Karran A. Phillips, MD, MSc, Peter D. Friedmann, MD, MPH, FASAM, FACP, Richard Saitz, MD, MPH, FACP, FASAM, and Jeffrey H. Samet, MD, MA, MPH
CHAPTER OUTLINE
■ POTENTIAL BENEFITS OF LINKED SERVICES
■ BARRIERS TO OPTIMAL LINKAGE
■ MODELS OF LINKED SERVICES
■ PROSPECTS FOR IMPROVED LINKAGE
Persons with substance use problems are at substantial risk for coexisting medical and mental health problems (see chapters on Medical Disorders and Complications of Addiction and Section Co-Occurring Addictions and Psychiatric Disorders in this text) and often present to medical and mental health settings. Similarly, patients in addictive disorder treatment commonly experience medical and psychiatric problems, which can distract from recovery and increase relapse risk (1–3). In both medical and addictive disorder treatment settings, the provision of comprehensive care for individuals with alcohol and other drug use disorders presents challenges to clinicians who traditionally have been concerned only with issues reflecting their own training and perspectives. For example, medical practitioners typically address the toxic effects of a particular substance, such as seizures or cirrhosis, or the health consequences of a high-risk lifestyle, such as viral hepatitis or HIV. Psychiatrists and other mental health professionals focus on the mental health issues that are prevalent among substance-using patients. Meanwhile, addiction medicine specialists may focus on the individual’s destructive preoccupation with obtaining and consuming a psychoactive chemical substance and the negative consequences of such actions. For the patient, these problems are inseparable, yet the providers operate in distinct systems of care, each with its own—often exclusive—focus. For example, the medical literature contains instances of medical practitioners not attending to the addictive disorders of their patients by failing to screen, intervene, or refer (4–6). Similarly, patients in addictive disorder treatment programs report unmet psychological and medical needs (7,8). It is as if substance-using patients with psychiatric or medical illnesses sometimes are bounced between systems—told that they must be abstinent before they can receive treatment for their psychiatric and medical problems or that they are too sick (medically or psychiatrically) to get into an addiction treatment program—resulting in a clinical “Catch-22.”
Patients who present with complex, interrelated, comorbid problems make apparent the disconnection between these parallel yet typically separate systems of care. The growth of the training of addiction medicine and addiction psychiatry physicians will help to close these gaps. However, for most systems that lack access to certified addiction physicians (9), linkages across the separate medical, mental health, and addictive disorder disciplines will be needed to improve the quality of care delivered to patients with addictive disorders. This chapter briefly reviews the potential benefits to linkages between primary medical care, mental health, and addictive disorder services; identifies the potential barriers to such linkages; and describes published linkage models.
POTENTIAL BENEFITS OF LINKED SERVICES
Effective linkage may benefit individuals with substance use problems in the following common scenarios: when issues related to addictive disorders are not addressed in primary care and mental health settings, when medical and mental health issues are not addressed in addictive disorder treatment, and when the patient is seen in two or more of these settings but no effective communication between or within the systems occurs.
From a patient’s perspective, the potential for improved overall care is the motivating force for linkage of systems (Table 28-1). For example, a patient receiving methadone maintenance who is prescribed efavirenz, which can decrease methadone blood levels, without coordination of care might experience withdrawal symptoms, toxicity, provider unease about possible methadone diversion, or relapse. Other possible benefits from such linkages include the potential for improved pain control in a patient receiving substance abuse treatment services, proper attribution of side effects of medications (vs. substance use or withdrawal), and better access to detoxification and treatment for patients in the medical system. A profound potential benefit of linked systems is the improved well-being of individual patients in terms of addictive disorder severity, medical and psychiatric problems, and overall quality of life (10,11). A pragmatic benefit is the provision of convenient, comprehensive, and coordinated care to patients. As this would likely result in increased service utilization, as noted in the broader spectrum of patients presenting to primary care–based buprenorphine treatment programs (12), careful assessment of its appropriateness would be necessary. Finally, linking services might also decrease stigma, as all providers would acknowledge and support the patient’s recovery efforts, and all medical and psychiatric conditions would be addressed in the same location.
TABLE 28-1 POTENTIAL BENEFITS OF LINKING ADDICTION TREATMENT WITH OTHER MEDICAL AND PSYCHIATRIC SERVICES
From the perspective of the primary care provider and the mental health clinician, possible benefits of linkage include early identification of and relapse prevention for substance use disorders (13), increased consideration of alcohol and drug problems in the formulation of differential diagnoses, better access to addictive disorder treatment services, enhanced patient adherence to appointments and medications, and improved addictive disorder training and experience for personnel. From an addiction treatment provider’s perspective, stronger linkages could yield improved outcomes of addictive disorder treatment, similar to that demonstrated with the addition of needed psychosocial services (14,15). Ready availability of needed medical and mental health services also would allow addictive disorder professionals to do what they do best: focus on the core substance use issues. Exposure to examples of successful treatment could reduce stigma on the part of medical and mental health professionals toward addictive disorders and enhance their appreciation of the value of addictive disorder treatment. Bringing addictive disorder treatment closer to mainstream medical care and exposing its similarities to the care of other chronic illnesses could support the effort to achieve reimbursement parity for addictive disorders. Addictive disorder providers could learn about the medical and mental health complications of addictions and enhance their appreciation of the client’s conditions, health care needs, and prevention approaches. Conceivably, the linkage of services could provide an opportunity to affect other behavior-related issues, such as sexually transmitted diseases (including human immunodeficiency virus) and smoking. Finally, linkage of services could enhance quality improvement efforts within addictive disorder treatment systems—as articulated in an accreditation requirement from the Joint Commission (that accredits health care organizations) (http://www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/) and by the focus of an Institute of Medicine (IOM) report (16)—by taking lessons from medical settings that have grappled with these issues as part of the restructuring of medical care systems.
