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Primary Care and Drug Abuse: A Research-Setting Round Table Seminar



Bethesda, Maryland
July 17–18, 2003

Sponsored by:
National Institute on Drug Abuse
Division of Epidemiology
Prevention and Services Research

Overview

As part of its ongoing commitment to develop and support research programs that lead to better understanding of how the physical health care system, and particularly primary care providers, can enhance the early identification, treatment, and long-term management of drug abuse and other addiction problems, the Division of Epidemiology, Services and Prevention Research (DESPR) of the National Institute on Drug Abuse (NIDA) convened a Research-Setting Round Table Seminar on July 17–18, 2003.

The meeting had two goals:

  1. To develop an agenda for supporting research on the role the of primary care system in the treatment of drug abuse and addiction; and
  2. To initiate planning for a national research-based conference on this topic.

Attendees included approximately 40 researchers, policy makers, funders, practitioners, providers, and payers in the fields of primary care, drug abuse, economics, and related areas. Jerry Flanzer, Ph.D., Senior Social Scientist, DESPR, moderated the seminar.

The meeting consisted of a series of six panels. The first part dealt with specific issues, such as screening and brief intervention tools and practices. The program then moved on to discussions of treatment and relapse prevention and of drug abuse among special populations. The focus of the meeting gradually broadened, as panelists turned to such topics as implementing research findings into community settings, care delivery models, and financing systems. Panelists in each group made 15-minute presentations that were designed to provide a common context for discussions.

This report presents highlights of presentations made at the meeting and the ensuing discussions. It then lists key research questions emerging from the session. The final part of the report describes participants’ suggestions concerning NIDA’s proposed national conference.

Welcome/Introductions

Nora Volkow, M.D.
Director
National Institute on Drug Abuse
Bethesda, Maryland

Dr. Volkow noted that her top three priorities for NIDA are prevention, treatment, and training. Primary care (PC) practitioners have a key role to play in prevention, and a NIDA research initiative that will maximize the contribution of the PC provider in substance abuse (SA) can help achieve this end. Although we commonly recognize the connection between addiction and medical morbidity and mortality and their associated costs, we do not pay sufficient attention to the connection between addiction and behavioral disorders, which are equally costly to society. PC providers are well positioned to help initiate the needed behavioral changes by taking more visible roles in prevention, early intervention, and referral.

Among the barriers that prevent PC providers from taking on this role, none is greater than lack of reimbursement. A second barrier is inadequate understanding of the availability of effective treatments. Existing medications, such as buprenorphine, must be more widely used. At the same time, better medications are needed. Finally, training of current and future health care providers must be expanded and improved.

Wilson Compton, M.D., M.P.E.
Director, Division of Epidemiology, Prevention and Services Research
National Institute on Drug Abuse

Dr. Compton described the Division of Epidemiology, Services and Prevention Research as the “standard bearer” for public health research within NIDA. The division uses the tools of the epidemiologist to look at populations—to find the differences, to determine the need for services and the causes of conditions of interest, to plan and implement services, and to determine the effectiveness of those services.

The division’s five-year research agenda sets forth three goals:

  1. To measurably impact public health prevention and treatment outcomes;
  2. To demonstrate the interactions of modifiable environmental factors with each other and with biological factors; and
  3. To develop transdisciplinary research teams focusing in drug abuse.

NIDA has joined with the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Agency for Healthcare Research and Quality (AHRQ) in a cross-agency “science-to-service” initiative that will blend the funding streams of the collaborating agencies and hasten the application of emerging research findings.

NIDA is committed to supporting programs that will expand the role of primary care in SA screening, intervention, and treatment. The research round table, defined as an opportunity to review the state of the science and to begin to identify critical research questions, marks an important step in this effort. On the basis of the outcome of the meeting, NIDA will develop a research agenda. The agenda will emphasize interagency collaboration and joint programs.

Jerry Flanzer, Ph.D.
Division of Epidemiology, Prevention, and Services Research
National Institute on Drug Abuse
Bethesda, Maryland

Dr. Flanzer underscored the multidisciplinary backgrounds of participants in the research round table with a special recognition of researchers from Australia and Canada. He acknowledged the many federal agencies represented at the meeting— The Substance Abuse and Mental Health Services Administration, represented by the Center for Substance Abuse Prevention (CSAP) and the Center for Substance Treatment (CSAT), The Agency for Health Care Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the Health Resources and Services Administration (HRSA), and the National Institute on Aging (NIA)—as well as the presence of international experts and representatives of organizations such as the Robert Wood Johnson Foundation, Clinical Directors Networks and the Association of American Health Plans. Dr. Flanzer expressed the hope that this meeting would mark the beginning of a sustained multi-agency effort towards the integration of drug abuse treatment into primary care settings. He also reminded the gathered group that the outcome of this meeting was to suggest research questions and directions for a NIDA led initiative.

