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Rethinking Early Interventions for SUD an Urgent Cause
While stigma may be declining for mental illness, addiction is as stigmatized as ever. Our field has a limited impact on the cultural drivers of stigma, but we can make our healthcare system more responsive to signs of need. Fewer than 20% of people with substance use disorders (SUDs) get professional help, and care is usually delayed until the disorder’s late stages.
Physicians are missing opportunities for early intervention, and the typical response—continuing education for MDs and more use of screening tools—is inadequate. Primary care physicians (PCPs) need licensed therapists working beside them in primary care. Our executives must start the long, collaborative process of making primary care the frontline for behavioral health interventions.
Let the Paradox Be Our Guide
Therapy was once romanticized as having a transformative moment of insight. Unfortunately, behavior change is hard and does not flow from insight or rational decision-making. Resolving ambivalent thoughts and feelings about change takes time. Clinicians can help tip the scales over time. For an SUD focus, it is best to start with moderately high users—an abundant type.
Most of the damage of substance use in a population (e.g., a primary care practice) comes from moderate users. If the concern is poor health and high costs from using, the “prevention paradox” argues for targeting lower-risk rather than the highest-risk heavy users—population health improves more if a percentage of this larger group responds to interventions.
The prevention paradox runs counter to the training and experience of clinicians. They tend to focus on getting heavy substance users into treatment. Executives need to take the lead here. We need a sense of urgency about engaging early-stage users before the damage spreads. Executives must connect with their primary care colleagues to reconfigure that setting for brief therapeutic interventions.
A Culture of Behavioral Health
Behavioral executives should be exploring this shift into primary care on a broad scale, but this transition is complicated for financial, operational, and interdisciplinary reasons. Let us start with small steps. Funding a few hours each week of a therapist’s time is a good beginning, and in addition, clinicians might focus on building a culture of behavioral health in primary care.
The culture of health model has many roots, including employers with large workplaces. Its goals include raising awareness of how behavior drives health and increasing the use of behavioral resources like EAP counseling. However, the workplace environment is also a focus, exemplified by designing cafeterias to nudge people toward healthier food choices.
How does this apply to behavioral health and, specifically, addiction? A culture of health certainly exists in primary care offices, yet it tends to minimize the many drivers of behavioral health. Primary care offices tend to administer screening tools like the PHQ-9 and file them without discussion. Consider the following simple ways to help build a behavioral health culture:
- Post flyers about support group meetings for a range of behavioral health problems and possibly even hold one in the primary care suite.
- Evaluate digital therapeutics platforms that PCPs might find helpful as referrals for behavioral issues raised during patient visits.
- Schedule lunch meetings with PCPs for therapists to demonstrate the basics of motivational interviewing. The goal is to show that listening and questioning are critical for helping people get ready to work on negative behaviors like substance use.
The primary care setting should become an environment for understanding how thoughts, feelings, and behaviors impact health. A culture should support people as they decide to work on challenging behavioral goals. Culture can be quietly therapeutic by reinforcing people's actions to change. It can activate patients to take small steps in changing behavior.
Let us replace society’s current image of an addiction intervention—a surprise confrontation with a person in the late stages of addiction. The goal should be a less dramatic, honest conversation during a primary care visit. This will not happen on its own. Executives must launch structural changes, making primary care the first tier in the behavioral system.
No Primary Care Without Behavioral Care
Patients are often unresponsive when an issue is first raised, but primary care is like planting seeds. There is nothing unique about substance use. People are ambivalent about changing all types of behaviors. PCPs often see how unhealthy behavior sustains chronic medical conditions.
This is less a clinical problem to be solved than a care delivery problem needing executive-led institutional change—we need the right professionals working in the right settings. Today’s fragmented care can be fixed, but it will take executives willing to bust a few silos.
Many healthcare leaders are beginning to see that behavioral care is essential to primary care. Yet the focus is typically on mental health and health behaviors. Substance use is as critical and as responsive to intervention. We have excellent treatments for addiction, but we also know how to engage people before they reach that stage.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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