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Benefits of Linking Primary Medical Care and Substance Abuse Services
Patient, Provider, and Societal Perspectives
Jeffrey H. Samet, MD, MA, MPH;
Peter Friedmann, MD, MPH;
Richard Saitz, MD, MPH
Arch Intern Med. 2001;161:85-91.
ABSTRACT
Individuals with alcohol and drug use problems may receive health care
from medical, mental health, and substance abuse providers, or a combination
of all three. Systems of care are often distinct and separate, and substantial
opportunities for benefit to patient, provider, and payer are missed. In this
article, we outline (1) the possible benefits of linking primary care, mental
health, and substance abuse services from the perspective of the major stakeholders—medical
and mental health providers, addiction clinicians, patients, and society—and
(2) reasons for suboptimal linkage and opportunities for improving linkage
within the current health care system. We also review published models of
linked medical and substance abuse services. Given the potential benefits
of creating tangible systems in which primary care, mental health, and substance
abuse services are meaningfully linked, efforts to implement, examine, and
measure the real impact should be a high priority.
INTRODUCTION
A 41-year-old man with a history of heroin dependence and alcoholism,
depression, human immunodeficiency virus (HIV) infection, and hepatitis C
presented to initiate medical care and to obtain HIV medications. His medical
history was significant for 4 detoxifications over the past 8 years, methadone
treatment, a positive HIV test result 3 years before treatment, and no consistent
medical care before he was incarcerated a year before we saw him. His drug
of choice was heroin, but he had used both alcohol and cocaine regularly.
He denied substance use in jail except for smoking 1 pack of cigarettes daily.
He presented from a prison prerelease treatment program to establish medical
care.
Providing health care for individuals with alcoholism and other drug
use disorders presents challenges to clinicians, including those who have
traditionally been concerned with specific medical issues (medical clinicians),
mental health issues (mental health clinicians), and issues focused on the
substance dependence itself (substance abuse clinicians). These clinicians
approach these patients from a perspective reflecting their respective training
and background. Medical clinicians typically address the toxic effects (such
as seizures or alcoholic cirrhosis) of a particular substance or the health
consequences of a high-risk lifestyle (such as infectious hepatitis or HIV
infection). Psychiatrists and other mental health clinicians focus on the
mental health issues prevalent among substance-dependent patients. Chemical
dependency counselors typically focus on the individual's destructive preoccupation
with obtaining and consuming a psychoactive chemical substance, and the negative
consequences thereof. For the patient, the issues from all of these perspectives
are pressing, often inseparable problems, yet health care providers operate
in separate systems of care. The shortcoming of these parallel approaches
is that the patient's problems are interrelated and require input from all
systems for optimal treatment.
The case presented above illustrates the reality of health care for
an individual with severe substance abuse, and mental health and medical problems.
The patient had a clear history of receiving care in a substance abuse treatment
setting while not having his hepatitis C, HIV infection, or depression treated.
It is not uncommon for patients similar to the one presented to be discouraged
from taking effective medication for depression by well-meaning acquaintances
in recovery. Similarly, there are many cases in the literature that document
instances of medical clinicians neglecting the substance abuse needs of patients
by failing to screen, intervene, or refer.1, 2
Collaboration across the separate systems of substance abuse, medical, and
mental health treatment promises to improve the quality of care delivered
to patients with addictive disorders.
In the past decade, there have been proposals to link substance abuse
and primary medical and mental health care treatment systems for optimal care
of affected individuals.3, 4 The
HIV epidemic brought this issue to the fore: astute observers realized that
patients with alcoholism and drug abuse issues have a disproportionate burden
of medical and mental health problems, use these services in inefficient ways
(eg, emergency department visits instead of outpatient clinic visits), and
do not receive primary care in a consistent, ongoing manner.5
Primary care has been defined as "the provision of integrated, accessible
health care services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained partnership
with patients, and practicing in the context of family and community."6 Several models have been proposed to bring the system
of care for patients with substance use disorders closer to a system based
on integrated, accessible care.7, 8, 9
One model uses colocation services, described as a "one-stop shopping" centralized
approach in which substance abuse treatment, primary medical care, and mental
health services are accessible at a single site. Alternatively, in a distributive
model, the sites providing care can be linked by more effective systems to
refer patients between sites. In this article, we briefly outline the potential
benefits of linking primary care, mental health, and substance abuse services,
review the barriers to such linkage, and describe feasible published models
of linkage.
