Primary care physicians are in the best position to identify and treat threats to a patient’s health and well-being, but they are often the last to recognize signs of substance abuse and addiction. This is a lost opportunity to address a leading cause of preventable death and one the greatest threats to public health and safety in the United States. Early intervention is critical for successful addiction treatment, and people with substance abuse issues are at much greater risk of developing numerous health problems, including hypertension, diabetes, pneumonia, congestive heart failure and liver disease.
Extensive studies by the National Center on Addiction and Substance abuse at Columbia University (CASA Columbia) indicate that 40 million Americans age 12 and above meet the criteria for addiction, and twice as many engage in risky use of tobacco, alcohol and drugs, including prescription medications. In spite of the fact that addiction is considered by most to be a chronic, recurring disease, it is estimated that only 10 percent of addicts receive any form of addiction treatment, as opposed to 70 to 80 percent of patients with chronic illnesses such as high blood pressure or diabetes. Simple screening for alcohol or drug use issues is effective if done. Brief one or two question screening questions have been shown to reduce use of alcohol or drugs simply by asking the questions. NIAAA has shown that asking the question “How many times have you had more than 5 (4 for women) drinks in the past year?” is 80% accurate in identifying a use disorder. Medicare and other insurers actually pay a small amount to those physicians asking a brief 4 question intervention panel called SBIRT for Screening Brief Intervention Referral for Treatment.
There are several reasons why primary care providers fail to spot signs of substance abuse in their patients, and one of the most obvious is a lack of adequate training. Addiction is not emphasized in medical school, and most doctors are not skilled at spotting signs of addiction – including prescription drug addiction. By the time the addiction becomes apparent, the problem is already well established. Physicians don’t know where to turn and are often unaware of area rehabs or 12-Step groups.
It’s true that addiction treatment is complex and it isn’t a matter of simply writing a prescription. Primary care providers usually don’t have time or staff to do a full addiction screening, which requires assessments of mental health disorders and family medical history. Drug treatment generally requires an integrated approach that may involve counseling, medications and support groups or long-term drug or alcohol rehab. Even with the best treatment, risk of relapse is high.
Even when doctors recognize signs of addiction, they aren’t sure what to do, and they are reticent about provoking shame or anger in their patients. It’s true that addicts aren’t always the easiest of patients, and they may become angry or defensive when the doctor’s diagnosis is addiction. Denial and addiction go hand-in-hand, and it often takes time for addicts to confront the illness and accept treatment. Doctors are unable to demand or insist that a client accept treatment, even when it is desperately needed. Unfortunately, cultural stereotypes and stigmas about addiction are pervasive and doctors aren’t immune. Many continue to blame addicted people for a perceived weakness or lack of willpower.
Hope for the Future
Scientific awareness – Addiction is a misunderstood disease often thought to be a social issue stemming from weakness or lack of character. However, advancements in scientific research continue to provide evidence confirming addiction as a chronic, recurring disease that alters the chemical makeup of the brain. Although change is slow, the disease model of addiction continues to gain acceptance by drug addiction professionals and the medical community. The disease that is today called by medical nomenclature as a “substance use disorder” is firmly established scientifically as a disease state, and those that argue this point are demonstrating an opinion that has led to gross mismanagement of a disease that kills 120 people per day in this country.
New anti-addiction medications – New drugs developed for treatment of addiction are safer and more effective – especially medications devised to treat opioid addiction and alcoholism. These medications and others that are currently in clinical studies provide greater possibilities for long-term recovery. However, insurance funding for anti-addiction medications is limited, and primary care knowledge of the use of these medicines also falls short.
Changes in laws affecting healthcare – Important laws, including a Parity Bill passed by Congress in 2008, require that substance abuse and mental health disorders should be actively treated much like other chronic diseases such as diabetes and high blood pressure, and that treatment must be covered by insurance. Unfortunately, although progress is being made, this law is not routinely enforced by any agency and it is simply paid patronage or ignored more often than not. In addition to earlier diagnosis, one of the main obstacles in the proper treatment of the fatal and chronic disease of addiction is it’s consideration as an acute problem needing only a few days of stabilization. The complex behavioral and physiologic abnormalities must be given time to adequately treat. So far, this kind of treatment is still not funded so it simply is not offered as best care. This results in an average of 5-7 expensive “acute care” treatment episodes (rehab stays) before recovery is seen, with much avoidable pain, suffering and deaths occurring during the time this takes. Similarly, the Affordable Care Act includes addiction treatment as an essential health benefit, which means that more people will receive treatment. Unfortunately, insurance companies continue to place limits and stipulations on funding. Insurance rarely pays for more than 2-3 weeks of treatment despite research by the National Institute of Drug Abuse (NIDA) that short drug rehab durations (<90 days) are ineffective for most with this disease.
