NC’s first addiction psychiatry fellowship program

By Clarissa Donnelly-DeRoven

North Carolina psychiatrists who want to become board certified in treating addiction will have an in-state option to learn and practice starting as soon as July. 

The Mountain Area Health Education Center — known as MAHEC — will train up to two psychiatrists in a yearlong fellowship based in western N.C. They’ll learn trauma-informed practices for managing substance use disorder, as well as skills for identifying and effectively treating people experiencing both addiction and other mental illnesses.

There are only about 50 other addiction psychiatry fellowships nationwide, just two others are located in rural regions.

Leading MAHEC’s program is Stephen Wyatt, an addiction psychiatrist based in Charlotte. Wyatt began his career working in the emergency room in Traverse City, a small town in northern Michigan. 

“I had seen a lot of problems associated with substance use in the emergency department,” he said. “About 40 percent of all trauma that comes in the emergency department is related to alcohol and other drugs — not only physical problems but emotional problems.”

Also steering the new program is Steve Buie, the director of the psychiatry residency program at MAHEC, who isn’t officially an addiction psychiatrist but has been working with people experiencing substance use disorder in the Asheville area for about a decade.

“There was a suboxone clinic here in town, and they were losing their psychiatrist with not much notice,” he said. Buie and the clinic’s administrator knew each other, and she asked him if he could help temporarily. He didn’t have any experience, but he agreed. Before he could start, he had to attend a training that would allow him to prescribe suboxone, one of the medications used to help reduce opioid cravings and withdrawal symptoms.

“I found that I really enjoyed the work,” Buie said. “People made a lot of progress in a short period of time and were very engaged and grateful that they had access to this medication that was helping them recover from their opioid dependence.” 

He planned to fill in at the clinic for six weeks or so. He ended up staying for a year and continuing to see people for opioid use disorder in out-patient settings after. 

Relationship between substance use disorder and other mental illnesses

Substance use disorder is a psychiatric diagnosis. It’s listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), considered by many to be the authoritative handbook for describing and treating mental illness. Much of the treatment for patients with substance use disorder, Wyatt said, comes out of psychiatry. 

“How you talk to patients, how you spend time with them, how you look at some of these other coexisting mental health problems,” he said. “It’s hugely important.”

While substance use disorder is its own diagnosis, it often tags along with other mental health problems. Some research suggests that half of all people who have a mental illness experience substance use disorder, and vice versa. 

Methamphetamine is a great example. The drug has a large presence in western NC, even for people who don’t strictly use stimulants. While methamphetamine doesn’t lead to overdose deaths in the same way opioids do, it can wreak havoc on a person’s brain by increasing dopamine levels. 

Dopamine is a neurotransmitter that’s released when somebody experiences pleasure. In general, people need dopamine, but too much for too long can actually lead to psychosis

The psychosis itself can be treated by administering drugs that block dopamine receptors. But unlike opioids, there’s no equivalent to medication-assisted treatment, such as suboxone, for people who use methamphetamine. “Which is a reason that these folks need, really, more support from a psychotherapy standpoint,” Buie said. 

While psychosis might seem like the most extreme psychiatric consequence of methamphetamine use, it can often be resolved relatively quickly with medication. Depression, on the other hand, can take much longer to treat. 

Medications meant to treat depression don’t work as well for people who’ve used methamphetamine for a long time because of changes the drug causes to their dopamine and serotonin receptors — again, those neurotransmitters that make you feel good.

“Medication doesn’t reverse that,” Buie said. “So you have to treat them from a therapeutic standpoint.”

The depression from stimulant withdrawal doesn’t last forever, though. 

“The brain does have some capacity for regeneration — that’s called neuroplasticity. So if people can abstain for a long period of time, and engage in positive, life-affirming experiences, the brain can repair itself to some extent so they can get better,” Buie said.

Sharing the knowledge

The addiction psychiatry fellows will train and work alongside people in MAHEC’s more generalized addiction medicine program, which trains family medicine doctors and others how to help people manage the physical issues that often accompany substance use disorder, such as treating infections and withdrawal symptoms. The addiction psychiatry fellows will go through some of that same program, but their primary focus will be on therapeutic and pharmacological interventions. 

They’ll train in a variety of different locations: the state run drug treatment hospital in Black Mountain, the emergency room and other departments at Mission Hospital, a medication-assisted treatment program, and the Veterans Affairs Medical Center, all in Asheville. 

Each facility plays a different role in the continuum of care for substance use disorder treatment, and by working at each location fellows will have the unique opportunity to follow patients through their journey.

Mission Health, headquartered in Asheville, is the sixth largest health care system in North Carolina and the biggest health care porvider in the state’s mountain region. Fellows in MAHEC’s addiction psychiatry program will spend time at Mission Hospital. Photo credit: Liora Engel-Smith.

“They’ll really get a longitudinal view of identification, treatment, and then recovery,” Wyatt said. “A big part of this is really trying to help people stabilize in their recovery.”

While the program is small, Wyatt argues it still holds a lot of potential.

“There’s never going to be addiction specialists in every town,” Wyatt said, “But, my whole career has been around teaching. Because once you get this expertise, then you’re able to actually help other physicians and other community members to be more effective in what they’re trying to do.”

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