Dr. Flanzer briefly reviewed NIDA’s experience in the substance abuse and primary care arena, noting gaps in prevention and treatment knowledge in general, and in research to practice in particular. Recognition of these gaps was a major motivator for the calling of this Research Setting Round Table.

Future Directions of the U.S. Primary Care System: Implications for Research

Jeffrey H. Samet, M.D., M.A., M.P.H.
Boston Medical Center and Boston University School of Medicine and Public Health
Boston, Massachusetts

Dr. Samet talked about primary care from three perspectives: the ideal, the reality, and the future.

The Ideal. Primary care (defined as “integrated and accessible health services provided by primary care clinicians [generally, physicians, nurse practitioners, and physician assistants]”) is the gateway for public health interventions. It is a vehicle for preventive care and an appropriate place to address drug abuse and dependence. From the perspectives of providers, patients, and society, there are many benefits of linking SA services with those that traditionally fall under the primary care umbrella.

The Reality. The typical PC physician in the United States today is responsible for 2,500 patients. The size of this caseload makes it impossible for PC physicians to spend sufficient time providing preventive and screening services. Today, as in the past, there are two parallel systems of care for patients with drug dependence—general medical care and SA treatment.

The Future. Leaders in primary care and other sectors have become increasingly aware that the historical definition of PC is inconsistent with current realities of medical care organization, financing, and preferences of patients and physicians. Realizing a new ideal for PC will involve the following:

  • Reorganizing and reconstructing health care to serve the needs of patients;
  • Making the goal of PC to be the delivery of the highest-possible quality of care, as documented by measurable outcomes;
  • Taking maximum advantage of information and information systems; and
  • Revitalizing PC education to emphasize new delivery models and training in sites that deliver excellent primary care.

Panel on Screening and Brief Intervention

Moderator: Helen Burstin, M.D., M.P.H.
Center for Primary Care Research
Agency for Healthcare Research and Quality
Washington, DC

Dr. Burstin noted that the AHRQ fully supports the science-to-service initiative. Prevention and clinical partnerships are part of the agency’s mission. As an example, she noted AHRQ’s collaboration with Robert Wood Johnson Foundation for improving healthy behaviors in primary care practice.

Patient Screening Tools and Approaches
Thomas Babor, Ph.D., M.P.H.
University of Connecticut School of Medicine
Farmington, Connecticut

A good screening test is valid and reliable in different cultural settings; short and easy to administer; addresses a wide range of psychoactive substances; provides estimates of substance-related health risks; identifies cases of substance disorders; is applicable in different models of PC; and does not require extensive training.

There are two major screening techniques:

  1. Self-report (direct and indirect); and
  2. Biological test procedures.

Direct self-report screening tests for adults include the Drug Abuse Screening Test (DAST), the CAGE-AID, the Substance Abuse Screening Instrument (SASI), and the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Common drawbacks of many screens are that they are not specific, do not have a severity measurement, and do not distinguish between lifetime and current use.

Self-report tests for adolescents include the Problem-Oriented Screening Instrument for Teenagers (POSIT); the Drug Use Screening Inventory (DUSI); the Personal Experience Screening Questionnaire (PESQ); and the Drug and Alcohol Problem (DAP) Quick Screen. Common problems with these instruments are that they are long and can be difficult to administer.

Indirect self-report tests include the MacAndrew Alcoholism Scale (MAC), the Addiction Potential Scale (APS), and the Substance Abuse Subtle Screening Inventory (SASSI). These scales can identify factors that might lead an individual to go on to drug abuse but are not highly sensitive or specific and therefore not generally recommended for use in PC.

Biological methods include urinalysis, hair testing, and saliva and blood testing. They are generally easy to perform and provide rapid results. However, these methods are also subject to false negatives and do not enable one to detect the route of drug ingestion or the quantity, frequency, or time of ingestion.

Routine screening faces formidable legal, ethical, and methodological challenges. Further work is needed to develop and validate accurate screening instruments, especially instruments that may be used in PC. Screening for drug abuse might be most successful by using a “Trojan horse” approach—namely, integrating screening for drug abuse with other comprehensive screens that include tobacco, alcohol, exercise and diet.

Brief Interventions to Motivate Behavior Change
Carlo DiClemente, Ph.D.
University of Maryland
Baltimore, Maryland

Dr. DiClemente suggested a new definition for “zero tolerance”—namely, that there would be no tolerance for not dealing with substance abuse. Every time a problem related to SA is encountered in a health care setting, it will be addressed.