POTENTIAL BENEFITS OF LINKED SERVICES
Effective linkage may benefit individuals with substance abuse, mental
health, and medical problems in the following common scenarios: (1) when substance
dependence issues are not addressed in primary care and mental health settings;
(2) when medical and mental health issues are not addressed in substance abuse
treatment; and (3) when the patient is seen in 2 or more of these settings
but no effective communication occurs between the systems. The potential benefits
discussed below are listed in Table 1.
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Potential Benefits of Linking Primary Care and Substance Abuse Care
Services
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From a patient's perspective, the potential for improved overall care
is the motivating force for linking systems. A striking example is the patient
described above who, one year later, was receiving methadone maintenance and
antiretroviral therapy, including nevirapine. As nevirapine can decrease methadone
blood levels, the patient's methadone dose had to be increased to stabilize
his opioid maintenance treatment. Without coordination of care, a decline
in methadone levels on initiation of nevirapine therapy might lead to withdrawal
symptoms, concern about methadone diversion, and potential relapse. A significant
benefit of linked systems would be the improved well-being of patients in
terms of substance abuse severity, medical and psychiatric problems, and overall
quality of life.10 Another patient benefit
is convenient service, but this must be weighed against a likely increase
in service utilization.
From the primary care and mental health clinicians' perspective, possible
benefits of linkage are improved early identification of substance abuse and
prevention of relapse,7 increased identification
of alcohol and drug causes when formulating differential diagnoses, better
access to substance abuse treatment services, enhanced adherence with keeping
appointments and taking medications, and substance abuse training opportunities
for personnel.
From an addiction perspective, stronger linkage may yield improved outcomes
in substance abuse treatment, similar to improvements that occur when psychosocial
services are added.8, 9 Knowledge
of cases of successful treatment may reduce stigma among medical and mental
health clinicians about substance dependence and enhance these providers'
appreciation of the value of such treatment. Bringing this treatment closer
to mainstream medical care and exposing its similarities to the treatment
of other chronic illnesses may increase reimbursement parity for substance
abuse services. Substance abuse providers could learn about the medical and
mental health complications of addiction and enhance their appreciation of
prevention strategies and their clients' conditions and health care needs.
Conceivably, linking services may provide an opportunity to create an impact
on other behavior-related issues, such as smoking and sexually transmitted
diseases, including HIV infection. Finally, linking services, a relatively
recent requirement for Joint Commission on Accreditation of Healthcare Organizations
accreditation, could enhance quality improvement efforts within substance
abuse treatment systems by providing information about such efforts in medical
settings in which these issues have been grappled with when restructuring
medical care systems.
From the societal perspective, cost-effectiveness analyses of these
linkages are needed to assess possible increased health care costs in the
short-term but reduced overall long-term costs, including savings from reduced
incarceration and other criminal justice expenditures, from avoiding HIV infection
and other health-related sequelae of substance use, and from increased productivity.
Another benefit may be a decrease in duplicating services since each provider
would be aware of the other's clinical activities. Finally, a potential public
health achievement would be improved health outcomes of specific populations
with a high prevalence of alcoholism or drug abuse.
WHY SUBOPTIMAL LINKAGE?
