Pubdate: Mon, 29 Jan 2001
Source: American Medical News (US)
Copyright: 2001, American Medical Association
Contact: http://www.ama-assn.org/public/journals/amnews/edlet.htm
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Website: http://www.amednews.com/
Author: Victoria Stagg Elliott

LINKS BETWEEN PRIMARY CARE, ADDICTION SERVICES MAY HELP TREATMENT
Researchers say more integrated care may mean better outcomes and
improve doctor involvement in the diagnosis and treatment of substance
abuse. When Jeffrey Samet, MD, MPH, sees a primary care patient who also
needs substance abuse treatment, he makes one phone call to the Boston
Public Health Commission's Addiction Services, paging a counselor who
will either be in his office or on the phone to speak to the patient
within 15 minutes. At the inpatient detoxification unit at his hospital,
the Boston Medical Center, there is a twice-weekly clinic with a
physician, a nurse and a social worker to address patients' medical
problems in addition to their addiction. If patients do not have a
primary care physician, one is found for them and an appointment made.

"Does it work? We don't know, but it's a system we're trying to
implement to see if we can provide better services within primary care
for alcohol and drug problems," Dr. Samet said. "And for our dependent
patients who get into a detox, there are a lot of medical issues.

If they're not getting into medical care, but they are getting into the
substance abuse system, take advantage of it."

These steps are just two ways to integrate what are usually distinct
systems, said Dr. Samet, associate professor of medicine and public
health at Boston University School of Medicine and primary author of an
investigation into the benefits of linking primary care with substance
abuse services.

His findings are published in the Jan. 8 Archives of Internal Medicine.

Substance abusers can access medical care. Medical patients can access
addiction treatment. "It's not by any one particular mechanism," Dr.
Samet said. "But there should be a commitment to moving toward more
interaction between the two systems.

The linkage can take place in lots of ways. Be creative. Patients
benefit.

Docs benefit.

Addiction treatment places benefit. Society benefits."

Many hurdles to overcome His proposal is part of an increasing trend
toward more integrated care for many chronic conditions from back pain
to diabetes.

That trend, however, has been slow to affect treatment of addiction
because of more stringent confidentiality rules governing the condition,
long-documented hesitation on the part of primary care physicians to be
involved in the treatment of addiction, mental health services coverage
carve-outs and uncertain reimbursement for substance abuse treatment.
"Pay issues will always come up," Dr. Samet said. And he concedes that
medical clinics at drug treatment sites have frequently withered away
from lack of funds and may not be the best way to link services despite
the fact that they do connect with some of the most hard-to-reach
patients, many of whom are uninsured, limiting their access to primary
care. "In Massachusetts, there's some coverage for people one way or
another," he said. "I trained in Texas, and I know in that system, you
were out of luck." The greatest potential for improved care of patients
with substance abuse issues, he said, rests in improving the ability of
primary care physicians to refer their patients to addiction treatment
services. "We know how to get people to the podiatrist; we may not be
aware of how to get patients to the alcohol counselor because we're not
connected with that piece of the system," he said.

But the link is essential, he added, because windows of opportunity to
address the issue are narrow and infrequent. "Building systems where you
can get rapid responses are crucial.

And you get more bang for your buck." Linkages are hampered by strict
federal confidentiality guidelines. A cardiologist may share information
with a primary care physician about a patient's heart condition, but
primary care physicians may not be able to access information about
their patient's addiction treatment quite so easily. "Confidentiality
rules are tough," Dr. Samet said. "They're meant to be protective so you
don't really want to knock them, but you can knock your head against
them sometimes."

Linkages are also frustrated by the trend to carve out funds for mental
health managed care systems. "They're trying to provide care in
efficient ways, but by patients being able to tap into mental health
services directly, there isn't always built-in communication between
treatment and the primary care provider," he said.

Meanwhile, addiction medicine specialists supported the concept of
increased linking but said the proposal ignored the existence of
specialists like themselves who were able to provide addiction, mental
health and medical services.

"The article overlooks the thousands of physicians in this country who
specialize in addiction medicine and who therefore have expertise in
each of the areas described," said Stuart Gitlow, MD, MPH, a Rhode
Island addiction medicine specialist.

Most concede, however, that there just aren't enough of them to go
around. Therefore, a patient is much more likely to be seen by a primary
care physician, particularly when initiating treatment.

And primary care doctors have traditionally fared poorly at treating and
diagnosing the problem.

But increasing linkages between the systems may make primary care
physicians better at dealing with addiction issues.

"Docs aren't picking it up as much as they need to, but if there were
these connections around, they'd think about it more," Dr. Samet said.
Addiction medicine specialists also criticized the proposal for
segregating addiction, mental and physical health issues that in reality
are often tightly intertwined. "If somebody comes in with substance
abuse problems and depression, we want to treat the addiction right
away, but we're not sure if the comorbid issues may or may not be a
result of the substance use," said Daniel Hall-Flavin, MD, medical
director for addiction psychiatry services at Mayo Clinic in Rochester,
Minn. At Mayo, addiction psychiatrists work onsite in the general
hospital and at the liver transplant clinic, but Dr. Hall-Flavin
suggested another element that needed to be added to the mix of primary
care, mental health and substance abuse services.

"Family services should be considered whenever anybody is referred for
substance abuse problems," he said. "Families are going to be an
important ally in getting the person to keep their medical appointments
and work with the various professionals that they have to work with."
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