From a societal perspective, stronger linkages might lower long-term costs, including savings from reduced HIV incidence and other health-related sequelae of averted substance use, reduced incarceration and other criminal justice expenditures, and increased productivity (17,18). Other benefits include reduced duplication of services across these systems. Finally, a potential public health achievement would be improved health outcomes for specific populations burdened with the substantial morbidity associated with alcohol or drug use disorders.
BARRIERS TO OPTIMAL LINKAGE
Medical Training
Many barriers impede better linkage of services. One well-documented problem has been the perspective of many medical practitioners that addressing alcohol and drug abuse issues is not providing medical care and thus is outside his or her purview (19). This viewpoint is slowly changing. Medical education about substance dependence has been sorely deficient in past years (20). In the mid-1980s, medical students’ suboptimal knowledge, perceived responsibility for caring for patients with alcohol use disorders, and confidence in clinical skills were related to reported screening and referral practices; resident physicians perceived even less of a responsibility for care, had less confidence in their skills, and had more negative attitudes (21). These reports suggested that curricula needed improvement and that education, though necessary, may not be sufficient to maintain appropriate attitudes and practices on the part of physicians. Efforts to rectify that situation have been under way, most notably in the past decade, with development of appropriate standards, curricula, and effective addictive disorder educators within many disciplines. Past efforts by the Health Resources and Services Administration and the Center for Substance Abuse Treatment (CSAT) include addiction educators in place in every health professional school in the United States (22–27) and more recently CSAT support for resident physician training in Screening Brief Intervention and Referral to Treatment and the creation of the Coalition On Physician Education in Substance Use Disorders (http:// www.cope-assn.org/). Progress requires time, dedicated resources, attention to continuing medical education, and maintenance of high-quality care.
Medical clinicians in practice generally report having received minimal training in substance use disorders, and they screen inadequately for preclinical cases (25,28). Because they neither find patients with less severe addictive disorders nor follow up those who have had success in treatment, most physicians have experienced few successes. This latter product of poor linkages 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” (29). 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 (30–32).
Payment and Service Linkage Issues
In our current health care system, payment for addiction treatment and mental health care has been limited, compared with payments for other medical services (33,34). Although in recent years, there have been successes in the effort to achieve parity for health care benefits; nonetheless, parity as yet is not the norm.
In 1950, the Uniform Accident and Sickness Policy Provision Law (UPPL) stating insurers are not liable for any loss sustained or contracted while the insured is intoxicated or under the influence of any narcotics was passed. The refusal of reimbursement serves as a disincentive for physicians to screen and document alcohol use, and the opportunity for intervention is missed despite an estimated health savings of 3.81 U.S. dollars for every 1.00 US dollar spent on screening and intervention (35). Since 2001, numerous organizations including the National Association of Insurance Commissioners (the organization that in 1947 adopted the UPPL and encouraged states to implement it as state policy), the American College of Surgeons, and the American Medical Association (AMA) have supported the repeal of the UPPL. In 2010, several states took steps to repeal their UPPLs; for example, in New York, Governor David Paterson (D) signed the No Fault Intoxicated Driver Bill (S.B. 7485) into law, which requires insurance companies to compensate health care providers for emergency services provided regardless of whether the injury was the result of driving while intoxicated. As of 2010, 17 states (WA, OR, CA, NV, CO, SD, IA, IL, IN, OH, ME, CT, RI, MD, DC, NC, SC) had repealed their UPPL.
Moreover, many managed behavioral health plans have “carved out” addictive disorder benefits, separating the financing of care for mental and addictive disorders from that for the rest of the patient’s ailments (36–39a). Such plans have reduced the utilization of services for addictive disorders, and the effect they have had on clinical outcomes, quality of care, integration of care, and physician attitudes remains unclear. Separate systems have frequently fostered the delivery of episodic, poorly coordinated care for substance-using patients.