There are many reasons for the lack of services linkage. One well-documented
problem is medical clinicians' perception that treating alcoholism and drug
abuse is not providing medical care and is therefore beyond their purview.11 This point of view is slowly changing within the
profession, but medical education about these issues was sorely deficient
in past years.15 In the mid-1980s, medical
students' lack of knowledge and their attitudes and perceptions about treating
patients with alcoholism and about their own clinical skills in this area
affected their screening and referral practices—resident physicians
felt less responsibility for care and had less confidence and more negative
attitudes toward patients with alcoholism.13
These reports suggested that curricula needed improvement, and that education,
while necessary, may not be enough to encourage better attitudes and practices
by physicians. Efforts to improve the situation have been underway, most notably
in the past decade, with the development of appropriate standards, curricula,
and effective substance abuse educators within many disciplines.14, 15
Nonetheless, progress requires time, dedicated resources, attention to continuing
medical education, and maintenance of quality care. Substance abuse clinicians
have viewed the medical and mental health issues of recovering individuals
as secondary to the substance use problem; this perspective does not lend
itself to effective collaboration.
Medical clinicians generally report having received minimal training
in treating substance abuse disorders, and screen inadequately for preclinical
cases.16 Because they do not identify patients
with less severe addictions and do not follow up with those who have had successful
treatment, most physicians have experienced few successes. This result of
poor linkage biases the spectrum of medical providers' clinical experience
and further discourages physician involvement. In effect, only patients who
do poorly and develop severe medical and psychosocial problems are "visible."17 In such an environment, it is difficult to convince
even well-meaning providers that the diagnosis and management of these disorders
are worthwhile; however, training can help overcome these barriers.18, 19
PAYMENT AND SERVICE LINKAGE
Payments for treating addictions and for mental health care have been
lower than payments for other medical care in our current health care system.20, 21 While there have been efforts to
achieve parity for health care benefits, this is not the norm. Furthermore,
many managed-care behavioral health care plans have carved out substance abuse
benefits, separating the financing of mental health and substance abuse care
from other patient health care.22, 23, 24, 25
These plans have decreased utilization of substance abuse services: it remains
unclear how this affects outcomes, quality of care, integration of care, and
physicians' attitudes. Such separate systems may foster episodic, poorly coordinated
care for substance-dependent patients.
Current payment systems do not cover substance abuse services provided
by primary care physicians. Reimbursements to medical and behavioral health
clinicians are generally charged to separate budgets, and the financial benefits
are reaped later. Consequently, health care savings from preventing HIV infection
after substance abuse treatment may only be counted as a treatment expense,
and not a savings on future medical care. Another financial disincentive to
linking services is the perception that the cost of such care may be limitless.
Apprehension about the cost of appropriate substance abuse services persists,
despite analyses showing the modest cost of unlimited substance abuse benefits.26
Well-intentioned concerns about patient confidentiality may also impede
effective linked medical, mental health, and substance dependence care. Practical
difficulties can interfere with timely 2-way communication. Substance abuse
information should be specified in information releases so that it may be
shared; however, this history is often kept separate from the standard medical
record, a phenomenon that occurs in cases of HIV infection as well. While
these processes are a noble attempt to protect patient confidentiality, they
can impede integrated care. Methods for addressing these issues are needed.
Stigma remains a fundamental barrier to progress in treating patients
with alcoholism or drug abuse. In addition to affecting whether patients recognize
their needs and their readiness to accept services, stigma can manifest in
medical clinicians not wanting to spend time dealing with drug and alcohol
issues or can lead to a lower perception of providers who work in this field.
Both results prevent overall progress.
Medical and mental health providers may not appreciate the efficacy
of substance abuse treatment. The overwhelmingly supportive body of research
on substance abuse treatment appears infrequently in the medical literature:
physicians do not appreciate the fact that treatment for alcoholism or heroin
dependence has a therapeutic value comparable with that of standard treatment
for diabetes mellitus or asthma.27, 28
In summary, the obstacles to an integrated system of care for patients
with substance use disorders are manifold. Barriers include issues of professional
responsibility, education among providers, financial disincentives, concerns
about confidentiality, and stigma, among others. While these seem extensive,
they are not insurmountable. On a broad level, addressing linkage at the systems
level would greatly improve integrated care. Systems approaches for implementing
linkage models of care include payment systems that encourage linkage, and
quality measures that value coordinated care. Parity of health care benefits
for mental health, substance abuse, and medical health (as achieved recently
in Connecticut) would help decrease stigma and improve coordination of care.
