Mastering Letters of Recommendation for Addiction Medicine Fellowship

Understanding the Role of Letters of Recommendation in Addiction Medicine

Letters of recommendation (LORs) are one of the most influential parts of your addiction medicine fellowship application. In a specialty that depends on trust, communication, and nuanced interpersonal skills, programs rely heavily on letters to understand who you are as a clinician, not just your scores and CV.

For addiction medicine fellowship directors, a strong set of residency letters of recommendation can:

• Confirm your clinical competence with complex, often stigmatized conditions
• Demonstrate your empathy, professionalism, and maturity in caring for people with substance use disorders (SUDs)
• Highlight your commitment to the field—including advocacy, research, teaching, or systems-level work in addiction care
• Distinguish you from strong applicants who may look similar on paper

This guide walks you through how to get strong LOR, who to ask for letters, how to support your writers, and what makes addiction-medicine–specific letters stand out.

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What Addiction Medicine Fellowship Programs Look For in Letters

Addiction medicine is interdisciplinary and relationship-driven. Fellowship directors often read letters looking for specific signals that you will thrive in this environment.

Core Qualities Programs Want to See

Beyond generic praise, programs want evidence of the following:

1. Clinical judgment with complex patients

   • Ability to manage co-occurring medical, psychiatric, and substance use disorders
   • Comfort with uncertainty and evolving treatment plans
   • Safe prescribing practices, especially around controlled substances

2. Communication and rapport-building

   • Skill in motivational interviewing and trauma-informed communication
   • Respectful, non-stigmatizing language toward people who use drugs
   • Ability to engage patients who are ambivalent, frustrated, or fearful

3. Professionalism and reliability

   • Accountability, punctuality, and follow-through
   • Good team communication and appropriate escalation of concerns
   • Ethical thinking in challenging cases (e.g., nonadherence, diversion, relapse)

4. Commitment to addiction medicine as a field

   • Consistent interest in substance abuse training opportunities
   • Participation in addiction consult services, clinics, research, or advocacy
   • Demonstrated curiosity about systems of care, harm reduction, and public health

5. Capacity for self-reflection and growth

   • Open to feedback and able to change practice based on new evidence
   • Insight into personal biases and emotional responses in challenging encounters

Letters that provide specific examples of these qualities are far more effective than generic “top 10%” statements without context.

Addiction-Medicine–Specific Content That Stands Out

Fellowship directors especially value letters that address:

• Your work with medications for opioid use disorder (MOUD)—buprenorphine, methadone (if applicable), naltrexone
• Experience with alcohol withdrawal management and long-term treatment (acamprosate, naltrexone, disulfiram where appropriate)
• Collaboration with interdisciplinary teams: social work, peer recovery specialists, psychiatry, pain medicine, infectious diseases
• Involvement in harm reduction (naloxone distribution, syringe service programs, safer-use counseling)
• Work with high-risk or marginalized populations (e.g., people experiencing homelessness, people leaving incarceration, pregnant patients with OUD)

When you plan your letters, think about which settings or mentors can authentically speak to these experiences.

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Who to Ask for Letters (and How to Choose Strategically)

Choosing who to ask for letters is as important as the content itself. Strong, detailed letters from people who truly know your work will always outrank generic letters from big names.

Ideal Letter Writers for Addiction Medicine Fellowship

Aim for 3–4 letters depending on fellowship requirements. Prioritize:

1. An addiction medicine or addiction psychiatry attending

   • From an addiction consult service, outpatient addiction clinic, methadone program, or integrated primary care/SUD clinic
   • This is often your most critical letter if you have access to one
   • They can speak directly to your performance in substance abuse training settings

2. A primary clinical supervisor from residency

   • Program director, associate program director, or chief of service who has directly observed you
   • Especially valuable if they can compare you to peers and comment on your overall trajectory

3. A collaborator from a relevant subspecialty (if applicable)

   • Psychiatry, infectious diseases, pain medicine, hospital medicine, emergency medicine, OB/GYN (particularly if you worked with pregnant patients with SUD)
   • Look for someone who can discuss how you manage SUD in complex, interdisciplinary settings