However, in March 2008, the House of Representatives passed Mental Health and Addiction Equity Act of 2007 (HR 1424), which seeks to improve health for all Americans by granting greater access to mental health and addiction treatment and prohibiting health insurers from placing discriminatory restrictions on treatment. HR 1424 goes beyond the 1996 Mental Health Parity Act, which required equity only for annual and lifetime limits by requiring equity across the terms of the health plan. President Bush signed this bill into law on October 3, 2008, as part of the Emergency Economic Stabilization Act of 2008. The Mental Health and Addiction Equity Act became effective in January 2010, and, in February 2010, the Federal Departments of Health and Human Services, Labor, and Treasury issued regulations to implement the federal parity law, and those regulations became effective for most health plans on January 2011. The Mental Health and Addiction Equity Act applies only to group health plans with greater than 50 employees and does not apply to the individual insurance market or group health plans for companies with ≤50 employees, the latter of whom are subject to current state mental health parity requirements. Currently, federal agencies are addressing implementing the Mental Health and Addiction Equity Act while navigating health care reform under the Affordable Care Act, which advocates for equal and quality benefits and mandates inclusion of substance abuse treatment in minimum benefits packages for all Americans (40).
Current systems of payment often do not cover addictive disorder services provided by primary care physicians. Financial reimbursements to medical and behavioral health clinicians generally are taken from separate budgets, and the financial benefits of averted medical complications occur late. Consequently, the cost of treatment for an addictive disorder that prevents subsequent HIV infection may be appreciated as a treatment expense, rather than as a savings of future medical care costs. Another financial disincentive to linked services is the perception that costs of such care may be limitless. The fear of the cost of appropriate addictive disorder services persists, despite analyses that document the limited effect even a worst case scenario would have on health care expenditures (41). In January 2001, the Office of Personnel Management required parity of mental health and substance abuse coverage for all federal employees. A 2006 study comparing seven Federal Employee Health Benefit Plans with a matched set of plans that did not have parity of mental health and substance abuse benefits found that implementation of parity was associated with an increase in service utilization in one of the seven federal plans (+0.78%; p < 0.05), decrease utilization in one of the seven plans (−0.96%; <0.05), and no significant difference in the five other plans (range, −0.38% to +0.23%; p > 0.05 for each comparison). Additionally, they found that there was a statistically significant decrease in spending attributable to parity in three plans (range, −$201.99 to −$68.97; p < 0.05 for each comparison) and no significant change in spending attributable to the implementation of parity in the remaining four plans (range, −$42.13 to +$27.11; p > 0.05 for each comparison). The authors concluded that implementation of parity in insurance benefits for mental health and substance dependence coupled with management of care can improve insurance protection without increasing total costs (42).
In October 2007, the White House Office of National Drug Control Policy announced new health care codes for substance abuse screening and brief intervention. The AMA’s Level I Current Procedural terminology codes (99408 and 99409) went into effect on January 1, 2008, and allow health care providers to report and be reimbursed for structured screening and brief intervention. Now that these codes exist, their success is largely dependent on their uptake and utilization by health care providers. A 2011 study by Harris et al. (43) demonstrated that identifying substance use disorder treatment and diagnosis and procedure codes has a high concordance with chart review, which is a positive indication the codes are being used and are being used appropriately.
Concerns about Confidentiality and Stigma
Well-meaning concerns about patient confidentiality can be barriers to effectively linked medical, mental health, and addiction care. Practical difficulties interfere with obtaining timely two-way written releases of information. Substance dependence programs are required to comply with both the federal confidentiality regulations (42 Code of Federal Regulations [CFR] Part 2) and with the “Standards for Privacy of Individually Identifiable Health Information” final rule (Privacy Rule), pursuant to the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164, Subparts A and E (http://www.hipaa.samhsa.gov/download2/SAMHSA’sPart2-HIPAAComparisonClearedWordVersion.doc). Addictive disorder information must be specified in information releases to be shared and is often kept separate from the standard medical record. Though the protection of patient confidentiality is noble, in some cases, it can impede integrated care.
The dissemination of electronic health records promises a major revolution in information sharing across systems. Electronic health records create the potential for real-time data-sharing networks, information sharing protocols among the health sector and treatment organizations, central warehousing of health information, and cross-organizational data management. In the United States, projects such as Agency for Health Research and Quality’s State and Regional Demonstration in Health Information Technology Project are working toward interoperability and sharing of patient data between hospitals, physician offices, labs, and other health care providers. However, regulatory barriers, such as patient optin provisions (where patients must give written permission to have their data included in a local or regional registry), will need to be addressed to maximize utility of these systems. Uptake of Internet-based systems in the addiction treatment sector will need an influx of resources, as occurred in the health care sector with the American Recovery and Reinvestment Act of 2008.
Nonetheless, the integration of addictive disorder information into electronic medical records will continue to be challenging. Regulators and clinicians will continue to struggle to balance protections against discrimination with the need for information sharing among health care providers in integrated systems of care. Such integration of care is encouraged by the Affordable Care Act, with central involvement of patient-centered medical homes in treating and managing substance use, with the benefit of electronic medical records and electronic data exchanges (for more information, see http://lac.org/index.php/lac/webinar_archive).
Stigma remains a fundamental barrier in the treatment of any patient with alcohol or drug abuse. In addition to effects on patient behavior, such as limiting recognition of needs and readiness to accept services, stigma might result in medical clinicians’ disinclination toward spending time addressing drug and alcohol issues or a perception of diminished stature of substance abuse treatment providers. Both outgrowths of stigma impede the overall progress.
