would just do like a very small intervention, like bringing them some clothes or bringing them some food, and that would be it. There would be no medical or psychiatric conversation. So they would build up this trusting relationship. But if you took the students or took whatever you have residents and started getting them into this, and then linking them to the formal, whatever program, training for addictions, it would really, like apparently we have 1,000 of these people in Niagara, which is quite a lot for this small area. I don't know how many you'd have in the Syracuse area. But it was just, I think it was the best talk I went through so far. Sounds terrific. You know, you raise a really important point, which is this sort of, there's no really good word for this, multidisciplinary or interprofessional or however you want, sort of nature of this work, how it needs to be that in order to be effective. And so I think this idea of collaborating with primary care, collaborating with community agencies, homeless shelters, it really needs to be that kind of an encompassing approach, I think, for it to be effective. The housing argument is very interesting. I mean, there's a lot of data about all kinds of mental health disorders that actually, in certain populations, the most effective thing you can do is to give them housing, right? So I think it's, we need many more models of that. It's a really interesting, I think, and effective approach. And you read Tracy Cater's book about Jim O'Connell. Powerful stuff, right? Yes. How about just this? Yeah, exactly. What was the name of Tracy Cater's book? I forgot what it was. I'd have to Google it. Tracy Cater is a well known American nonfiction writer who takes on all kinds of interesting topics, but I can't remember the title of this particular book. We should have a, I mean, having a book club, a movie night, you know, I think these are all also potential fun ways of teaching this stuff. It was on the Sunday at 9.30. The Tracy Cater? It was on a Sunday at, oh, oh, the presentation. Okay, I was gonna say, I don't think that's a Tracy Cater time. I mean, you can look back at Sunday, but they had these before and after pictures, and I'll just give you one example of them. They were, I'll just pass my phone, but. Can you just talk into the mic so that other people. Sorry, I mean, we should probably get closer since there's all five of us or whatever, but I'll just pass one of these pictures that is so dramatic of the before and after of this thing, and then the other one that kind of got me interested is in, there was this black filmmaker from Toronto, and he's also like a carpenter, so there's a movie that really makes you feel deep empathy for these under-housed people. So what happened in Toronto was they were, you know how they live in garbage dumpsters or they live behind little alcoves? Well, this guy, he's a carpenter, and he started building these boxes on wheels and would leave them for these under-housed people not to freeze to death in Toronto. So they were all over, dotting the landscape, and they were just like a little box, maybe five feet by five feet, and he had the foresight to fire resist or fireproof the exterior, but he didn't fireproof the interior, and so it caught fire, and then, of course, everybody went on like ballistic that these were dangerous people and under-housed people were dying in them, and so the city of Toronto brought this injunction against him making these things, but they weren't providing any housings for them anyway, but it's called Somebody Lives Here, and it was like a preview showing, but it's another way to get these students to see what it must be like living in this wooden cubicle on wheels, and he'd bring it in the back of a truck and then just deposit them all over Toronto. It was quite an eye-opener, but I forgot the name of the filmmaker, it's Somebody Lives Here, but this is it. Thank you for that. Oh, okay. Hi. I'm Virginia. I'm from University of Wisconsin-Madison. And yeah, I mean, I completely agree with the integration, you know, interdisciplinary approach to this, but I really, really connect with your sort of mission to get psychiatry to be more involved in this. I feel like especially in Madison, we are lucky. I guess to have a really strong family medicine department and so not just family medicine, but addiction medicine. So there's a lot of family medicine physicians who are trained in addiction medicine, and they are really the ones who are doing the addiction work. And it's great and they do wonderful work and they also are not mental health providers. And so there's all these co-occurring conditions that they're just not trained to take care of. And they are very much aware of that, but they do what they can. And meanwhile, the Department of Psychiatry is here and we're just not doing much about that. So yeah, I trained in New Orleans at LSU, Louisiana State University, and we had a very, very strong addiction kind of piece to our training. And addiction belonged in psychiatry, so I had a very strong training in residency. But then I went to Madison for a number of different reasons, but I did my addiction psychiatry fellowship in Madison and most of my training was with family medicine folks. Interesting. Yeah. Yeah. So I sort of signed up for an addiction psychiatry fellowship and I did mostly an addiction medicine fellowship. Yeah. But yeah, as a new faculty member, I've been trying to help general psychiatrists get more comfortable in this. I think part of my trouble is just getting past my frustration that we have to be doing this work. I treat psychosis, for example. I'm certainly not a psychosis expert, but I do it. And when a situation is a little complicated or I feel a little bit out of my comfort zone, I reach out to my colleagues who are experts in psychosis. And there's no fellowship for psychosis. But somehow people can get away