Brief interventions can provide motivation to prevent experimentation and initiation, provide early intervention for those who have begun to use, prevent use from becoming abuse, and motivate abusers to change. Types of interventions include brief general advice from health care providers of a general nature; feedback related to a specific risk (e.g., tying a patient’s chronic cough to cigarette smoking); substance abuse evaluation and referral; motivational enhancement; and follow-up (reinforcement of initial advice). The motivational enhancement strategy is particularly useful because it places the patient on a continuum of readiness for change, puts the client in charge of change, and offers objective feedback about the problem and its consequences. Many studies in the past decade have shown that brief interventions are effective in reducing alcohol use. Some of these interventions have taken place in settings, such as emergency departments.

Brief interventions may be provided by a variety of trained professionals. Persons with training in behavioral change, rather than traditional health educators are most effective in this role. Ideally, they should offer multiple options that vary in intensity and scope.

Challenges for Drug Screening Research and Practice in Primary Care:
An Example from a Health Maintenance Organization

Jennifer Mertens, M.A.
Division of Research, Kaiser Permanente
Oakland, California

Ms. Mertens reported on a joint NIDA/Robert Wood Johnson Foundation study that examined the prevalence of drug and alcohol problems in primary care clinics of a health maintenance organization (HMO); how patients with such problems compared with other patients in terms of medical conditions and cost of care; and the value of and barriers to screening in a clinics. The study group included 1,419 patients in Kaiser Clinics in Sacramento; the controls were 16,000 other clinic patients. Self-report screening instruments for drug and alcohol problems were used. The overall prevalence of drug use problems was 3.2 percent; in the youngest group (ages 18–30), it was 6.6 percent.

The researchers found significant differences between the drug and alcohol users and the controls with respect to a number of comorbidities. They concluded that time constraints, competing priorities for screening (e.g., hypertension, diabetes) and lack of a prescribed referral protocol/best practice were major barriers to screening on the part of providers. Many providers expressed interest in screening for SA as part of a larger behavioral screener that also screens for depression and anxiety. Administrators stated that report card measures of Health Plan Employer Plan Data and Information Set (HEDIS®) requirements of the National Committee on Quality Assurance (NCQA) drive priorities for screening.

Questions remaining for the field: Are we screening for any illegal drug use or a certain level of drug use, and how does it vary by type of drug? New screening and intervention approaches should be examined, such as drug testing, screening targeted at younger patients, and group physician visits.

International Perspective: Early Intervention in a Canadian Setting
David C. Marsh, M.D., C.C.S.A.M.
Center for Addiction and Mental Health
University of Toronto
Toronto, Canada

Canada has a publicly funded, single-payer system that guarantees universal access to care. Health care expenditures in Canada in 2001 were just under 10 percent of the national gross domestic product; for the United States, they were around 15 percent. Primary care physicians are the gatekeepers to health care in Canada. Barriers to screening relate to attitudes (reluctance to be involved, pessimism about outcomes), insufficient time, and lack of knowledge and skills.

Dr. Marsh described the Alcohol Risk Assessment and Intervention (ARAI) project, sponsored by the College of Family Physicians of Canada in the 1990s. The project developed and disseminated training materials, including a manual and a video, to PC physicians. Physicians were encouraged to ask patients about drug use, using questions and tools such as CAGE; to assess the patient's motivation and the severity of alcohol-related problems; and to advise or assist by offering a brief intervention or referring the patient to treatment. Analysis of the outcome of this program revealed a need for training, for links to ongoing support, and for chart-keeping tools and other forms.

Among other efforts under way in Canada is a new model for methadone treatment that involves co-location of medical and social services. Key to expanding services to methadone patients has been training, a focus on communities most in need, and provision of educational supports for providers. Among such supports are a physician quality assurance program and a service that offers free telephone consultation service for physicians.

The Canada experience has shown that, with appropriate support, PC physicians can have a significant role as change agents with respect to SA problems.

Screening and Brief Intervention Panel: Questions and Comments

  • Physicians have many priorities and limited time. Including routine screening for drug use into their routine patient encounters will require changing mindsets and providing incentives; the latter need not be only monetary. Suggestions include:
    • Use every opportunity to intervene. For high school athletes, for example, the sports physical can be used to deliver a message about drug use.
    • Make physicians more aware of the connections between SA and the “behavioral piece,” possible interaction with other drugs, and overall health outcomes.
  • Think about integrating biological screening methods and self-report methods.
  • Evidence-based medicine has been effective in certain fields (e.g., the relationship between tobacco use and heart disease). Find ways to apply it to substance abuse.
  • Make sure that screening instruments are as simple as possible and are available in many languages.
  • Explore the value of group visits in SA; this has been done with chronic medical conditions.

Panel on Treatment and Relapse Prevention

Moderator: Suzanne Feetham, Ph.D. R.N., F.A.A.N.
Bureau of Primary Health Care
Health Resources and Services Administration
Rockville, Maryland

Dr. Feetham expressed HRSA’s interest in joining with other agencies to support programs that will help translate science into practice. More than two-thirds of HRSA’s health centers are involved in collaborations, and all include a focus on prevention. Nearly half of the centers now provide SA services, and that number is growing.