Medical and mental health providers often inadequately appreciate the efficacy of treatment for addictive disorders despite an overwhelmingly supportive body of research. For example, physicians do not appreciate the comparable therapeutic value of treatment for alcohol or opioid dependence relative to standard treatment for other chronic disorders, such as diabetes mellitus or asthma (44–46).
In summary, the barriers 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. Though the barriers can appear to be extensive, they are not insurmountable. At the “macro” level, addressing systems linkages would go a long way toward improving integrated care. Examples of system approaches include implementation of the following: linkage models of care, payment systems that encourage linkage, and quality measures that value coordinated care. Parity of health care benefits for mental health, addictive disorders, and medical problems (as part of legislative efforts in Connecticut and Minnesota) can help to reduce stigma and improve care coordination, but impediments to the care of addictive disorders in primary care settings exist even in states where parity legislation has been enacted. These impediments include the arbitrary health insurance practice of discounting or denying primary care reimbursement for visits in which the provider indicates a mental or addictive disorder as the primary diagnosis (47).
Confidentiality issues can be addressed at the system level by having all care occur under the umbrella of one health system facilitating records availability and at an individual patient–clinician level by having office systems that prompt clinicians and staff to obtain patient information releases to allow health care providers to communicate. Recently published and future studies demonstrating the feasibility and effectiveness of these models should help to convince payers and practitioners of the need to move in this direction.
The growth of office-based opioid agonist treatment has enhanced communication between some primary medical care providers and opioid treatment staff members and provides models for the opportunity of integrated medical and/or psychiatric care with addiction treatment. At the clinician level, various approaches can be taken simultaneously to help overcome the barriers to integration. Physician attitudes, skills, and practices can be changed by active learning educational programs (30,31). Convincing theoretical and empirically proven benefits of linked services also will lead clinicians to favor better-integrated care (48–50).
MODELS OF LINKED SERVICES
Alcohol and drug-abusing patients use services in “inefficient” ways (e.g., emergency department [ED] presentations rather than outpatient clinic visits), and they do not receive care in the continuous, longitudinal, and comprehensive manner that is often essential for the high-quality management of any chronic disease (51–54). Two basic models have been proposed to bring the system of care for patients with substance use disorders closer to a primary care or chronic disease management (CDM) model (Table 28-2). One model uses a centralized approach in which treatment of addictive disorders, primary medical care, and mental health services are colocated at a single site. A second model uses a distributive approach to facilitate effective patient referrals to services at different sites. This section describes these models of linked primary medical, mental health, and addictive disorder services and reviews the available evidence of their success in facilitating the multidisciplinary care of addicted patients (16).
TABLE 28-2 FEATURES OF CENTRALIZED AND DISTRIBUTIVE INTEGRATED SERVICE MODELS
Centralized Models
Centralized or onsite models bring primary care, mental health, and/or addictive disorder services together at a single site. This fully integrated, “one-stop-shopping” model has been best described in primary care medical clinics and in addictive disorder treatment programs. In addition to overcoming the substantial political, bureaucratic, attitudinal, and financial barriers that separate addicted persons from needed services (55,56), centralized delivery overcomes the problems of geographic separation, patient disorganization, and poor motivation that inhibit patients with addictive disorders from keeping outside appointments (56,57).
Willenbring and Olson (58) reported favorable results for a model of integrated medical and alcohol treatment in a specialty clinic, so-called “backward integration” for poorly motivated, medically ill individuals with alcohol dependence. Their model included at least monthly visits (30), outreach to patients who missed appointments (22), clinic notes that cued the primary care provider to monitor alcohol intake at each visit (59), provider-delivered brief advice that emphasized reducing the harm from alcohol use and cutting down rather than strict abstinence (60), verbal and graphic feedback of improvement and deterioration in biologic markers such as gamma-glutamyltransferase (GGT) (61), and onsite mental health services as needed (62,63). In a randomized design, medically ill alcohol-dependent patients in the integrated clinic were compared with similar patients referred to traditional alcohol dependence treatment and ambulatory medical care. During 2 years of follow-up, patients in the integrated clinic had improved alcohol treatment outcomes (including greater abstinence), improved outpatient visit adherence, and lower mortality. Though this model may prove too elaborate for many primary care settings, it serves as a starting point for a disease management system for substance use disorders similar to those used for asthma, diabetes mellitus, and congestive heart failure (51,64). With further study, this model may prove cost-effective for recalcitrant alcohol-dependent patients or for other poorly motivated or complicated substance-abusing patients. Less resource-intensive intervention models developed for problem drinkers in primary care also have proved feasible. The cost analysis of project 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 (65). A primary care study from the University of Massachusetts reported that 2.5 hours of primary care provider training in patient-centered alcohol brief intervention was feasible (30) and reduced alcohol consumption among problem drinkers (66). An early study suggested that feedback about changes in biologic markers, such as GGT in alcohol-dependent patients, can itself reduce sick days, hospital days, and mortality (67). Saitz et al. (68) demonstrated that a systems intervention (physician prompting with suggested courses of action) can improve counseling for alcohol problems and reduce drinking. In another model of addressing alcohol dependence in primary care, O’Connor reported the successful treatment of patients with naltrexone (69). Other models have incorporated behavioral health personnel into primary care practices (70,71). However, if these efforts are to be generalized to primary care settings as they exist today, substantial training of clinicians will be required as physicians often estimate their competence in alcohol-related behavior change lower than in other health-related behavior change such as smoking cessation, stress, exercise, and weight management (72).