with saying, you know, I just don't feel comfortable treating the addiction part, so I'm going to refer. And I think that's just so unfair. Yeah. Yeah. So anyway, I guess one of the issues that I'm facing, and there's a lot of people, even within the Department of Psychiatry, some of, you know, Art Woloszek is there and there's lots of folks who are very much in line with what you're saying and supportive of addiction psychiatry and all of that. But there's also part of me that feels like some of the department is like, okay, now, you know, we hired an addiction psychiatrist, you are here to solve all the problems. And you know, I'm a new faculty member. I do research, you know, I have a lot of other competing interests. And so I guess one question is, do you have advice for, you know, an assistant professor who's really just beginning, but at the same time, who's being sort of, I don't know, charged with this huge task of, you know, bringing more addiction training to the whole department? Great question. And I truly empathize when my first job out of training was to be the only child psychiatrist in an entire community hospital. And very quickly, it became clear to me that I was just standing there with my finger in a dike. And, you know, there was just no way I was going to be able to see all these kids, but, you know, in a month, my wait list was nine months and, you know, it was ridiculous. So really important to feel that you're not alone in this. And so, you know, I would give the same advice about having a team of people you're working with to help you. I would highly recommend going to the ADPERT meeting, connecting with the ADPERT Addictions Committee, and learning from some of the folks there who are in similar positions about how to leverage what already exists in the system to be able to improve both the addiction teaching and care where you are. The, you know, when there's a sort of a vacuum that you're being asked to fill as one person, sometimes I think the best thing is to just take it one step at a time, to establish a set of priorities and think about where can you start effectively, and really view it as a five to ten year project, and chip away at it over time. But it's extremely helpful to talk to other people who have been brought into similar situations and have been asked to do the same kind of thing. I would say that what you're experiencing, though, also reflects this stigma, right? Which, you know, this notion that it's sort of addictions is a hot potato and people just want to, you know, get rid of it and not own it and not take it in. And I think one of the first things you might want to do is to think about, you know, organizing a Grand Rounds of physicians with lived experience. I did a Grand Rounds, not on that topic, but on integrating, yeah. Great. Great. And it was like my third month on the job. Oh, good for you. That's fabulous. So you've done an early start on the Grand Rounds. I will say, I think there's just something very powerful about bringing people who look like us, were trained like us, speak the same language. And you know, in my experience, as I mentioned, people just weep when they hear these stories. And it sort of gets at the they are us issue, right? And I think that can be very, very powerful. If you have a faculty member who would be up for doing something like a movie club, that's also, I think, a great way. It can be fun. It's good for resident cohesion. And generally speaking, in my experience, training directors are delighted to have faculty lead those kinds of things. So it's a sort of gradually chipping away at the stigma, gradually heightening a sense of sort of personal responsibility and ownership in this area. And then, you know, you may want to give combined Grand Rounds. You might want to see if psychiatry and family medicine can do a Grand Rounds together. And again, modeling. Modeling is one of the most powerful ways to teach. And modeling this notion that these are not topics that should be siloed. These are topics that should be integrated. If there are folks working in the community, bring them in. You know, from community agencies, shelters, mutual help groups. I used to work in a community where it turned out one of my neighbors was the most sought after sponsor in AA in our town. And you know, it was one of these things I learned about him as I got to know him. And when you have someone like that speak, it's incredibly powerful. I've also had panels of parents speak about their experience with their kids with addictions and the way in which once the child turns 18, how shut out they feel from the system. And how we do no favors by being overly rigid about HIPAA. Obviously, we have to respect HIPAA, but we nonetheless need to be doing family-centered care. As I always say to my fellows, you can guarantee that when there's a call in the middle of the night, it's going to be the parents who are going to be expected to go and get that kid, right? And so those are the kinds of things that I think help to start opening people's eyes and getting them involved to recognize that this is really part of what they should be doing. I'm really, I am hoping that as requirements hopefully will change, that that will help folks like you have sort of systemic backup in terms of the need to be doing all of this. Your comments brought a couple more ideas to my mind, but I did find the talk. It's called Field-Based Mental Health Teams, Developing and Integrating Street Psychiatry. And they were kind enough to put their, it's called the HOME, H-O-M-E, HOME Team, and they have a full PDF handout with it. Terrific. And the main doctor who's a psychiatrist is Cheyenne Rubb. It's a gentleman, S-H-A-Y-A-N, last name R-A-B, but there were other people like the nurse practitioner and the coordinator of the program. So if you want to follow up, it was on Monday at, I mean, sorry, Sunday at 10.30 a.m. Thank