Treating the Chronic Opiate-Addicted Patient
Ernest Drucker, Ph.D.
Department of Epidemiology and Social Medicine
Montefiore Medical Center
Bronx, New York

As in other countries, many general physicians in the United States are willing take a greater role in addiction treatment, provided that appropriate support systems are available for the patients and for the professionals. The states have a key role in supporting office based opium treatment (OBOT) and ensuring that the prevailing standards of healthcare are applied. Advocacy work at the state level is always essential to ensure that opiate-addicted patients have adequate access to quality treatment.

Dr. Drucker set forth the following implications for a research agenda related to care of the opiate-addicted patient in primary care settings:

  • Reformulate goals. Expand routine medical practice models to include chronic addiction treatment. Targets are public health goals and need health services research approaches, not addiction research per se. Rethink the role of health care leadership and organizations, state insurance programs, and public health policies to support these goals.
  • Acknowledge the role of community pharmacists. Pharmacists are a trusted, accessible community health resource well suited to dispense methadone and help manage chronic care patients. The United States can benefit from the experience of countries such as Canada and Australia, where pharmacists and physicians train jointly.
  • Do a market analysis. Many methadone patients in the US may be sufficiently stable to allow OBOT – with an attendant reduction in the resources that a methadone clinic needs to provide (and in costs). There is a need to develop a spectrum of care that would enable patients to move to the primary care setting but also have access to acute care and more intensive supports should they relapse.
  • Develop new tools. Making the transition from methadone maintenance treatment programs (MMTPs) to OBOT will require new models for interdisciplinary training and accountability and procedures to ensure coordination of care between diverse professional working in different settings (e.g. pharmacy, medical practice), and including the future use of secure electronic medical records and communication systems based on the internet.

Relapse Prevention in Primary Care Settings
Richard Saitz, M.D., M.P.H.
Boston Medical Center and Boston University School of Medicine
Boston, Massachusetts

Drug abuse-related activities in primary care settings range from screening and case finding, to assessment and diagnosis, to brief interventions aimed at the substance use itself or at referral for more specialized treatment. In addition, specialized services such as detoxification and pharmacotherapy (buprenorphine) can be delivered by primary care physicians. Physicians or other health professionals supporting the physician can perform these activities. Relapse-prevention activities that may be provided by a physician or other provider in a primary care setting begin with identifying patients in recovery and proceed to include, scheduling follow-up sessions; mobilizing family support; helping patients deal with relapse precipitants(depression and comorbid conditions); encouraging 12-step group attendance; and facilitating lifestyle changes. As front line clinicians, these physicians can identify and help manage early relapse and can manage pharmacotherapy, in collaboration with addiction professionals.

Among the studies cited by Dr. Saitz that indicate the benefits of PC provider involvement in relapse prevention are the following:

  • A study involving 2,878 patients at 52 SA treatment programs showed that onsite primary medical care was associated with less addiction severity at 12-month follow-up compared with patients who attended programs that offered no primary medical care.
  • A prospective study of 470 adults in a residential detoxification program showed that the number of primary care visits correlated significantly with improvements in alcohol and drug addiction severity.
  • Integrated substance abuse treatment and primary medical care led to more abstinence in patients with substance abuse related medical or psychiatric conditions, compared with those receiving usual primary care in a randomized trial of 592 adults after chemical dependency treatment.
  • In one study of 29 adults, alcoholism treatment in primary care with naltrexone led to decreased drinking; in a randomized trial comparing buprenorphine treatment in primary care versus specialty treatment, treatment retention rates were higher, opioid use was less, and abstinence was greater in those in the PC program. Similarly, a randomized trial of primary care versus usual narcotic treatment program methadone treatment, outcomes were no worse in primary care and patient satisfaction was better.
  • Preliminary work with physicians in Rhode Island suggests that training in relapse prevention in primary care can lead to relapse prevention in specific physician behaviors with patients.

Some relapse-prevention activities are feasible in PC settings, but further work is needed to determine the efficacy and costs of specific approaches and the real world effectiveness of these approaches.

Treatment and Relapse Prevention Panel: Questions and Comments

  • Issues relating to confidentiality of medical records must be overcome if PC and SA programs are to be fully integrated. At present, there are varying rules governing confidentiality of medical, psychiatric, and methadone records.
  • Changes in Drug Enforcement Administration (DEA) policies will be essential. All the innovative things now being done with respect to methadone are done under waivers.
  • It would be of interest to compare the performance of physicians and residents, and of physicians and other types of health providers, in providing drug information.

