Combatting SUDs requires collaboration with primary care

The headlines are dramatic. More than 70,200 Americans died from drug overdoses in 2017, nearly 200 a day. Opioid overdoses in particular account for 130 lives lost each day. Studies show that 22.7 million Americans meet medical criteria for a substance use disorder (SUDs) and need treatment, but only about 2.5 million people receive it. That means an overwhelming 90 percent of people struggling with addiction are not receiving any treatment.

Can you imagine if that were the case for any other chronic condition – that only 10 percent of people with heart disease or diabetes got treatment? The country would be outraged. What’s more, those who are receiving addiction treatment got there with little involvement by their trusted primary care physician (PCP). It’s time for collaboration and it’s time to get people the help they need.

One of the major drivers of our current opioid crisis was mass education targeting PCPs by pharmaceutical companies looking to sell their drugs. They did so unethically by inappropriately quoting findings of studies which increased sales exponentially, but they were profoundly successful. It’s been wisely suggested that the addiction treatment field take a page from their sales playbook, this time using ethical means, to mass educate physicians about addiction (“academic detailing”).

Substance use disorders (SUDs) can be reliably and easily identified through screening, and less severe cases often respond to physician advice and other types of brief interventions that can be done in the physician’s office, much like education on diabetes and other conditions. I commend the physicians who actively address substance use with their patients. But screenings just aren’t happening often enough. Is it that some primary care physicians are unaware of the magnitude of our current drug crisis? Doubtful. It may have more to do with time, a lack of training and the discomfort/uncertainty associated with asking patients about their drug or alcohol use, in large part related to stigma.

It’s true that most PCPs receive little to no training for SUDs in medical school, despite the fact that nowadays 20-25 percent of primary care patients are likely to have a current substance use or related health problem. Although training guidelines have been developed, grants have been made, and there has been some progress in improving medical school, residency, and post-residency substance abuse education (see the Aquifer Addiction curriculum), these directives have not been uniformly applied. Yet PCPs are on the front lines and have the ability to affect change in our current drug crisis.

The National Institute on Drug Abuse (NIDA) provides several evidence-based screening tools and assessment resource materials. From ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) to SBIRT (Screening, Brief Intervention, and Referral to Treatment), these questionnaires are generally brief and are designed to identify, reduce, and prevent problematic use or abuse of alcohol and illicit drugs. Many are specifically intended for primary care providers to administer to their patients. An emergency room might use a short test that makes a determination based on four questions; a PCP could also make use of this and refer to their support staff to ask a few more questions while providing education around substance use disorders.

Some of the earliest screeners were developed in the 1970s and 80s, yet these instruments remain underutilized. Physicians reported to the American Academy of Family Physicians that they had low levels of preparedness to identify and assist patients with substance use disorders. The tools are there, why aren’t they being applied?

Could it be that discussing substance use and abuse can be uncomfortable without the proper training? Drug use has the unfortunate, enduring baggage of being misunderstood as a moral failing or lack of willpower. And while these ideas have long been disproven, science has shown and most people now see substance use disorder as the chronic medical condition it is, this stigma still exists. Accusing a patient of such a thing may feel assumptive, offensive and intrusive. It may get awkward. Many physicians would rather avoid it. I often have people ask me “What if I ask if someone is using drugs and they aren’t?” My response is always the same: Think what could happen if you don’t ask and they are.

Not asking about a patient’s drug use may lead to dangerous prescription drug interactions, ineffective treatment of other conditions or misdiagnosis of illness. For a medical practice, this omission could create liability for such outcomes. Not taking the opportunity to assess patients while they are in your office has costs, financial and otherwise, for the patient, health insurance companies, and society. Abuse of tobacco, alcohol, and illicit drugs exacts more than $740 billion annually in costs related to crime, lost work productivity and health care. And today, all too often, patients pay the ultimate price with their lives.

Current techniques for encouraging more PCP intervention for individuals with SUD incorporate motivational interviewing tactics such as understanding, empowering, reflecting and affirming. Teaching PCPs more about these simple techniques could be key.

If you are a PCP and suspect that a patient may have a problem with alcohol or drugs, utilize an evidence-based screening tool. Familiarize yourself with available treatment resources. Give your patient hope and caring rather than judging them or contributing to the perpetual stigmatization. Importantly, understand that people struggling with SUDs don’t have to hit the proverbial rock bottom to be ready for help. Your intervention can be just what they need.

Like most other health-related behaviors, substance problems can be positively impacted with early identification. Primary care providers are in the unique position to serve in this role with just a little training, training that is readily available. And they likely already possess many of the right tools to be effective with the assessment process: compassion, respect, and dignity.

Well-supported scientific evidence shows that substance use disorders can be effectively treated, with recurrence or relapse rates that are no higher than those for other chronic illnesses. The time has come for the discussion of substance use disorders to be fully integrated into health care. All primary care physicians must understand the risk factors for addiction, how to screen for risky substance use and how to intervene when needed, just as they do with other diseases.