Recent studies have demonstrated the effectiveness of incorporating pharmacologic treatment for alcohol use disorders in the primary care setting. Lee et al. described the feasibility of utilizing long-term extended-release naltrexone plus medical management in alcohol-dependent adults in two public primary care clinics. The authors found that 62% of participants completed a 12-week observational trial and that during an additional 48-week active extension phase, 29% continued treatment for a median of 38 weeks total (range, 16 to 72 weeks). In active extension phase participants, self-reported drinking days were low compared to 30-day pretreatment baseline (median 0.2 vs. 6.0 drinks per day; 82% vs. 38% days abstinent; 11% vs. 61% heavy drinking days) demonstrating that long-term extended-release naltrexone in a primary care medical management model was feasible and may promote reductions in drinking and increased abstinence from alcohol (73).
Prior to the Drug Addiction Treatment Act of 2000, few American studies had integrated treatment of illicit drug dependence into primary care. Though general practitioners have frequently participated in the management of these disorders elsewhere in the world, this has only recently occurred in the United States with the enactment of legislation permitting office-based treatment of opioid dependence with Schedule III, IV, or V pharmacologic agents approved by the U.S. Food and Drug Administration. Sublingual buprenorphine and a combination of buprenorphine and naloxone have been used for this purpose in the United States since 2003. Several studies have found that buprenorphine works as well as methadone for patients with opioid dependence of mild to moderate severity. In a 12-week randomized trial of 46 opioid-dependent patients treated with buprenorphine maintenance, there was higher retention in the primary care setting than in a drug treatment program (78% vs. 52%; p = 0.06) and lower rates of opioid use based on urine toxicology (63% vs. 85%; p < 0.01) (74). In addition to achieving positive treatment outcomes, office-based buprenorphine has been well received by patients. Barry (75) surveyed 142 opioid-dependent patients receiving primary care–based buprenorphine/ naloxone. Their mean overall satisfaction with treatment was 4.4 (of 5). Patients were most satisfied with the medication and ancillary services; and they indicated a strong willingness to refer a substance-abusing friend for the same treatment. With the development and dissemination of new pharmacologic therapies for alcohol and other drug use disorders, the impetus for addictive disorder services in the primary care setting will only increase.
Though methadone is an effective treatment for opioid dependence, its use is heavily regulated. Few experimental programs have looked at the use of medical methadone maintenance involving stabilized methadone patients in a medical setting. In a study by Merrill et al. (76), regulatory exemptions were granted to establish a methadone medical maintenance program. Of the 30 enrolled stable methadone patients transferred to a medical office for care, 28 remained after 1 year and only two patients had opioid-positive urine tests. In addition to good substance dependence treatment outcomes, previously unmet medical needs were attended to as demonstrated by an improvement in the medical composite score of the addiction severity index (p = 0.02), and patient and physician satisfaction were high with an improved attitude of physicians toward methadone maintenance (p = 0.007).
Centralizing primary medical care, substance dependence treatment, and psychiatric services has also proven an effective way to manage concomitant medical conditions such as hepatitis C, tuberculosis, and HIV. In 2012, the Centers for Disease Control and Prevention released a report urging the integration of prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis in persons who use drugs stating that linkage and integration of these services will improve quality, reduce duplication, increase access, improve timeliness of service delivery, and increase effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants (77). Substance dependence treatment physicians often perform initial hepatitis C management including screening for hepatitis C virus (HCV) antibodies, recommending hepatitis A and B vaccines, and referring patients to subspecialists for hepatitis C treatment (78). In a 2007 study by Sylvestre and Clements (79), methadone maintenance patients received hepatitis C treatment in a community-based nonprofit clinic providing on-site medical and psychiatric treatment. Adherence to hepatitis C treatment (defined as taking at least 80% of prescribed interferon and ribavirin) occurred in 68%, and those who were adherent were more likely to achieve a sustained hepatitis C virologic response (42% vs. 4% in nonadherent patients; p = 0.001). Furthermore, pegylated interferon did not appear to precipitate opioid withdrawal in HCV- and HIV-coinfected methadone maintenance patients (80). Stein et al. implemented a concurrent HCV treatment group that discussed side effects, interferon injection administration, and adherence among methadone maintenance patients receiving HCV treatment and found that 42% achieved a sustained viral response and 87% of genotype-1–infected patients treated with a direct-acting antiviral agent achieved an undetectable viral load at 24 weeks (81). Additional studies have also shown that current and former injection drug users can be engaged successfully in evaluation and treatment of HCV infection when these services are collocated with methadone maintenance treatment (82,83). Less is known about tuberculosis management within a centralized medical care and substance dependence setting. However, O’Connor et al. (84) demonstrated that by utilizing an admixture of isoniazid and methadone, 72% of methadone maintenance patients eligible for tuberculosis chemoprophylaxis completed therapy. The delivery of HIV care in methadone maintenance settings has also been shown to improve retention and increase medication adherence and viral suppression (85).