Panel on Drug Abuse and Special Populations

Moderator: Sidney Stahl, Ph.D.
National Institute on Aging
Bethesda, Maryland

Dr. Stahl noted that as the U.S. population ages, SA is an increasing concern to the NIA. He underscored the institute’s interest in the issues being set forth at the round table.

Primary Care and the Homeless Adult Drug Abusers
Lillian Gelberg, M.D., M.S.P.H.
Department of Family Medicine, University of California
Los Angeles, California

The literature on homeless drug users’ health status and their use of health services is limited. However, it is safe to say that homelessness is a national crisis (there are an estimated 3.5 million homeless persons in the United States at present) and that a majority of homeless adults report problem drug use. Few homeless drug users receive treatment; one reason is that drug treatment facilities are not co-located in medical settings where they can receive continuous quality care. Homeless problem drug users now have a costly and inefficient pattern of medical care; they rely excessively on the emergency room (ER) and inpatient care.

The health status of homeless persons is poor, and that of homeless persons who abuse drugs is poorer still. The mortality rate for homeless problem drug users is threefold greater than health of other homeless adults. Problem drug use among homeless adults is related to disproportionately high rates of infectious diseases and a number of other conditions.

Research on improving the health status of homeless persons with SA problems should focus on:

  • Increasing the availability of primary care;
  • Conducting research on barriers to care and care preferences among this population and testing out models of care that address these factors;
  • Developing effective ways to engage homeless drug users in PC (e.g., by co-locating PC at shelters and meal programs); and
  • Increasing our understanding of the role that PC can play in treating persons with drug addiction for their addiction, and for their co-morbid problems.

Primary Care and Drug Abuse in the Elderly
Kristen L. Barry, Ph.D.
Department of Psychiatry, Division of Substance Abuse, University of Michigan
Treatment Research and Evaluation Center, Department of Veterans Affairs
Ann Arbor, Michigan

Alcohol is the drug most often used by older people. Rates of illicit drug use decline with age; nonetheless, the NIDA supported National Survey on Drug Abuse and Health, 2000 revealed that 568,000 adults over the age of 55 had used illicit drugs in the past month. Of particular concern among the elderly is the use of prescription and nonprescription drugs that do not meet traditional abuse definitions. Also of concern is the unintentional misuse of drugs due to memory loss or misunderstanding of dosing instructions. Finally, many older persons do not meet traditional criteria for dependence such as those of DSM-IV.

CSAT Treatment Improvement Protocol #26, Substance Abuse in Older Adults, recommends that ever person over 60 be screened for alcohol and prescription drug abuse as part of their regular physical exam, and that patients be screened or rescreened at the time of major life transitions. Screening questionnaires appropriate for older persons include the MAST: Geriatric Version and the Health Screening Survey. Nontraditional techniques, such as brown-bag sessions, may be used to identify elders’ use of prescription, nonprescription, and alternative therapies.

Older persons receive a majority of their medical care in PC settings; therefore, this represents an opportunity to develop innovative methods for screening, intervention, and referral. A linkage model that includes the PC provider, along with aging services agencies, self-help groups, the community of faith and fraternal groups, volunteer groups, and others, and is coordinated by a care navigator, may merit exploration.

Primary Care and Co-Occurring Disorders
Kathryn Rost, Ph.D.
University of Colorado Health Sciences Center
Aurora, Colorado

Patients who are seriously mentally ill and who abuse alcohol or use illicit substances are said to have co-occurring disorders. These individuals are hard to diagnose. Functional deficits vary from person to person, and even within a given patient from one visit to another. In general, PC providers have inadequate knowledge of how to manage persons with these disorders. Financial pressures in some states exacerbate the situation. In Colorado, for example, community mental health programs are discharging large numbers of patients to primary care. In rural areas, PC providers are the only source of care for patients with co-occurring disorders. Lack of communication between PC and mental health providers complicates the problem. Nonetheless, studies have shown that many of these patients are ready for change, and contacts with PC can be an important point for this transition.

Methods of resolving the current disconnect in services include:

  • Models that co-locate mental health providers in PC settings;
  • Models that co-locate PC providers in mental health settings; and
  • Joint management by PC providers and mental health providers in their respective settings, supported by systems that ensure efficient and timely information exchange (in this scenario, a care manager is key to service coordination).

Dr. Rost illustrated the role a care manager can take in a primary care setting using experience with screening for depression. An office nurse was trained for this role, which serves as a conduit between identifying patient needs and ensuring they are appropriately managed. The new service cost very little and provided substantial improvements in physical and emotional functioning.

Special Populations Panel: Questions and Comments

  • Statistics showing a decreased prevalence of substance use with aging are based largely on cross-sectional studies. Long-term studies are needed; adding relevant questions to an ongoing longitudinal study might do this. An issue was raised that drug use among the elderly might not be a critical issue, since the rates are so low.
  • With respect to the elderly, as well as other special populations, representatives from many disciplines need to be brought to the table when discussions of their needs take place.

