Physician Roles in Addressing Alcohol and Drug Use Disorders in the 21st Century
Dennis McCarty, PhD
Oregon Health Sciences University
Acknowledgements. Awards from the National Institutes on Health supported the preparation of this essay: R33 DA035640, R01 DA036522, R01 MH1000001, P50 DA018165, R01 DA030431, R01 DA029716, U10 DA015815. Dr. McCarty is also the Principal Investigator on Research Service Agreements with Purdue Pharma and Alkermes, Inc.
Addiction treatment in the 21st Century must be more fully integrated with health care to assure that patients and their families receive treatment for co-morbid medical conditions and have access to medications that support recovery. Treatment for alcohol and drug use disorders will remain a specialty service because primary care practitioners are unlikely to provide behavioral therapies. Behavioral therapies, however, can be provided in healthcare settings and surviving addiction treatment centers are likely to become co-located services in medical settings. As a real example, the Executive Director of a progressive addiction treatment center has located counselors in four primary care clinics; about 20% of his revenue comes from healthcare settings and he expects that to be over 50% within five years.
Effective integration also requires changes in the healthcare settings and the ways in which practitioners address alcohol and drug use with their patients. To enhance physician involvement in addressing alcohol and drug use disorders, questions on alcohol and drug use must be added to the electronic health record. Currently, the health record includes little or no information on alcohol and drug use. Progressive clinics may have information on screening (e.g., Do you drink?) and, if individuals complete a standardized screen, the record may include an AUDIT or DAST score. Detail on amount of use, pattern or use, and frequency of use is usually not recorded for alcohol use and almost never recorded for drug use. Practitioners cannot address disorders without minimal data on the nature of the disorder and some mechanism for tracking response to care. Information on alcohol and drug use must be integrated into the electronic health record and updated at each visit.
Screening, Brief Intervention and Referral to Treatment (SBIRT) is the dominant strategy to alert health care practitioners to excessive alcohol and drug use and the possible need for a structured intervention. The U.S. Preventive Services Task Force (USPSTF) recommends routine screening for alcohol use disorders in primary care; the initial recommendation was released in 2004 (Whitlock et al, 2004) and updated and reiterated in 2013 (Moyer, 2013). The value of screening for drug use disorders was less apparent and the USPSTF found insufficient evidence to support a recommendation for routine screening for illicit drug use among adolescents, adults and pregnant women (Polen, et al., 2008). Because of the lack of evidence, the National Institute on Drug Abuse (NIDA) supported clinical trials to assess the value of screening and brief intervention for drug use disorders in primary care settings.
The drug use SBIRT studies are coming to fruition with unexpected results. Initial results were shared at the March 2014 meeting of the National Drug Abuse Treatment Clinical Trials Network Steering Committee. Three multi-site trials conducted in different settings, located in different regions of the county, and using different intervention strategies reported consistent findings – there was no benefit to screening for illicit drug use and conducting brief interventions; drug use was not affected.
The disappointing results may open, rather than close, conversation that more carefully articulates roles for primary care practitioners in treating alcohol and drug use disorders. Primary care is not specialty care. Individuals who use drugs frequently often require specialty care. At the same time, drug users have ongoing health care needs that cannot be addressed efficiently and effectively if the practitioner is blind to the ongoing drug use.
The primary care practitioner is well positioned to provide ongoing support much like they provide for their patients with chronic disorders.
Primary care practitioners can provide a persistent intervention rather than a brief intervention. Screening and Persistent Intervention with Treatment (SPIT) may be a more appropriate model for engaging primary care practitioners in treatment for alcohol and drug use disorders. It reflects a chronic care perspective on addictive disorders and asserts a role for the physician or other practitioner in supporting recovery and the treatment process. Primary care supports specialty addiction treatment and does not deliver treatment for alcohol and drug use disorders. The most aggressive practitioners will encourage the use of medications to support recovery from alcohol and opioid use disorders. Less progressive practitioners will build effective referral and handoff strategies with local addiction treatment centers. Patients will continue to receive the primary care services they need and learn the benefit of open communication with their practitioners on the status of their alcohol and drug use.
Aggressive addiction treatment programs will be persistent and build linkages with primary care. One strategy is to develop patient and practitioner decision aids that help both understand the range of available services. In the 21st Century, most patients will benefit from intensive and traditional outpatient services; research consistently documents that there is little or no additional benefit for most patients in residential treatment (McCarty et al, 2014). Patients and providers need guidance on the services available, potential use of medication, and an understanding that residential care is not appropriate for most patients.
Physicians, however, cannot play a supportive role if the electronic health record fails to include information on alcohol and drug use. The collection of data on alcohol and drug use changes the physician’s role. She or he now is aware that alcohol and drug use may contribute to the presenting health problems and make better diagnoses and more efficient treatment plans. The physician becomes a key player in addressing alcohol and drug use disorders by discussing the issues with their patients and building a long-term supportive relationship.
McCarty, D. Braude, L., Lyman, D.R., Dougherty, R.H., Daniels, A.S., Ghose, S.S. & Delphin-Rittmon, M.E. (2014). Substance abuse intensive outpatient programs: Assessing the evidence. Psychiatric Services. On-line in advance of print, January 21, 2015. doi: 10.1176/aapi.ps.201300249. PMID: 24445620.