Centralized models of primary medical and mental health care in addiction treatment settings may also improve addicted patients’ access to these services (86). Umbricht-Schneiter et al. (56) found that 92% of patients randomly assigned to a centralized model in a methadone treatment program received medical services, compared with only 35% of patients referred to a local clinic. A trial of veterans found that primary care on-site in an addiction treatment program increased attendance at primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53 to 3.15) and engagement in addiction treatment at 3 months (adjusted OR = 1.36; 1.00 to 1.84) but showed no effect on overall health status or costs (87). Among patients with substance abuse–related medical conditions, integrated care models compared to independent care models have shown significant decreases in hospitalization rates (p = 0.04), inpatient days (p = 0.05), and emergency room use (p = 0.02) (88). Similarly, Friedmann et al. (86) found that on-site delivery of primary care to patients receiving methadone maintenance and long-term residential patients reduced subsequent ED and hospital use (17). Other work suggests that integration of addictive disorder treatment and community mental health services reduces relapse and improves social stability for patients dually diagnosed with addictive disorders and mental illness (62,89,90).
In general, patients with nicotine dependence, at-risk drinking, and low-severity illicit drug use can be managed in primary care settings without subspecialty addiction medicine consultation. Conversely, patients with addictive disorders or substance dependence generally should be cared for in collaboration with addiction specialists and/or treatment counselors (whether integrated in a primary care office or located elsewhere). Recent advances support and encourage a major role for primary care physicians and office-based psychiatrists in the pharmacologic management of patients with opioid or alcohol dependence while at the same time recognizing the need for substantial collaboration and coordination with addiction treatment providers. For example, with the availability of office-based buprenorphine/nalox-one, the primary care physician or general psychiatrist can prescribe medication for opioid dependence while counseling is delivered by the physician, a health behavior expert in the practice, or referral. Similarly, medications for alcohol dependence can have efficacy when given along with low-intensity medication management counseling that addresses adherence, side effects, and alcohol use (60,69,73); such counseling can be done in medical settings because it is similar to adherence counseling for medications for other chronic conditions such as hypertension and diabetes mellitus. Medications for alcohol dependence can be as effective when delivered with medication management counseling as with more specialized behavioral counseling.
All patients should have primary and preventive health care—again, where this care is delivered will depend on the system of care. An ideal centralized model of care can provide addiction, mental health, and medical care at a single site. Whether specialty addiction medicine or addiction psychiatry services are delivered at an addiction specialty treatment site or within the primary care setting, the key is that systems be integrated to deliver the most appropriate and efficient care.
Distributive Models
In light of the lack of parity in reimbursement for the treatment of substance use disorders and the absence of unified budgets for medical and behavioral health services (91), most providers lack resources to provide comprehensive, centralized services for addicted patients (86). Moreover, patients (especially those in long-term recovery) may object to long-term primary care in settings primarily identified as addiction treatment programs. Therefore, the development and dissemination of effective decentralized or distributive models is an important step toward service integration in the current health care environment.
Successful referral is the central task of the distributive model. Anecdote and limited data suggest that simple referral alone cannot integrate the care of addicted patients in primary care settings. For example, among 1,440 patients who were in addiction treatment with a primary care physician, 45% reported that the physician who cared for them was unaware of their addictive disorder (6). 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 fewer than 10% of addictive disorder programs (92). Thus, the substantial interorganizational distance 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 substance-dependent patients to needed services (61,93).
In addiction treatment programs, distributive arrangements are commonly used to link patients to medical and mental health services (94–96). Distributive arrangements range, for example, from an addictive disorder 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, patients in an inpatient detoxification unit who received a facilitated referral to primary care in the local community from a multidisciplinary team (physician, nurse, and social worker) were more likely to link with primary medical care (97). This model requires no rearrangement of existing health care delivery systems; however, it does require efforts (and therefore costs) to assure that linkage is facilitated.
Case management or transportation assistance can facilitate these referrals (94,98,99). A study of public addiction treatment programs found that contracted referral with case management increased medical services utilization two-to threefold over ad hoc referrals (100). Other work has emphasized the importance of transportation assistance to increase the delivery of needed services (98).
There is also some evidence for the efficacy of a model utilizing a combination of centralized and distributive approaches. Islam et al. describe an Australian needle syringe program–based primary health care center that implemented a hepatitis C treatment assessment plan resulting in successful referrals to a tertiary liver clinic (71% of those referred attended) utilizing facilitated appointment scheduling, phone and SMS appointment reminders, confirmation of attendance, referral outcome communication, and immediate rescheduling of missed appointments (101).