Panel on Adopting and Implementing Research-Based Findings into Community Settings

Moderators: Frances Cotter, M.A., M.P.H., and Mady Chalk, Ph.D.
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland

Dr. Chalk emphasized CSAT’s support of initiatives related to expanding the role of PC in alcohol and other drug abuse treatment. One goal of the Addiction Technology Transfer Centers was to link with the PC community to do training. CSAT Treatment Improvement Protocols #24 is a Guide to Substance Abuse Services for Primary Care Physicians. CSAT's Screening, Brief Intervention, and Referral to Treatment program will enable states to pilot innovative approaches and lead to broad-scale implementation of effective strategies.

Transferring Technological Advances for Screening, Brief Intervention, and Treatment: Teaching and Assessing Resident Substance Abuse Skills
Julia Arnsten, M.D., M.P.H.
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, New York

A survey of 1,831 directors of residency programs in various primary care disciplines (65 percent response rate) revealed that only 56 percent had any required curriculum in the prevention and treatment of alcohol and drug use disorders. The mean number of hours devoted to this was seven. Most of the training took the form of grand rounds lectures, and there was little experiential learning. It is therefore not surprising that a majority of residents feel ill prepared to deal with substance-abusing patients.

Dr. Arnsten referred to a system of core competencies in SA for a physician that has three levels—beginning with basic competencies for all physicians with clinical contact (Level I) and ending with physicians who provide specialty services to patients with SA disorders (Level III). She described a study at Montefiore to assess and improve the performance of substance abuse-related skills at Levels I and II by residents in primary care specialties (Internal Medicine and Family Medicine). The assessment tool is the Objective Structured Clinical Examination (OSCE). The study is part of a grant under which substance abuse investigators are working with faculty to develop curricular innovations that incorporate research-based findings into the care provided to drug users by residents.

The OSCE is carried out with the assistance of standardized patients who act-out preset clinical vignettes and provide additional information at the request of the resident. Ten residents in internal medicine will participate in the pilot session of the study. They will rotate through five stations; at each they will encounter a standardized patient with a different complaint. Faculty observers will rate residents’ performance. Each encounter will last about 10 minutes and will be followed by a five-minute feedback session. The vignettes have been developed to include alcohol, heroin, and cocaine-specific cases, and to describe patients at different stages of both drug dependence and readiness to change.

On the basis of results of the pilot, the program will be expanded to other primary care specialties. The ultimate goal is to develop a new curriculum that will be used in all Internal Medicine and Family Medicine residency training at Montefiore Medical Center, and will then be adapted for use by medical students at the Albert Einstein College of Medicine.

Professional Education of Primary Care Providers
Jeffrey A. Hoffman, Ph.D.
Danya International, Inc.
Silver Spring, Maryland

Meta-analyses have shown that screening and brief interventions can lower health care utilization and enhance treatment efforts. One of the key reasons why screening is not more widespread is the lack of reimbursement. Financial incentives are needed if screening and the necessary accompanying activities—intervention, assessment, and referral to treatment, and continued engagement—are to become more widespread. Better training and protocols for providers and office staff are also needed—in other words, it will require a systems approach.

Simplification is also essential. For example, Dr. Hoffman suggested the use of a two-question prescreening system that might be effective. This screen asks: “In the past year, have you ever drunk or used drugs more than you meant to?” and “Have you felt you wanted or needed to cut down on your drinking or drug use in the past year?” All providers could work these two questions into the routine office visit without a strain on resources. A standard assessment tool, such as MAST or CAGE, could then follow, and the provider should be reimbursed for this additional responsibility.

Dr. Hoffman described the Online Drug and Alcohol Problem Assessment for Primary Care, developed by Danya with support from NIDA. PC providers can use the results of this short questionnaire to tailor an appropriate message to a patient, ranging from no comment to a patient with any positive answers to a motivational message to seek treatment to someone with three or more positive answers.

With respect to training and education, simple approaches are also recommended. They include flash cards and manualized protocols, as well as online tools.

Operationalizing Research to Practice
Andrea Cassells, M.P.H.
Clinical Directors Network, Inc.
New York, New York

Ms. Cassells described some recent activities of the Clinical Directors Network, Inc. (CDN), an informal network of clinical leaders who provide PC in low-income and minority communities. CDN is a research and educational organization that focuses on translating research into practice.

She described an example of CDN practice-based behavioral and mental health research that took place in two community centers. The purpose was to test the feasibility of improving the detection of drug abuse and depression. Patients were intercepted in the waiting room and screened using the SDDS (PC) DSM-III-R and the SDDS (PC) DSM-IV. The prevalence of depression was found to be 30 percent, drug abuse three percent, and alcohol abuse four percent. The study demonstrated the feasibility of using a brief diagnostic screening tool and clinical practice guidelines for improvement the recognition of depression in a PC setting. Clinicians found the screen less helpful in detecting alcohol and other drug use.

