Practice Settings

YNHH is an ideal hospital system for research studies because it serves an extremely diverse patient population. The hospital is in New Haven, Connecticut, which ranks among the poorest cities in the US. Twenty-four percent of New Haven residents live below the poverty level. The city is racially and ethnically diverse: 44 percent White, 37 percent Black, and 21 percent Hispanic. Since YNHH’s merger with the Hospital of Saint Raphael in 2013, YNHH is the only hospital in New Haven, resulting in an increase of in-patient beds to 1500 beds, making YNHH the fifth largest hospital in US. YNHH is part of Yale New Haven Health System, which incorporates four other hospitals in the state: Greenwich, Bridgeport, Westerly, and Lawrence + Memorial hospitals. The health system uses Epic® for EHR (electronic health records). Thus, offering many opportunities for training and research for the DAHRS Scholars. YNHH recently acquired the Hospital of Saint Raphael (HSR). YNHH is the only hospital in New Haven and will experience a significant expansion in its inpatient (number of beds) and outpatient services, including the emergency department and primary care clinics that currently operate on the HSR campus. As a result, training and research opportunities will be further enhanced for the Yale-DAHRS program.

The Department of Emergency Medicine (DEM) became the 28th Department in the Yale School of Medicine in July 2009 reflecting the reputation and the maturation of emergency medicine at Yale and as an academic discipline. It has grown to 89 faculty members, who have responsibility for over 100,000 patient visits a year at Yale New Haven Hospital and at the satellite Yale New Haven Shoreline Medical Center. The DEM’s successes are outlined in the Program Plan. Weaved throughout this proposal one can formulate an appreciation of the comprehensive research and mentoring processes developed in the department. Expert research faculty (Chawarski, Melnick, Moore, Safdar, Taylor, Venkatesh), emerging researchers and Scholars (Abujarad) include physicians, scientists and experts in informatics, statistics, and engineering that have been strategically recruited to advance the science of emergency medicine. The department has a history of successfully directing fellowships, Emergency Medical Services, Ultrasound, and Global Health. We recruit top tier fellows who have gone on to academic leadership positions, in addition to partnering with the RWJ-CSP in multiple EDs.

Record numbers of patients are seeking care in United States in emergency departments (ED's), far outpacing general population growth. In 2008, data obtained from the Drug Abuse Warning Network (DAWN) reported that ~ 1 million ED visits involved non-medical use of prescriptions or over-the-counter drugs and illicit drugs accounted for ~ another 1 million visits. Therefore, the ED provides an excellent venue to identify patients with alcohol, other drug, tobacco use and HIV risk. The Yale New Haven Hospital (YNHH) Emergency Department and Trauma Center is the only Level I Trauma Center in Southern Connecticut and the only Level I ACS verified pediatric trauma center in Connecticut, serving the state’s population of nearly 3.5 million residents. Given the large annual emergency department and trauma center census, as well as the rich demographic diversity of the patient population encountered at YNHH, there is an abundant opportunity for the enrollment of patients into research studies and clinical trials. Their annual census is approximately 83,000 adults with about 16% reporting having used an illicit drug or prescription drug for non-medical reasons in the past 30 days. The pediatric ED sees 33,000 patients/year with approximately 200 documented diagnoses of alcohol and drug use or dependence.

The faculty participate in a broad range of highly successful research, clinical, educational, and community-based activities at Yale and beyond. Under Dr. O’Connor’s direction, the Section has experienced unprecedented growth. Since 2004, the number of faculty has increased from 34 to 100 and the research budget has increased by a factor of 7 to over $28 million annually, the vast majority of which are NIH funds. In addition, he has recruited and mentored a number of highly skilled clinical investigators (his faculty include 17 alumni of the RWJ Clinical Scholars Program who are doing groundbreaking work in clinical epidemiology, health services, outcomes and clinical effectiveness research and focusing on chronic diseases such as diabetes, heart failure, and cancer – along with substance abuse.

Beginning with Dr. D. Fiellin, and followed by the recruitment and mentoring of Drs. Amy Justice, L. Fiellin, and 2 new junior faculty - Jeanette Tetrault, and William Becker, Dr. O’Connor has built one of the nation’s most accomplished internal medicine-based substance abuse research programs. The research portfolio of this group includes topics at the core of the Yale DAHRS program related to opioid dependence, alcohol use disorders, and the overlap between addiction and chronic pain. In addition to participating in the recruitment and mentoring of Dr. O’Onofrio, Dr. O’Connor has fostered a wide range of collaborative research activities with faculty in departments throughout the Yale School of Medicine as well as with faculty at other institutions. His accomplishments as a mentor and academic leader have been recognized by his receipt of two major national awards: the Association for Medical Education and Research on Substance Abuse (2005) and the Society of General Internal Medicine (2007).

