Practice Settings
Given its intellectual milieu, academic infrastructure, training expertise, and institutional support, Yale is an exceptional venue for an investment in drug use, addiction and HIV research training. There are a variety of general medical settings at Yale, including the VA and community drug treatment centers, available for the Scholars to learn about substance use disorders, addiction, and HIV. These locations also act as potential research settings for the Scholars.
Yale New Haven Hospital (YNHH)
Yale Department of Emergency Medicine
Adult and Pediatric Emergency Departments
Yale Section of General Internal Medicine
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 use disorder.
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 use disorder 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).
YNHH Primary Care Center (PCC) and Federally Qualified Health Centers (FQHCs)
Yale Internal Medicine Associates (YIMA)
VACT General Internal Medicine/Primary Care
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:
- Compare longitudinal patterns and consequences of alcohol and multi-substance use in HIV-infected and uninfected patients.
- 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.
Yale Primary Care and Medicine-Pediatrics Residency Programs
Adolescent Clinic
Yale New Haven Hospital Women’s Center and Maternal Fetal Medicine (MFM) Clinic
The Nathan Smith Clinic (NSC)
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.