Specialty Profiles

What it’s like in addiction psychiatry: Shadowing Dr. Balasanova


As a medical student, do you ever wonder what it’s like to specialize in addiction psychiatry? Meet AMA member Alëna A. Balasanova, MD, an addiction psychiatrist and a featured physician in the AMA’s “Shadow Me” Specialty Series, which offers advice directly from physicians about life in their specialties. Check out her insights to help determine whether a career in addiction psychiatry might be a good fit for you.

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Alëna A. Balasanova, MD

“Shadowing” Dr. Balasanova (@DrPsychMD)

Specialty: Addiction psychiatry.

Practice setting: Academic medical center.

Employment type: Employed by university/hospital.

Years in practice: Five.

A typical day and week in my practice: The best part of addiction psychiatry is that it’s multifaceted and truly transcends the continuum of care. Having a variety of clinical and academic responsibilities is what I find most stimulating and rewarding. I am especially passionate about clinical education and training for medical students, residents and fellows, and health professions students.

For two and a half days per week I am the attending psychiatrist leading the inpatient addiction psychiatry consultation liaison service, which is a multidisciplinary team consisting of resident physicians and fellows, medical students and allied health professions students, and a psychiatric social worker. We are consulted about patients on the medical and surgical units who have co-occurring substance use with other psychiatric concerns. We can initiate treatment right then and there and arrange for appropriate follow-up care.

Another half-day per week I supervise trainees in LIMSOC [Longitudinal Integrated Mental Health/Substance-Use Disorder Outpatient Clinic), a continuity clinic rotation I developed and now direct for third-year psychiatry residents and addiction medicine fellows.

I also maintain a small panel of outpatients in my own clinic, including patients with serious and persistent mental illness whom I have been caring for since my first days on faculty. I use medications for addiction treatment and individual psychotherapy to help meet patients where they are at on their recovery journey.

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The rest of my time is spent on special academic and research projects such as educating health care professionals on safe opioid prescribing, assisting community overdose prevention efforts through naloxone distribution initiatives, designing and developing addiction psychiatry and psychotherapy curricula and teaching medical student and resident courses.

The most challenging and rewarding aspects of addiction psychiatry: Addressing patients’ psychosocioeconomic needs is such an integral part of promoting recovery. This can be very challenging given the complexity of patients’ needs and the constraints within our health care system. For example, long-term outpatient treatment is what’s been shown to be most effective for chronic illness such as addiction.

Unfortunately, not all patients have access to such services, and having a systems level view of community resources is essential as an addiction psychiatrist. Social determinants of health truly do determine health!

Being able to contribute to a patient’s recovery is immensely rewarding. Working with a patient to help them regain employment, repair relationships with their family, improve their health and maintain their recovery is an absolute privilege. Another aspect of my job I find rewarding is the ability to reduce stigma through teaching medical students, residents, fellows, faculty and staff.

The best way to reduce stigma is to engage with a patient with substance-use disorder (SUD). Watching stigma being reduced right in front of my eyes when under my supervision a trainee works with a patient with SUD, forms a therapeutic alliance and helps them on their path to recovery is quite possibly the most gratifying aspect of addiction psychiatry.

How life in addiction psychiatry has been affected by the global pandemic: COVID-19 has really changed the landscape of addiction treatment nationally and locally. When the pandemic first began many treatment centers temporarily closed or pivoted exclusively to telehealth.

Telehealth has transformed the way in which we provide care; however, while immensely helpful, it is not feasible for our patients without access to mobile devices or secure internet connections. Some estimates suggest that alcohol sales have increased by 40% over the past year and we are seeing more patients with alcohol related liver disease, pancreatitis, and other physical sequelae of substance use.

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How I am dealing with the challenges of the pandemic: By further amplifying education efforts to penetrate undergraduate medical education around the subjects of substance use and addiction. The goal is to prepare students on the verge of residency with how to address patients with SUDs since they will assuredly see them regardless of which specialty they match into—the likelihood of this is even higher now given the pandemic.

The long-term impact the pandemic will have on addiction psychiatry: The pandemic has understandably worn out health professionals, including medical students, residents and fellows. Fewer residents are choosing to pursue addiction psychiatry fellowship training to subspecialize in this field. With fewer specialists in the pipeline, it is all the more important to ensure physicians of all specialties have the basic knowledge and skillset to address substance use in their patients.

Three words to describe the typical addiction psychiatrist: Nonjudgmental. Flexible. Advocate.

Skills every physician in training should have for addiction psychiatry but won’t be tested for on the board exam: Language matters—words have power. Using clinically accurate, non-judgmental and affirmative language when describing SUD and addiction is a small yet crucial thing that every future and current physician can do to reduce the deadly stigma surrounding these disorders.

I am passionate about reducing the stigma around SUDs through language and exposure to patients. An important component to addiction psychiatry is advocacy—advocating for our patients to receive the care they need and deserve. It is an honor to be able to use our voice to advocate for society’s most vulnerable.