The faculty from General Internal Medicine are based in specific clinical programs and academic units including the YNHH Primary Care Center (PCC), Yale Internal Medicine Associates (YIMA), the Yale Occupational and Environmental Program (YOEMP), The Yale Primary Care Internal Medicine Program (YPCRP), The Yale Medicine Pediatrics Residency Program (YMPRP), the VA Connecticut Healthcare System (VACTHS) and has academic affiliations with New Haven’s two Federally Qualified Health Centers (FQHC’s).

The PCC is responsible for the care of approximately 12,000 patients who made over 30,000 visits in 2012 and serves an ethnically diverse patient population which is largely medically underserved and characterized by high level complex medical and psychiatric co-morbidity along with a substantial burden of substance abuse. The PCC has been the “home base” of multiple successful NIDA-funded clinical trials (O’Connor, D. Fiellin, and D’Onofrio) of office-based opioid treatment and serves as the site of research on chronic pain, quality and patient safety. The PCC is the primary teaching site for Yale medical student and “traditional” internal medicine resident training in outpatient medicine.

Yale Internal Medicine Associates is a university-based primary internal medicine care for over 5000 individuals who made approximately 10,000 visits in 2013 and view YIMA as their “medical home.” YIMA is also the site of research related to general medical care such as a current NHI-funded study of the treatment of obesity.

The VA Primary Care Service Line provides clinical services to nearly 50,000 veterans and has been nationally recognized within the national VA system as a model for efficient and effective patient care and is the home to the new VA Center of Excellence in Primary Care. The program continues to lead the way nationally in key measures of quality including tobacco outpatient counseling, lipid control in diabetics and ischemic heart disease, and influenza immunization. Finally, a new pain management initiative has taken route in VA Primary Care while more broadly, the practice is providing critical leadership in the VA effort to adopt a Patient Centered Medical Home (PCMH) model nationally.

Drs. O’Connor, D. Fiellin, and Justice have played major roles in the development of this initiative and Dr. Becker was recently recruited in General Internal Medicine to lead research, clinical, and educational activities. Dr. Becker will run this clinic with input from Director of Pain Services for the VA Nationally, Dr. Robert Kerns, and the Director of Psychiatry, Dr. Ismene Petrakis, runs the Yale Addiction Psychiatry fellowship. As with PCC and YIMA, the VA is a major research and teaching site.

At VACT, Dr. Justice is the Principal Investigator of the Veterans Aging Cohort Study (VACS) and Consortium to improve Outcomes in HIV/AIDS, Alcohol, Aging, and multi-Substance use (COMpAAAS). Dr. D. Fiellin is Co-PI of COMpAAAS and PI of the intervention component. VACS is the largest clinical cohort of HIV+ individuals in North America and Europe. With a focus on alcohol, HIV and aging, it is the only large study that directly matches those with HIV infection to demographically and behaviorally similar uninfected individuals and collects parallel in-depth data on alcohol and substance use using validated methods (e.g. AUDIT, Timeline Follow Back) in both groups, cohorts that will be available for Yale-DAHRS Scholars.

The VACS Virtual Cohort is a cohort of 40,594 HIV+ and 81,188 HIV- where there is access to administrative (e.g. ICD-9 codes and health service utilization), pharmacy, laboratory, and health factors (smoking, alcohol using AUDIT C, and depressive symptoms using PHQ-9) data. In the VACS 8 cohort we have collected in-depth, longitudinal data on alcohol, multi-substance use and outcomes (8 years) on 7,312 HIV+/- veterans at 8 sites (VACS 8) through waves of surveys. Since 2002, VACS 8 has consented and enrolled 3,660 HIV+, 3,652 HIV- controls in Atlanta, Baltimore, the Bronx, Houston, Los Angeles, Manhattan/Brooklyn, Pittsburgh, and Washington, D.C.

The primary aims of VACS/COMpAAAS are to:

1. Compare longitudinal patterns and consequences of alcohol and multi-substance use in HIV-infected and uninfected patients.
2. Collect detailed Time Line Follow Back data in HIV-infected and uninfected patients initiating care, to study contemporary fine grained longitudinal associations of alcohol, tobacco, opioids (heroin + non-medical use of prescription opioids) and cocaine, with outcomes.