For community and migrant health centers, participating in research has many advantages. Chief among them are earlier access to new drugs technologies, training for staff, and improved quality of care. Collaborative practice-based research can also build infrastructure and decrease ethnic health disparities.

Special Populations Panel: Questions and Comments

  • Financial incentives can be the catalyst for testing of the effectiveness of new approaches, such as population-based screening. Individual providers must decide how they want to use the funds. Some may use the funds to hire new paraprofessional staff that can be trained to provide the screening or brief intervention. Physicians need to be part of the process, but they need not bear total responsibility for it.

Panel on Care Delivery System Models

Moderator: Constance Pechura, Ph.D.
Robert Wood Johnson Foundation
Princeton, New Jersey

Dr. Pechura noted that the Robert Wood Johnson Foundation sees doing things that the public sector cannot do as an important part of its role. She stressed the importance of the Foundation’s collaboration with NIDA and other agencies. The Foundation has a new president and has reorganized its grant portfolio. Services to vulnerable people continue to be a major focus.

Organizational Linkage between Primary Care and Drug Abuse Services
Peter Friedmann, M.D., M.P.H.
Division of General Internal Medicine
Rhode Island Hospital
Providence, Rhode Island

Dr. Friedmann summarized the results of studies that compared the effectiveness of drug abuse services offered under various integrative linkage models, ranging from co-location of services (i.e., at a PC site, an addiction treatment site, or a population-specific site such as a shelter or needle-exchange program) to distributive arrangements (involving formal and informal referrals) to facilitation services such as case management and transportation. The hypothesis is that integrative linkages will improve access, service quality, and health and social function and decrease substance use. Such services will be more efficient, less redundant, and more cost-effective, although not necessarily less expensive.

Studies of co-locating PC services in a methadone clinic and with addiction treatment showed that this approach produced statistically significant differences in terms of receipt of medical treatment and number of medical visits in the first month of treatment, respectively. Co-location improves addiction outcomes for certain groups, especially those with substance-related medical or psychiatric conditions. The proximity allows for staff communication and informal/unscheduled contacts with patients. Disadvantages include cost and redundancy of infrastructure and, in some cases, less patient acceptability.

Distributive models have the advantage of lower cost and a less redundant infrastructure. They allow for a greater variety of providers and do not require that the patient return to the treatment program for primary care, which may be one reason that they might be more acceptable to patients in the long run. Disadvantages include less certainly about service delivery, fewer opportunities for communication among staff, and less opportunity for drop-in care.

Care Delivery System Models
Alfred Medina
San Diego County Alcohol and Drug Services
San Diego, California

Mr. Medina described the San Diego Country Screening, Brief Intervention, and Referral (SBIR) Services: A Systems Approach for Application in Medical Settings. The Robert Wood Johnson Foundation and funds received from the state tobacco settlement supported the effort. It was designed to determine how to identify and engage nondependent and dependent drug users in appropriate interventions and treatment in PC settings. The approach tested was routine screening and delivery of brief interventions or making referrals during office visits to a large patient population. SBIR services were seen as a link between the community health system and the treatment system.

SBIR uses trained, bilingual peer health educators to carry out the screening and interventions. The program operates at 17 sites and served more than 115,000 patients in 2002. It operates in a variety of primary care settings, including dental offices, breast exam clinics, and emergency services, and in public as well as private settings. It screens for alcohol and drugs, alcohol-medication interactions, and tobacco use. Screening for sexually transmitted diseases and chronic diseases will be integrated into the program soon.

The services have a structure parallel to that of medical care; this entailed developing a patient protocol, defining staff competencies, and developing procedures for quality assurance, accountability, and evaluation, as well as a point-of service management information system. This project has been well accepted; physicians now do not consider a visit complete unless the SBIR has taken place.

Integrated Primary Health Care for Alcohol and Drugs in Australia
Alex Wodak, M.B.B.S., F.R.A.C.P.
St. Vincent’s Hospital
Sydney, Australia

Australia, which has universal health care, spends relatively less (8.5 percent versus nearly 15 percent of its gross domestic product) on health care than does the United States.

PC physicians have provided methadone treatment in Australia since the 1980s and are a key to success of methadone treatment programs in that country. Nonetheless, many general practitioners have been resistant to this role. A two-tier system is evolving under which patients to go clinics for stabilization or treatment of relapse but receive their ongoing medication from a general practitioner.