Linking services may also serve to decrease stigma. Confidentiality issues
can be addressed at a systems level (ie, by having all care occur under the
umbrella of one health care system, thereby facilitating record availability),
and at an individual patient-physician level with office systems that prompt
clinicians and their staffs to advise patients to sign appropriate releases
that allow all of their caregivers to communicate. Recently published and
future studies demonstrating the feasibility and effectiveness of these models
will help convince payers and practitioners to move in this direction.
At the clinician level, various approaches can be taken simultaneously
to help overcome barriers. Physician attitudes, skills, and practices can
be changed by active learning educational programs.18, 19
Studies showing the benefits of linked services will also lead clinicians
to favor better-integrated care. The next section describes feasible models
of linked primary medical, mental health, and substance abuse services that
have overcome these barriers, and shows evidence about their success in facilitating
the multidisciplinary care of addicted patients.
MODELS OF LINKED SERVICES
Centralized Models
Centralized (on-site) models have brought primary care, mental health,
and/or substance abuse services together at a single site. This one-stop shopping
model has been attempted best in primary care clinics and in substance abuse
treatment programs. In addition to overcoming the substantial political, bureaucratic,
attitudinal, and financial barriers that separate substance-dependent persons
from needed services, centralized delivery solves the problems of geographic
separation, patient disorganization, and poor motivation that inhibit patients
receiving substance abuse treatment from keeping outside appointments.29, 30
In general, patients with tobacco dependence, at-risk drinking habits,
and moderate illicit drug use can be managed entirely in primary care settings.
Patients with substance abuse or dependence should generally be cared for
in settings that offer specialty addiction input (either integrated in a primary
care office or located elsewhere). All patients should have primary and preventive
health care—where this care is delivered will depend on the system of
care. Clearly, a specialist's medical input is often necessary, and whether
this occurs at an addiction specialty treatment site or in a primary care
setting, the key is that systems be integrated to deliver the most appropriate
and efficient care.
Willenbring and Olson31 report favorable results for a model
of integrated alcoholism treatment in a primary care clinic for poorly motivated,
medically ill alcoholics. Their model included (1) a minimum of monthly visits
(2) outreach for patients who missed appointments (3) clinic notes that cued
the primary care physician or nurse practitioner to monitor alcohol intake
at each visit (4) advice for physicians or nurse practitioners that emphasized
reducing the ill effects of alcoholism, and cutting down consumption instead
of strict abstinence; (5) verbal and graphic feedback about improvement and
deterioration in biological markers, such as  -glutamyltransferase (GGT);
and (6) on-site mental health services as needed. 32, 33
In a randomized design, medically ill patients with alcoholism in the integrated
clinic were compared with similar patients referred to traditional alcoholism
treatment and ambulatory medical care. During 2 years of follow-up, patients
in the integrated clinic had improved outcomes, including greater abstinence,
returning twice as often for outpatient visits, and a lower mortality rate.28 Although this model may prove too elaborate for many
primary care settings, it serves as a starting point for a disease-management
system for substance abuse disorders similar to the management of asthma,
diabetes mellitus, and congestive heart failure.34, 35
With further study this model may prove cost-effective for recalcitrant alcohol-dependent
patients or other poorly motivated substance-dependent patients.
Less resource-intensive intervention models developed for problem drinkers
in primary care settings have also proven feasible. The cost analysis of Project
TrEAT (Trial for Early Alcohol Treatment), a randomized study of physician-delivered
brief interventions, showed substantial improvements in drinking outcomes
and substantial savings for society and health systems.36
An early study suggested that the simple feedback changes in biological markers,
such as -glutamyltranferase, may by themselves reduce sick days, hospital
days, and mortality.37 Adams et al22 reported that 2.5 hours of primary care provider
training in a brief patient-centered alcohol intervention was feasible and
reduced alcohol consumption among problem drinkers.38
In another model of alcohol treatment in primary care, O'Connor et al39 reported successful treatment with naltrexone in
a series of patients with alcoholism. Other models have successfully incorporated
behavioral health personnel into primary care practices.40, 41
Substantial training of the clinician delivering the service in primary care
is needed before these results can be generalized to primary care settings
as they exist today.
