Treating Opioid Addiction in Appalachia

The impact of opioid addiction across the urban and rural Appalachian region Carilion Clinic serves received widespread attention in the books Demon Copperhead and Dopesick, which was made into a drama miniseries in 2021.  

It also was the motivation behind the health system’s unique Addiction Medicine Fellowship program, which trains post-residency physicians in comprehensive addiction care. 

This month, Ananya Mishra, D.O., (pictured) along with Rachael Hawkins, M.D., will complete the immersive one-year program and begin their careers as practicing physicians.  

Dr. Mishra has a special interest in helping patients facing financial barriers or who lack insurance. Post fellowship, she plans to treat patients struggling with addiction while practicing as a primary care doctor at a Federally Qualified Health Center (FQHC) in Durham, N.C.   

Dr. Hawkins is passionate about working with adolescents. In her career at Children’s National in Washington, D.C., she hopes to help identify at-risk youths and help them course-correct early on to avoid the detrimental health impacts of substance abuse disorder later in life. 

The fellowship has prepared them with training in several aspects of addiction treatment, including rotations at Carilion Clinic hospitals as well as methadone clinics, opioid treatment centers, and other facilities.  

 “We're everywhere. There isn't really a typical day,” Dr. Mishra said about her fellowship. “We're really focused on meeting people where they are.”  

Carilion’s addiction medicine program -- one of 110 accredited Addiction Medicine fellowships in the United States and one of three in Virginia -- is supported by an inpatient addiction treatment team, as well as a clinical social worker and a care coordinator. Peer recovery specialists, who have struggled with addiction and recovery themselves, help patients navigate the treatment process. 

It emphasizes treating the whole patient, including addressing issues such as financial insecurity, housing instability, and stigma that prevents many from seeking care. 

The interdisciplinary program began in 2019 and is among Carilion Clinic-Virginia Tech Carilion Graduate Medical Education's 30 accredited residencies and fellowships involving more than 350 physician trainees, about a third of whom will graduate this year. 

“The program has a lot of heart. People are dedicating their whole lives to treating substance use disorder," Dr. Hawkins said. "I've really enjoyed being a part of it." 

 Opioid addiction, while still prevalent, has declined in recent years, yet the use of stimulants and other substances is rising, and comprehensive addiction care remains uneven in the region due to a shortage of specialists, according to the director of the fellowship program, according to Kimberly Simcox, D.O., a Carilion Clinic obstetrician/gynecologist who has dedicated her career to helping pregnant women and their families affected by substance use disorders. 

 “We have a very complex patient population to serve with a lot of psychosocial barriers and thinking creatively and collaboratively is the way that we're going to continue to meet the needs of the community,” she said.