4. A research mentor or QI/advocacy supervisor (optional but powerful)

   • Particularly helpful if you’re applying to academically oriented addiction medicine fellowships
   • They should highlight your scholarship, persistence, and intellectual curiosity in addiction topics

Who Not to Prioritize (Unless They Know You Well)

• Extremely senior faculty (chair, dean) who only know you superficially
• Letters based solely on one lecture you gave or a single day on service
• Personal/family acquaintances in medicine who have never supervised your clinical work

Name recognition helps only when paired with concrete, firsthand observations.

Balancing Your Letter Portfolio

Think of your letters as a portfolio of perspectives, rather than four copies of the same story. Ideally, together they should cover:

• Direct addiction medicine experience
• Your performance as a resident overall
• Your work ethic, professionalism, and team presence
• Any research, QI, or systems-level work in addiction care

If you’re worried you lack dedicated addiction medicine rotations, lean on:

• Hospitalist/ED attendings who observed you managing withdrawal, OUD, or complex chronic pain
• Psychiatry or primary care mentors who saw you integrate SUD treatment into general practice
• Faculty who supervised you on a quality improvement project related to opioid prescribing, screening, or care transitions

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How to Get Strong LOR: Timing, Approach, and Materials

Knowing who to ask is only half the battle. How you approach potential writers greatly influences the strength of the final letter.

When to Ask for Letters

Ideal timing:

• 3–4 months before your application deadline
• Immediately after a strong rotation or project, even if it’s months or a year before you apply
• If early, you can ask:
  • “Would you be comfortable writing a strong letter for me when I apply for an addiction medicine fellowship next year? I’d love to follow up closer to submission.”

Programs often accept letters via ERAS or direct upload to institutional portals, so give your writers:

• A clear deadline at least 4 weeks before your true submission target
• Periodic, polite reminders as the deadline approaches

How to Ask: The Exact Question Matters

When you ask someone for a letter, use language that gives them permission to decline if they can’t be strong advocates. For example:

“I’m applying to addiction medicine fellowships and would be honored if you could write a strong, supportive letter of recommendation based on our work together on the inpatient addiction consult service. Do you feel you know my clinical work and commitment to addiction medicine well enough to do that?”

This phrasing:

• Signals your seriousness
• Encourages honesty if they’re unsure
• Helps you avoid lukewarm or generic letters

If they hesitate or seem uncertain, thank them and consider asking someone else.

What to Provide Your Letter Writers

Make it as easy as possible for them to write a thoughtful, detailed letter tailored to addiction medicine. Share:

1. Your updated CV

   • Highlight addiction-related work, even if small: QI projects, talks, support group facilitation, naloxone trainings, etc.

2. A short personal statement or career goals paragraph

   • Emphasize why addiction medicine, your long-term goals, and what matters most to you in this work

3. A summary of your work with them

   • Rotation dates or project timeline
   • Specific patients or situations (de-identified) where you felt you grew or showed your strengths
   • Any feedback they previously gave you that shaped your practice

4. Program or specialty details

   • That you are applying to addiction medicine fellowship (not generic fellowship)
   • Any particular areas of interest: outpatient addiction care, pregnant patients with SUD, ED-initiated buprenorphine, harm reduction, etc.

5. Logistics and deadlines

   • Exact submission method (ERAS, institutional portal, email)
   • Deadline—earlier than the real one
   • Your contact information for follow-up

A Brief Example Email Template

Dear Dr. [Name],

I hope you’re well. I’m applying to addiction medicine fellowship positions in the upcoming cycle and was wondering if you would feel comfortable writing a strong letter of recommendation on my behalf.

I greatly valued working with you on [service/clinic/project] from [dates], particularly the opportunity to manage patients with [brief concrete details]. I learned a tremendous amount about [e.g., compassionate, evidence-based care for people with substance use disorders].

