Substance Use Disorders in Primary Care
Monday, May 11, 2015
Substance Use Disorders in Primary Care: Meet the Real Elephants in the Room
by Rachel Solotaroff, Central City Concern
Editor's Note: Rachel will be presenting on substance use disorders at the Spring Primary Care Conference May 16-19 in Portland, OR
In 2013, the official number of persons with substance dependence or abuse was 21.6 million, similar to the number each year from 2002 through 2012 (ranging from 20.6 million to 22.7 million).
This is roughly the same prevalence of diabetes in the United States. However, only 10 percnt of people who need treatment for substance abuse receive it, and the vast majority of those not receiving treatment don’t believe they need it.
In any illness, this level of under-treatment, year upon year, would be unthinkable. What accounts for it?
We tend, in our individualistic society, to think that the primary driver is individual choice. Yet we know that, as is true in so many areas of our society, an individual’s (or a population’s) behaviors are often enmeshed in a complex web of autonomous choice, public policy, and cultural mores.
Our public spending on research into and investment in substance use disorders is a fraction of what we spend on cancer or HIV, despite the vastly higher cost to society of drugs, alcohol and tobacco.
Our availability of evidence-based treatments for addictions, specifically medication-assisted treatment, is frighteningly low, given that these medications have been available to PCPs for well over a decade. And in primary care, we offer evidence-based practice for screening and intervention on substance use disorders only 10 percent of the time. Individual choice does influence our national outcomes in addiction, but our public policy and practice patterns in primary care are the real elephants in the room.
So what can we do in primary care to make a dent in this problem? Are we not busy enough with every other chronic disease or preventive health measure we must address in our 20 minutes? Yes and no. Some solutions are more time intensive, and some just require our openness and curiosity.
The first step is to recognize that addiction is a brain disease, not a moral failing. It is a chronic illness that waxes and wanes, and has relapses and remissions just like every other chronic disease we approach with our patients.
Second, we can educate ourselves about the disease, by seeking out CME opportunities (such as those available at the May NWRPCA Spring Primary Care Conference in Portland, OR). The neurobiological, developmental and social roots of addiction are both fascinating and eye-opening, helping us to better understand, contextualize and humanize the behaviors that may dismay us and even arouse anger and antagonism toward patients who display them.
Third, we can start to learn about treatments for these disorders, treatments we can practice in our own clinics, or at least can relate to and ask about if our patients are engaged in them at addiction treatment centers. We can talk to our patients directly about their substance use, their recovery, and their relapse, without judgment or righting reflex. We can get to know our partners in the community who treat addictions so that we may better coordinate care, improve outcomes, and communicate to our patients that we care deeply about how they are doing as they manage a substance use disorder.
Finally (and this is for the most motivated), we can participate in practice-based research to advance our understanding about how to best treat addiction in primary care. In the mid-1990’s, seminal work by behavioral health experts led to the development of the collaborative practice model for depression in primary care. Since then, mental health integration in primary care has become an evidence-based practice. However, we lack similarly powerful models and trials for integration of addictions into primary care; this is the new frontier for the primary care home.
By recognizing and destigmatizing addiction, then investigating and innovating a collaborative approach to treating it, primary care is in a place of unique opportunity.
We look forward to seeing you at the NWRPCA Spring Primary Care Conference to learn, explore and discuss.
For more resources on this topic, please join NWRPCA's Pain Management Group. This online community is designed to help clinicians, pharmacists, behavioral health specialists, and others network with colleagues, share best practices, and find tools and resources.
Group members will be able to access the free COPE-REMS training program.
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