Disease Management Model
CDM, also referred to as chronic care management, is a care delivery approach based on the chronic care model described by Wagner that links, integrates, and coordinates primary and specialty care (102,103). The key components are an informed and motivated patient, a proactive team, and an established delivery system resulting in maximized CDM and outcomes. Such an approach has been successfully applied to many chronic diseases but not yet to substance dependence. Saitz et al. (104) have proposed that the implementation of CDM focused on substance dependence should include attention to (a) systems of care; (b) addressing medical, psychiatric, and social problems; and (c) addiction-specific treatments. The systems component addresses the fragmentation of care through on-site longitudinal service delivery, referral agreements, multidisciplinary teams, coordination of an explicit care plan, patient reminders, electronic medical records, and collaboration of addiction, medical, and psychiatric physicians. Medical, psychiatric, and social components include assessment, management, and coordination of care with specialty referral. Addiction-specific components include all treatments with evidence for efficacy such as motivational interviewing, relapse prevention counseling, ambulatory detoxification, and appropriate referral. It is hypothesized that strong CDM linkages within and between systems of care and integrated case management will increase access and receipt of, and retention in, effective substance dependence and medical treatment that in turn will improve utilization and health outcomes. Kim et al. (105) demonstrated that high-quality CDM for alcohol and/or other drug dependence may improve addiction outcomes and that chronic care model quality measures may better reflect effective CDM than measures such as visit frequency. However, a randomized trial of chronic care management for alcohol and other drug dependence found few benefits for the group that received care management versus a control group receiving usual care (106). It may be that despite the logic and likely effectiveness of the approach, it may be insufficient if the health system at large does not also improve to facilitate care for patients with complex chronic conditions.
In a 2012 retrospective chart review, Pade et al. describe the treatment of patients with comorbid chronic pain and addiction in their Co-occurring Disorders Clinic embedded in a Veterans Affairs (VA) medical center in New Mexico. Among patients treated with buprenorphine/naloxone for co-occurring chronic noncancer pain and opioid dependence in a primary care setting, 65% continued on medication and 5% completed treatment and were no longer taking any opioids. Additionally, pain scores showed a modest but statistically significant improvement on buprenorphine/naloxone (107). Clinics in the CDM model have the potential to improve the quality of care as demonstrated in this study where participants experienced improved pain control while receiving substance abuse treatment services.
Vulnerable Populations
Integrated models may be most germane and show the most benefit to vulnerable populations including HIV-infected, homeless, and incarcerated individuals and veterans and active military. Integrated models have been found to promote delivery of HIV-related care, medication adherence, and outpatient medical services (95,98,108,109). An analysis of data gathered from New York State Medicaid claims found that regular drug abuse treatment and medical care reduced hospitalizations by approximately 25% among HIV-positive and HIV-negative patients with drug abuse diagnoses (110). Basu et al. (111) outlined four possible models for the integration of addiction disorder treatment with buprenorphine into the primary HIV care setting: (a) the HIV primary care model wherein the HIV primary care physician provides buprenorphine maintenance services, (b) the on-site specialist model wherein an addiction specialist provides buprenorphine maintenance therapy at an HIV primary care clinic, (c) the hybrid model wherein buprenorphine induction is performed by a specialist and maintenance by the HIV care provider, and (d) the drug treatment model wherein buprenorphine maintenance is provided through a substance abuse clinic with HIV care services. In a recent study investigating patient satisfaction and experience with buprenorphine/naloxone treatment and integrated care, patients described being more engaged with both their substance abuse treatment and HIV care, including greater ability to manage their own treatment, keep up with appointments, and adhere to antiretroviral medication regimes (112). Further research is needed to determine which of these models will be most feasible and effective and whether they can be applied to other addiction disorder treatments in addition to buprenorphine. A randomized trial of integrated primary care in an addiction treatment program concluded that integrated care may be cost-effective for patients with addictive disorder–related medical conditions (88,113).
With the increasing prevalence of substance abuse/ dependence and polysubstance use among urban homeless persons, these individuals have unique needs that will require tailored interventions (114). Homeless individuals have high rates of social instability, comorbidity, and chronic drug use, which make them ideally suited for systems of integrated care. Alford et al. (59) conducted a retrospective medical record review of 44 homeless and 41 housed patients enrolled in office-based opioid treatment over 12 months and found that homeless patients receiving buprenorphine/naloxone fared comparably to housed. Treatment failure for the homeless (21%) and housed (22%) did not differ (p = 0.94). Both groups had similar proportions with illicit opioid use (OR, 0.9; 95% CI, 0.5 to 1.7 p = 0.8), utilization of counseling (homeless, 46%; housed, 49%; p = 0.95), and participation in mutual help groups (homeless, 25%; housed, 29%; p = 0.96) at 12 months.