I’ve attached my current CV and a brief personal statement describing my interest in addiction medicine. I’m happy to also share a short summary of cases or projects we worked on together if that would be helpful. Letters are due by [date], and I can provide the upload link or ERAS details at your convenience.

Thank you very much for considering this.

Sincerely,
[Your Name, PGY level, program]

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What Makes a Strong Addiction Medicine Letter: Content and Structure

While you won’t usually see the full text of your letters, it’s helpful to know what strong letters typically include. You can indirectly influence this through the materials you give your writers and how you frame your experiences.

Core Elements of a High-Impact Letter

1. Clear introduction and relationship

   • Who the writer is (role, specialty, title)
   • How long and in what context they’ve worked with you
   • The type of setting (inpatient consults, outpatient addiction clinic, ED, co-occurring psychiatric unit, etc.)

2. Concrete, observable behaviors
   Strong letters don’t say “X is compassionate”; they show it through examples:

   • A story of you calmly de-escalating a patient in withdrawal who initially refused care
   • How you approached a patient with suspected diversion with honesty and nonjudgmental curiosity
   • A complex discharge plan you helped coordinate linking MOUD, housing, and mental health services

3. Comparative statements and global assessment
   Programs value:

   • “Among the top 5% of residents I’ve worked with in the last 10 years in terms of commitment to SUD care.”
   • “I would strongly recommend them for any addiction medicine fellowship and would hire them in my own practice without hesitation.”

4. Evidence of addiction-specific competency

   • Comfort initiating or managing buprenorphine, methadone coordination, and long-acting naltrexone
   • Understanding of harm reduction and nonpunitive responses to relapse
   • Ability to address co-occurring psychiatric illness and medical complications

5. Character and team-based strengths

   • How you function on interdisciplinary teams
   • Willingness to volunteer for difficult tasks without complaint
   • Teaching, mentorship, or leadership experience related to SUD

Red Flags or Weaknesses Programs Notice

While you can’t fully control what’s written, you can minimize risk by choosing appropriate writers and being transparent about your goals. Fellowship directors are wary of:

• Vague letters full of clichés with no specific examples
• Letters that damn with faint praise, e.g., “hardworking, punctual, reliable,” with no mention of clinical insight or interpersonal skills
• Comments hinting at unaddressed professionalism issues, such as poor communication, unreliability, or significant conflicts with staff
• Letters that clearly look like a template reused for multiple applicants

If you’ve had documented performance issues that are now resolved, it’s often better for a trusted mentor or program director to address this head-on in a supportive way than to leave it unmentioned and unexplained.

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Special Situations: Limited Exposure, Career Changes, and International Applicants

Not every applicant to addiction medicine fellowship follows a traditional path. Here’s how to navigate some common scenarios.

If You Had Limited Formal Addiction Medicine Rotations

You can still build a strong case if you:

• Highlight addiction-related care in general settings:

  • ED or hospitalist letters referencing your management of withdrawal, overdose, or complex pain/OUD
  • Primary care mentors commenting on your integration of SUD screening and brief intervention

• Engage in electives or short experiences before the application cycle:

  • Even a 2–4 week addiction consult or outpatient rotation can give you a key letter
  • Volunteer or moonlighting experiences in detox centers or community clinics (within training regulations)

• Emphasize your trajectory:

  • Show how your clinical experiences sparked a sustained interest in substance abuse training and led you toward fellowship

If You’re Changing Career Focus (e.g., from Hospitalist to Addiction Medicine)

For applicants who have been in practice:

• Include at least one letter from your current or recent clinical leadership (medical director, chief, department chair)
• Add one letter from someone who has supervised you in addiction-related work, even if part-time (e.g., buprenorphine clinic, jail health services, community MAT program)
• Provide your letter writers with:
  • A clear narrative of why now and why addiction medicine
  • Outcomes from your current work that relate to addiction (reduced opioid prescribing, ED buprenorphine pathways, QI projects)

Programs appreciate mature applicants who bring real-world experience—as long as letters show your skills are current and your transition is intentional.

