Treatment of substance use disorder often falls to overwhelmed and overburdened primary care physicians, an OHSU internist writes in an essay published in the December issue of the journal Health Affairs.
Jessica Gregg, M.D., Ph.D., an associate professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine, writes that many primary care clinics lack the resources and support to adequately address the nation’s opioid epidemic. She contends that this must change.
“Primary care successfully screens for, monitors and treats other complex chronic conditions,” Gregg writes. “I argue that addiction is just one more.”
The nation’s opioid epidemic has been declared a national emergency that kills 60,000 people a year. Closer to home, a recent national report revealed that Oregon had one of the highest cumulative increases of opioid-related hospitalizations of any state between 2009 and 2014.
Gregg, who has worked in addiction treatment centers, detox facilities and methadone clinics, argues that primary care clinics are often the only point of contact in the health care system for patients fighting addiction – at least until they end up in the hospital.
She suggests a series of improvements, including the following:
- Improve workflows that anticipate relapse. Providers should be able to direct patients to community mental health services, methadone clinics, emergency housing or needle exchange programs where available.
- Develop an outcomes-based reimbursement financial model. Payments would be focused on recovery rather than the number of times the patient is seen in the clinic.
- Eliminate barriers to prescribing buprenorphine, a medication that relieves symptoms of opiate withdrawal.
Gregg’s article traces the arc of a young man – “J” – she first encountered in a treatment clinic and then tracked through periods of struggle in and out of drug use and an abusive home environment. Through it all, he benefitted from mental health care, peer counseling and drug screens. In the end, this network of care gave him the confidence that he will eventually find his way to recovery.
“I wonder how patients like J would fare in a typical primary care practice,” Gregg writes. “What if he had been squeezed into a fifteen-minute appointment, perhaps between one patient recently discharged from the hospital with new onset heart failure and another with schizophrenia and diabetes, and it was just me – no workflow, no counselor, no peer navigator.
“Overwhelmed, out of time and unsure what to do next, I wonder how long I would have agreed to treat him.”
Gregg is board certified in internal medicine and addiction medicine. Her research focuses primarily on social and cultural barriers to disease prevention among underserved communities in Oregon. She is medical director of the OHSU ECHO (Extension for Community Healthcare Outcomes) clinic for addiction medicine and associate program director for OHSU’s addiction medicine fellowship.