Few US studies have integrated drug dependence treatment and primary
care, though general practitioners frequently participate in the management
of these disorders elsewhere in the world. In one randomized trial, drug-dependent
patients treated with buprenorphine maintenance had a higher rate of retention
in a primary care setting than those in a drug treatment program (78% vs 52%; P = .06) and had lower rates of opioid use based on urine
toxicology (63% vs 85%; P<.01).42
With the development and dissemination of new pharmacological therapies for
alcoholism and drug dependence, the impetus for linked services will only
strengthen.
Centralized models of primary medical and mental health care in addiction
treatment programs also improve addicted patients' access to these services.8, 10, 43 For example, Umbricht-Schneiter
and colleagues33 found that 92% of patients randomized to a centralized
delivery program in a methadone treatment program received medical services,
compared with only 35% of patients referred to a local clinic.This model has
also been found to augment delivery of HIV-related care and routine primary
care, and to promote medication compliance.44, 45
Other investigators suggest that on-site delivery of psychosocial services
with addiction treatment lengthens treatment retention, reduces relapses to
substance abuse, and improves health.8 Integration
of substance abuse treatment and mental health services similarly reduces
relapses and improves social stability for patients with a dual diagnoses
of addictive disorders and mental illnesses.46, 47, 48
Distributive Models
In light of the lack of parity for the treatment of substance dependence
and the absence of unified budgets for medical and behavioral health services,49 most providers lack the resources to provide comprehensive,
centralized services for addicted patients.50
Therefore, the development and dissemination of effective decentralized (distributive)
models is an important step toward integrating service in the current health
care environment. Successful referral is the central task of the distributive
model. Anecdotal and limited data suggest that referral alone cannot integrate
the care of addicted patients in primary care settings. For example, among
1440 patients undergoing substance abuse treatment with a primary care physician,
45% reported that the physician who cared for them was unaware of their substance
abuse.1 A study of one community in California
similarly noted that 45% of drug users had contact with the mainstream health
care system in a given year, but medical or mental health providers were major
client referral sources or destinations for less than 10% of substance abuse
programs.51 Thus, the substantial interorganizational
gap between addiction treatment programs and mainstream health care presents
great barriers to successful referral. Because substance-abusing populations
can have disorganized lifestyles and poor motivation, contemporary distributive
models typically use case management to facilitate referrals. Community-based
case management can effectively link substancedependent patients to needed
services.52, 53
In substance abuse treatment programs, distributive arrangements are
commonly used to link patients to medical and mental health services.54, 55 Distributive arrangements range,
for example, from a substance abuse treatment unit that contracts with a local
group practice to provide physical examinations and routine medical care to
its patients, to one that makes ad hoc referrals to a local community mental
health center. The advantage of this model is that it makes use of existing
health care systems. For example, in an ongoing study, patients in an inpatient
detoxification unit receive a facilitated referral to primary care in the
local community from a multidisciplinary team (physician, nurse, and social
worker).59 This model requires no rearrangement
of existing health care delivery systems. It does require efforts (and therefore
costs) to assure that linkage is facilitated. Case management or transportation
assistance can facilitate these referrals.50, 57, 58
A recent study of public addiction treatment programs showed that contracted
referral with case management increased medical services utilization 2- to
3-fold over ad hoc referral.9
In summary, addiction interventions in medical settings may be appropriate
for hazardous drinkers and those with other moderate substance use disorders,
medically ill substance-dependent patients who refuse formal treatment referral,
and substance-dependent patients who receive rehabilitative counseling elsewhere
yet would benefit from medical therapy. Minimally motivated patients who will
accept only harm-reducing interventions may also benefit from management in
primary care settings. Primary care physicians may have a productive role
in outpatient detoxification as well.59 For
patients in formal addiction treatment, linkage to needed medical and psychological
services may improve access to health care, improve physical and mental health,
and reduce relapses. Further research should determine whether these promising
models could be applied to other settings and populations of substance-dependent
patients. Cost studies of their implementation are also desirable.60 Such studies would evaluate costs and care utilization
of substance-dependent patients across the health care system over a period
sufficient to demonstrate any long-term substance-related, medical, and mental
health benefits of integrated models of care. However, one must acknowledge
the difficulties of developing adequate costing methodologies for these systemic
interventions. Indeed, few rigorous studies of system-level interventions
exist for other chronic diseases, and the inclination to hold substance use
disorders to a higher standard should not delay efforts to implement systems
of comprehensive, continuous, longitudinal care for patients with these devastating
disorders.45
IS BETTER LINKAGE POSSIBLE IN THE CURRENT HEALTH CARE SYSTEM?