For International Medical Graduates (IMGs)

Key considerations:

• Aim for at least 2–3 U.S.-based letters if possible, especially from addiction medicine, internal medicine, family medicine, psychiatry, or hospitalist attendings
• Choose writers who:
  • Are familiar with U.S. clinical standards and fellowship expectations
  • Can directly address your communication skills, cultural adaptation, and team integration
• Clarify your visa and training situation to letter writers if they might be asked to comment

If you have standout letters from your home country, you may still include one if:

• The mentor knows you exceptionally well
• They oversaw significant addiction-related work, research, or program development

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Practical Timeline and Checklist for Your LOR Strategy

To stay organized, treat letters of recommendation as a structured project.

6–9 Months Before Applications Open

• Identify addiction-related rotations or electives you can still schedule
• Seek out opportunities to work with addiction medicine faculty
• Start building or updating your CV with addiction-relevant experiences

3–4 Months Before Deadline

• Make a list of primary and backup letter writers
• Have a brief meeting or email conversation with each to gauge interest
• Begin drafting your personal statement or at least a career goals summary

2–3 Months Before Deadline

• Formally request letters with a clear ask for a “strong letter”
• Provide CV, personal statement draft, and summary of your work together
• Confirm submission mechanisms (ERAS, institutional portal, etc.)

1 Month Before Deadline

• Send polite reminders if a letter hasn’t been uploaded
• Finalize your program list and check each fellowship’s specific letter requirements
• Ensure at least one letter clearly addresses addiction-specific skills and interests

1–2 Weeks Before Submission

• Verify all letters have been received and correctly assigned in ERAS (or relevant platform)
• Thank your letter writers and let them know your final submission timeline

After Interviews and Match/Offer

• Update your letter writers on your outcome—program directors remember applicants who close the loop
• Maintain these relationships—they can become lifelong mentors, collaborators, and future recommenders for jobs or academic promotions

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Frequently Asked Questions (FAQ)

1. How many letters do I need for addiction medicine fellowship?

Most addiction medicine fellowship programs request 3 letters, though some accept or encourage 4. A common and strong combination is:

• 1 letter from an addiction medicine or addiction psychiatry attending
• 1 letter from your program director or associate PD
• 1–2 letters from clinical supervisors or research/QI mentors who know you well

Always double-check each program’s website or ERAS listing for specific requirements.

2. What if my program doesn’t have a formal addiction medicine service?

You can still demonstrate interest and competence by:

• Getting letters from hospitalist, ED, internal medicine, family medicine, or psychiatry attendings who directly observed you managing SUD-related cases
• Highlighting addiction-related content in QI projects, grand rounds, local talks, or journal clubs
• Seeking short-term electives, telehealth experiences, or community partnerships (e.g., outpatient buprenorphine prescribers)
• Clearly articulating in your materials how these experiences led to your interest in addiction medicine

Your letters should show that—even without a dedicated service—you pursued substance abuse training whenever possible.

3. Can I reuse my residency letters of recommendation for fellowship?

Sometimes. Strong residency letters of recommendation from core faculty can absolutely support your addiction medicine application, especially if they:

• Provide a global assessment of your performance as a resident
• Comment on your professionalism, work ethic, and growth
• Mention any early signs of interest in SUD care

However, for addiction medicine fellowship, you should also have at least one letter specifically focused on your addiction-related clinical work and commitment to the field. If your existing residency letters are more general, supplement them with one or two new, targeted letters.

4. Should I waive my right to see my letters?

Yes. In most cases, you should waive your right to view your letters in ERAS or other application systems. Waived letters are generally perceived as more candid and trustworthy. To ensure letters will be positive, ask potential writers directly if they can provide a “strong, supportive” letter on your behalf before they agree.

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Thoughtfully chosen, well-supported letters of recommendation can powerfully reinforce your story as a future addiction medicine specialist. Start early, be strategic about who you ask, and give your writers the tools they need to describe you vividly as a clinician, advocate, and colleague in this critical field.