Substance dependence is common in incarcerated individuals with a recent systematic review finding drug abuse or dependence in male prisoners ranging from 10% to 48% and in female prisoners from 30% to 60% (115). Despite the high prevalence of substance use disorders in correctional settings, a survey of the medical directors of all 50 states and the federal prison system demonstrated that among respondents who had jurisdiction over 88% of US prisoners, 48% provided methadone, predominantly for short-term detoxification and pregnant inmates, and only 8% referred opioid-dependent inmates to methadone programs upon release (116). Friedmann et al. implemented collaborative behavioral management (CBM) integrating the roles of parole officers and treatment counselors to provide role induction counseling, contract for prosocial behavior, and deliver contingent reinforcement of behaviors consistent with contracted objectives. Four hundred and eighty-six drug-involved parolees were randomized to either CBM or traditional parole. In the first 3 months, the CBM group had more parole sessions, face-to-face parole sessions, days on which parole and treatment occurred on the same day, treatment utilization, and individual counseling, without an increase in parole violations (117). The high prevalence of substance use disorders in incarcerated individuals and the limited treatment options create a gap in services. Efforts to close that gap should include improved treatment matching and linkage of services both during and after incarceration (118).
Fareed et al. reviewed the charts of 102 patients who received treatment at the Atlanta VA Medical Center methadone clinic between 2002 and 2008 to assess an on-site health screening and brief health counseling intervention to improve the delivery of health services for chronic medical conditions. They found that illicit opioid and cocaine use markedly decreased in patients overall and the effect was more robust for those successfully “retained” (p < 0.0001) in treatment, compared to those who “dropped out” (p = 0.05) of treatment; compliance with primary care appointments was high (82% and 88% before and after the on-site intervention, respectively) for “retained” patients; and hemoglobin A1c improved by 40% after the on-site intervention as reflected by the decreased percentage of patients with A1c > 7% from before to after the intervention (90% vs. 50%, p = 0.05). The authors concluded that the need for and potential benefit of enhancing the delivery of health promotion services for chronic medical conditions in patients receiving methadone maintenance is evident and improving management of hepatitis C, diabetes, hypertension, and other related conditions in this high-risk, difficult-to-treat, and underserved population may reduce their morbidity and premature mortality (119).
In summary, several effective models of centralized and distributive linkage in primary care and specialty addiction treatment settings have been developed. Addiction interventions in medical settings are appropriate for a spectrum of patients: at-risk drinkers and substance use disorders of mild to moderate severity; medically ill substance-dependent patients who refuse formal treatment referral; and substance-dependent patients who receive rehabilitative counseling elsewhere yet would benefit from substance-related pharmacotherapy and management of their medical problems. With adequate support, primary care physicians also can have a productive role in outpatient detoxification (120). Minimally motivated patients who will accept only harmreduction interventions can benefit from management in the primary care setting as well. For patients in formal addiction treatment, linkage to needed medical and psychological services can improve access to health care, improve physical and mental health, and reduce relapse. Both centralized and distributive models show promise for integrating care across these systems. The distributive model predominates in the United States (94). Though it can be less effective than the centralized model in linking substance-abusing patients to needed services (56,98), its relatively low cost, flexibility, and adaptability (especially to integration of secondary and tertiary care services) suggest that the distributive model, with further refinements, is likely to remain the method of coordinated services in the near future.
PROSPECTS FOR IMPROVED LINKAGE
Despite the enormity of the challenge, momentum is building for a transformation in the configuration of addictive disorder treatment and health care services. A number of signs suggest that a window of opportunity exists for innovation. The staggering burden of medical and mental health problems affecting substance-abusing patients is now well documented, from HIV, hepatitis C, and drug overdose to depression, anxiety, and victimization (121–124). The enormous economic burden that substance use problems place on our society, through costs related to health care, criminality/incarceration, and loss of productivity, is increasingly recognized and forces policymakers to consider alternative approaches to the management and care of this population (125). Moreover, advances in the diagnosis and treatment of substance-related disorders, including pharmacologic and behavioral approaches applicable in the primary care setting, promise to change the approach to clinical management of these prevalent disorders. The perspective that the current century is an opportune time to advance the linkage of substance use treatment with mental health and medical care was fully endorsed in report from the IOM, “Improving the quality of healthcare for mental and substance use conditions: The quality chasm” series (16). An underlying theme in the book is that only by addressing substance use and mental health problems can one achieve optimal benefit for patients engaged in medical care. One of the most important recommendations of the IOM report pertains to the delivery of coordinated care among primary care, mental health, and substance use treatment providers. The basis of this recommendation lays in the Crossing the Quality Chasm “rules” that endorse “shared knowledge and the free flow of information” and “cooperation among clinicians.”
Primary care and disease management systems are not achievable if only adopted by physicians but rather require a multidisciplinary team. Thus, the reported sense of overburdening of physicians should not preclude the development of linkage systems but rather influence its development so that its implementation does not solely rely on physicians’ functions (126). The ability to treat addictive disorders in less intensive settings will promote cost savings and cost-effectiveness. Increased attention to the improvement of quality in health care systems also presents opportunities to address linkage to addictive disorder treatment as a quality issue. Finally, the current era has seen rapid reorganization of health care services. Despite the difficulties associated with such periods, they challenge policymakers to rethink inadequate systems and can create a climate of innovation toward the delivery of high-quality, comprehensive, and coordinated care for patients with substance use disorders (16,58,68,104,127).
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