Despite the enormity of the challenge, the missed opportunities exemplified
in the initial case presentation compel us to suggest constructive solutions.
In fact, we are optimistic that it is time to transform the configuration
of substance abuse treatment and health care services. A number of factors
support our optimism that a window of opportunity exists for innovation: the
staggering burden of medical and mental health problems affecting substance-dependent
patients is now well documented, from HIV infection, hepatitis C, and drug
overdose, to depression, anxiety, and victimization.61, 62, 63, 64
The enormous economic burden that care of patients with substance use problems
places on our medical care system and society is well known, and forces policy
makers to consider alternative approaches to the management and care of this
population.65 New models of care for patients
with alcohol and drug use disorders are being explored and refined. Advances
in diagnosis and treatment, including pharmacological and behavioral approaches
in the primary care setting, promise to change the approach to these common
disorders. Primary care is not restricted to physicians, but rather includes
a multidisciplinary team. Thus, the fact that primary care physicians feel
overburdened66 should not preclude the development
of such a linkage system, but rather should influence its development so that
its implementation does not rely solely on physicians. The ability to treat
substance abuse in less intensive settings will promote cost savings and cost-effectiveness.
Increased attention to the improvement of quality in health care systems will
also create opportunities to address linkage to substance abuse treatment
as a quality issue. Present support from the National Institutes of Health
to examine linkage of substance abuse treatment to medical and mental health
care will provide data about the value of such linkages. Finally, this era
has seen rapid reorganization of health care services, and despite the inherent
difficulties this presents, it also presents the opportunity to restructure
inadequate systems of health care delivery. We believe that the time is right
to move ahead with innovative linkages between the substance abuse treatment
and mainstream health care systems.
AUTHOR INFORMATION
Accepted for publication June 30, 2000.
Drs Samet and Saitz received support for this project from the National
Institute on Drug Abuse (RO1-DA10019), National Institute on Alcoholism and
Alcohol Abuse (RO1-AA10870), and the Center of Substance Abuse Prevention,
Substance Abuse and Mental Health Services Administration (T26 SP08355). Dr
Friedmann is the recipient of a Mentored Clinical Scientist Career Development
Award (K08-DA00320) from the National Institute on Drug Abuse. Drs Saitz and
Friedmann are Robert Wood Johnson Foundation Generalist Physician Faculty
Scholars.
From the Section of General Internal Medicine, Department of Medicine
(Drs Samet and Saitz), and the Department of Social and Behavioral Sciences
(Dr Samet), Boston University Schools of Medicine and Public Health, Boston,
Mass; and the Division of General Internal Medicine, Departments of Medicine
and Community Health, Brown University School of Medicine, Providence, RI
(Dr Friedmann).
Reprints: Jeffrey H. Samet, MD, MA, MPH, Clinical Addiction Research
and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical
Center, 91 E Concord St, Suite 200, Boston, MA 02118 (e-mail: jsamet{at}bu.edu).
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