Reform shapes physicians` role in addiction treatment

Gathering steam from director of the federal Center for Substance Abuse Treatment (CSAT) Dr. H. Westley Clark's morning plenary on integration, Michael Miller, MD, FASAM, FAPA, gathered with addiction professionals in an afternoon breakout session to discuss the emerging roles of physicians in addiction treatment.

Miller, who is the medical director at Rogers Memorial Hospital's Herrington Recovery Center in Wisconsin, agreed with Clark, telling attendees that the specialty care delivery system works for some, but misses much of the population affected by addiction.

"As Clark said, [specialty care] is not where doctors practice, and it's part of stigma," Miller said. But healthcare reform aims to change that by investing the majority of funding into federally qualified health centers (FQHCs), which will integrate primary care and addiction services through the co-location of services or consults.

"Addiction must be treated in primary care," he said.

Physicians face paradigm shift
The specialty care delivery system that the majority of addiction professionals work in will be affected by healthcare reform's emphasis on integration, but it's unlikely that they'll be skeptical of its benefits. On the other hand, Miller pointed out, physicians may need more convincing.

"The biggest failure of American medicine is to appreciate addiction as a brain disease," he said. "Education has failed doctors in regard to understanding what these issues are all about."

However, Miller sees hope in the effectiveness of pharmacotherapies for withdrawal, detox, and addiction, including naltrexone, buprenorphine, methadone, and nicotine replacement therapies. These therapies medicalize the process of addiction treatment and finally “allow doctors to be doctors."

"I was in the business of subtraction, and now I'm adding medications," Miller said. "This changes doctors' thinking."

New roles, new partnerships
With this new attitude toward addiction, physicians will be responsible not only for providing direct treatment to patients, but for implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in their practices as well.

Though SAMHSA has funded SBIRT initiatives since 2007, Miller estimated that four out of five doctors still don't recognize or acknowledge addiction. “Some have never heard of case finding by SBIRT,” he added.

In addition to screening, physicians working in integrated care will also be responsible for providing what Miller calls the five A's: “ask, advise, assess motivational level, and arrange follow-up.”

One attendee pointed out the possibility of physicians hiring addiction professionals to screen patients for addiction, to which Miller responded by citing a study that showed non-physicians achieved better outcomes in similar efforts.

Another attendee added that their organization staffs a counselor at a primary care facility part-time just to screen patients, saying that “it works great.” Miller sees these types of multidisciplinary teams as another staple of effective integration in the wake of healthcare reform. Miller will also facilitate a breakout session tomorrow, Sept. 9, at NCAD. This session will focus on new opportunities available for providers through integration, healthcare reform, parity, and information technology.