you very much for that information. But regarding the movie club, like we used to have, not a movie club, but I remember at APA in the evenings and at CPA, Canadian Psychiatric, they used to, like if you wanted to stay and have a movie over like some small hors d'oeuvres or things or bring a brown paper bag lunch, they'd have a movie and then they'd have a discussant. But one guy, his last name is Robinson, and he had his own press called Rapid Cycler Press. He's from London, Ontario. And he has an annotated book of all these movies that are relevant to psychiatry that you could, I mean, they're probably old now, I don't know if he's updated it, but it was around when I was a resident and it was something psychiatry in the movies or something like that. And they also have like some sort of annual mental health week in Canada and they have movies being shown and a movie kind of, I don't know if I was on schizophrenia, but a movie like series that happens every year. So if you could also tie it, like I used to love journal club when the chair of the department would have journal club, but you could tie the movie to an actual academic reviewed article that people would come to the movie, have an informal discussion about the movies and then follow up with the article. And it would be fun, as you said, because it was always nice to get away from like studying. Yeah. Thanks for that. That's great. In this country, Francis Liu has written a lot about using film and Glenn Gabbard has also written about using film in psychiatry. Francis Liu. Thank you. Sorry, I missed. I was doing the LAI teaching. No worries. I just want to say, I want to do a talk sometime called like, we're the problem, it's us. Because I do feel like psychiatry is, sorry, I feel like in Canada, I think everywhere, like psychiatry is very structurally exclusionary, right? Like I was trained to book an assessment three months in advance and then do the beginning of the assessment and then bring them back for a plan. And then, you know, it was, it was this very like structural thing that worked for people who had housing and had education and all of our psychotherapy patients had university degrees. And so I try to bring the residents into my clinic, which is, I'm the consultant and really part of the team on what's called a RAM team. So that's an addictions drop in clinic. So in Canada, methadone is provided in like the CVS. We don't have methadone clinics. And so we provide methadone suboxone, but everybody has mental health concerns, right? And they're supposed to go plan an appointment in the hospital, you know, on a Monday at nine in the morning, three months from now, and remember to go, which isn't going to happen. So my manager, who's a pharmacy tech, really educated me and said, like, if you want to do something, you have to prescribe something after the appointment. You don't get to wait, you know, until you've like thought about it, you got to do this right now. And my resident called it the like pounce on the problem clinic, because it was so different from what she was trained to do everywhere else. And so it's like, it's us, like, we have to, we have to change how we, you know, and I see a lot of methamphetamine. And I feel like these poor people are like, between, you know, they don't qualify for the SMI system. Yeah. Because, oh, we got to clear, you got to clear, but you can't go to rehab because you're psychotic. So you can't go to rehab until you clear, but you can't go to the unit because you use meth and you'll presumably clear, but you all like, what are we supposed to do? We have no plan. These folks don't fit into addiction medicine, ask us for help. And they certainly don't fit into, you know, the schizophrenia program will just flat out refuse my referral. So I'm trying to bring the residents in and do more integrated work, but it's challenging. It is challenging. Now the system is filled with catch-22s and we are, I, that was sort of the, you know, the missing in action title was really about that. We have really just failed to step up and in all kinds of ways. And this is really what we need to do. I don't know how many of you saw Brian Stevenson's plenary, but he is so eloquent and he spoke about, you know, the criminal injustices of our carceral system, saying how important it is for all of us to be proximal. And I think this is another one of these issues that we can't keep distancing ourselves from this problem or these issues or these patients. We really need to be proximal. This is going to need to be the last comment because the guy is telling me we need to... There's a wonderful podcast that my friend in Brooklyn told me about that I didn't know called Lost Patients. Oh, great. Lost Patients. It's about, I think, California and just, they call it the churn. So the justice, mental health, hospital, homeless churn. And it's the same in Canada. It's a little bit different. I think our justice system is not quite as involved, but definitely, I mean, I've had folks where I'm about to treat them and then they get incarcerated and now they're in a black box that I can't access. But amazing. I'm in, like, episode two. And I think just the fact that all these folks, especially with psychosis, don't get treated for years. And you're like, how did this happen? Like, this is a very treatable thing. And but you're just sort of waiting for, I don't know, something to happen. Really good. Yep. Absolutely. Thank you for that recommendation. Thank you for being such a wonderful audience. It really shows that quality is always more important than quantity. So thank you so much for coming.

Sandra D. Young

addiction education

psychiatry

American Association of Directors of Psychiatry Residency Training

non-stigmatizing language

substance use disorders

mental illness

co-occurring disorders

stigma

interdisciplinary approaches

systemic barriers

community settings