These programs are part of YNHH along with Waterbury Hospital and Saint Mary’s Hospital, overseen by Yale Section of General Internal Medicine faculty. Like the YNHH/PCC, both serve ethnically diverse patient populations, which are medically underserved and characterized by a high level complex medical co-morbidity along with a substantial burden of chronic medical illness and substance abuse. The Chase Outpatient Clinic and the Medicine Pediatrics Clinic at St. Mary’s Hospital have participated in substance abuse focused research related to office-based treatment of opioid dependence and outpatient detoxification and management of alcohol dependence. The Medicine-Pediatrics continuity clinic at St. Mary’s Hospital offers primary care to multi-generational families and specialty care for HIV, Hepatitis C and substance abuse treatment with an active suboxone program.

Daily marijuana use increased to 6.1%, the highest since the early 1980s. This is coupled with the fact that the perceived risk of marijuana use has decreased over the past two years.142 Prescription and over-the-counter medications after marijuana account for most of the top drugs abused by 12th graders. Teens and young adults access the healthcare system through EDs and adolescent clinics. The clinic sees ~2300 13-18 year olds annually, primarily Medicaid recipients (40% Black, 40% Latino). Age in our clinic is between 13 and 22 - at least 75% between ages 13-18. A recent screen of 25% of patients during well-care exams found that 80% reported some experience with drugs, primarily marijuana with regular use estimated to be as high as 25%.

The YNHH Women’s Center has approximately 6,000 patients; it is staffed by 10 physicians and nurse midwives. It serves as a primary care facility for an indigent New Haven area population of Medicaid and Medicare enrollees: 40% African American, 40% Latino, 10% Caucasian, and 10% recent immigrants from Sub-Saharan Africa, the Middle East, and Southeast Asia serving 1,200 new pregnant women each year. The MFM clinic demographics are average age 24, and racial/ethnic mix is 43% Hispanic, 38% African American (non-Hispanic) and 13% Caucasian. Dr. Yonkers recently conducted a survey of 2,684 patients. Substances used in the past 30 days included tobacco 21%, alcohol 6%, Marijuana 6% and 1% heroin and cocaine. A total of 25% used any substance and 4% were engaged in substance use counseling.

The Nathan Smith Clinic was established in 1990 and is the 1st clinic in the State dedicated solely to the care of adults infected with HIV and is the largest provider of comprehensive services to adults in Connecticut and serves a total of 839 patients. Patients are either primary care continuity patients of NSC or are patients referred for consultation for HIV issues. Visits average approximately 6,200/year. Approximately 60% are male and 96% ages 25 to 64. Race/ethnicity include: 32% White, 45% African American and 20% Hispanic. Risk factors include: Heterosexual 36%, MSM 24%, IDU 29% and Perinatal 2%. The NSC is considered a YNHH community clinic. Specialty sessions include psychiatry, women’s health and neurology and include ongoing clinical trials and other research projects. Patients (33%) acquired HIV through injection drug use, primarily heroin use. Not all of these patients are currently using opiates and many maintain on methadone for treatment of their opiate-dependence. 172 HIV-infected drug users (80%) of referrals to the study were from the NSC and 76% of these were actively using heroin at the time of referral.

Another study conducted among NSC patients to assess the influence of physician-prescribed prevention suggested that 31% of the IDU subjects were actively using opiates during a six-month time period. Relapse to opiate use is common among opioid dependent patients and until the recent availability of buprenorphine, most patients were referred to local opioid treatment programs. In a review of clinical data from the electronic medical record maintained on all patients at the NSC over the past two years, the prevalence of alcohol abuse and dependence in patients receiving their care in the NSC was 139/775 or 18%. Dr. L Fiellin is a primary mentor related to a clinical trial of injectable naltrexone.

The APT Foundation is the largest provider of substance abuse treatment services in the Greater New Haven area, serving approximately 3,000 active patients on a daily basis, including over 2,000 in methadone maintenance. The APT Foundation programs are Yale-affiliated and they have strong clinical program and training connections to both Yale New Haven Hospital’s Primary Care Center and the Connecticut Mental Health Center (CMU). The CMU was established by Dr. Patrick O’Connor over twenty years ago who directs junior faculty that do research or train in this program. The CMU works in close collaboration with faculty in the Section of General Internal Medicine and its Primary Care Clinic. In addition, the Methadone Research Unit is located across the street from the hospital and helps coordinate and staff the randomized clinical trials by Drs. D Fiellin, L Fiellin, P O’Connor evaluating primary care based delivery of buprenorphine. K12 Scholars can have a primary placement either at the APT CMU or MRU and conduct research on office-based addiction medicine, chronic pain or infectious diseases related to addiction.