Dr. Wodak also described SNAP (Smoking, Nutrition, Alcohol, Physical Activity), a program designed to reduce smoking, improve nutrition, reduce alcohol abuse, and increase physical activity in Australia. The purpose was to overcome the fragmented approach across preventable risk factors. SNAP involves offering brief interventions during routine office consultations as well as tailored interventions. The program has the support of key health organizations in the country, which is critical to its success. Among its most useful functions is making guidelines and other resources, including online information, more accessible to general practitioners.

Care Delivery System Models: Questions and Comments

  • Studies are needed of the delegation of tasks formerly performed only by physicians to peer educators. The effectiveness of the team approach needs to be evaluated. What are the advantages and disadvantages of using peer educators, or other non-physician staff, for screening and brief intervention? Qualifications and desired skills and competencies of peer educators need to be articulated. Any training must focus on skills building and be done in the context of interventions at multiple levels.
  • Experience with SNAP and elsewhere shows that physicians need a lot of support if they are to take proactive roles in SA screening and related activities.
  • Changing roles will necessitate changing billing patterns to cover the work of physicians doing substance abuse treatment and for the greater burden of providing medical caring for such complex patients. Even though the role of the physician has changed, he or she still has legal and fiscal responsibly.
  • It will be difficult to make a case for adding large amounts of substance abuse training to the medical curriculum if core SA content is not also added to licensing examinations.

Panel on Financing Systems

Moderator: William Cartwright, Ph.D.
Division of Epidemiology, Prevention and Services Research
National Institute on Drug Abuse

Overview of Financing Models of Primary Care Drug Abuse Services
Stan Wallack, Ph.D.
Schneider Institute for Health Policy
Brandeis University
Waltham, Massachusetts

Dr. Wallack described a number of issues relating to financing models and achieving parity for SA treatment services. With respect to reimbursement, the United States has undergone a radical shift. In 1970, 95 percent of care was provided on a fee-for-service (FFS) model. Today, only five percent of care is FFS. That switch means that we have integrated the financing and the organization of care. Although parity has long been a goal, it has not been achieved. Mean cost sharing remains higher for behavioral health (mental health and substance abuse services) than for general medical care.

In the end what counts is not the level of payment but the unit of payment (i.e., fee for service, capitation, and case rate). Under FFS, providers must keep their charges under those of their competitors. Under capitation, they most control the volume and intensity of services received by each member, which could mean curtailing prevention. Under a case rate system, providers must control the volume and intensity of services received by each case.

When considering the diffusion of a new practice, such as the prescribing of buprenorphine in an office-based practice, it is essential to consider environmental processes and organizational characteristics. These factors, combined with various clinician-related factors, lead to organizational acceptance. It is a top-down process. Organizational affiliation is the most important determinant in predicting physician adoption of emerging practices.

Dr. Wallack suggested the following approach with respect to integrating PC and SA services:

  • Align the commitment of the managed care organization with that of private providers (e.g., what factors motivate managed care organizations (MCOs) to adopt a specific program? Do providers see drug abuse as a chronic condition? Do they know that effective treatment options are available?).
  • Identify the incentives that will lead MCOs and providers to identify, imitate, and engage? (e.g., create financial incentives that are tied to care outcomes; determine what type of financial incentives or other changes such as workload reductions or staff additions are most effective).
  • Look for systems approaches to care coordination (e.g., document the microprocesses the plan takes to coordinate care between organizations and providers; determine what team member has lead responsibility for identifying and arranging for treatment).

Managed Care: Financing Challenges and Opportunities
Charles Stellar, M.A.
American Association of Health Plans
Washington, D.C.

The American Association of Health Plans (AAHP) represents health plans of all sizes, types, and organizational structures. Health plans are in a unique position to offer incentives to encourage providers to screen for SA and recommend appropriate interventions. They also provide education. Health plans embrace prevention and design packages that emphasize it.

Health plans have placed great emphasis on smoking cessation; for example, more than three-quarters of AAHP members have no limits on coverage for smoking interventions and require providers to ask about it and include it as a vital sign.

Co-payments are higher for substance abuse than for medical care. Seventy-five percent of AAHP members use carve-outs to control the cost of substance abuse services. About half of AAHP plans have a case manager devoted to SA. Only 14 percent of AAHP members contract SA treatment out; 83 percent provide such services in-house.

AAHP makes awards to encourage innovation in areas such as tobacco use prevention. A pilot program in Seattle produced quit rates of around 20 percent and a substantial return on investment.

Financing Systems: Questions and Comments

  • The 2004 HEDIS will have three SA measures; this is a step forward and an opportunity to use the system to drive quality.
  • Distinguishing between screening and assessment is a critical question for reimbursement policy. For example, is the Addiction Severity Index (ASI) a screening instrument or an assessment instrument? Where, and when, and by whom is the assessment done? How can we determine how to use assessments to determine the most appropriate intervention?
  • There is a link between our reimbursement system and the low quality of SA care being provided. How do we make SA treatment a higher priority?


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