Individuals with substance use disorder have high rates of co-occurring medical disorders and are many times more likely to experience serious conditions such as heart disease, cirrhosis of the liver, and pulmonary disease than individuals without substance use disorders. Additionally, individuals with substance use disorders have been shown to be less likely to adhere to medical treatment certain conditions such as HIV and diabetes. Despite the increased prevalence of medical illness in this population, substance abuse treatment is not readily available in coordination with medical treatment in most settings.
Integrated treatment, in which substance abuse treatment (and often behavioral health treatment) is provided in collaboration with primary care services at the same location, allow individuals to receive care from a team of treatment providers and increases access to care. Further, integrated treatment models may reduce the stigma that can be associated with seeking substance abuse treatment by providing treatment from clinicians with whom the patient has already developed a therapeutic relationship with, in a setting that is already familiar to the individual.
The provision of office-based opioid therapy (OBOT), in which an individual receives medication for the treatment of an opioid use disorder, is an ideal model for an integrated treatment team, consisting of primary care providers who are Buprenorphine prescribers, and behavioral health providers such as psychiatrists and social workers who function as experts in the diagnosis and treatment of substance abuse disorders. The team meets monthly to review cases, assess for treatment adherence to the Buprenorphine policy and develop guidance and training for staff and patients regarding opioid treatment.
In this model, all patients are screened by the behavioral health staff to assess appropriateness for Buprenorphine treatment. Ideal candidates are patients with opiate dependence who are interested in interested in office-based treatment, are able to understand the risks and benefits of Buprenorphine, are not taking medications that negatively interact with Buprenorphine, and are relatively stable psychiatrically and psychosocially such that they can be expected to be reasonably adherent to treatment. The goal is patient success, therefore if a patient is not a good match for this modality (i.e. dependent on high doses of benzodiazepines, alcohol, or other central nervous system depressants), they are referred to a different level of care and cases are reviewed by the larger team as needed. Once a patient is assessed as appropriate, an appointment is made for a medical consultation, where a primary care doctor reviews the induction or maintenance protocol.
After the consultation phase, the patient is seen for Buprenorphine induction (if they are being prescribed for the first time) or maintenance (if they are transferring care but already taking the medication). Patients continue to see the prescribing physician for ongoing medication management, and also engage in ongoing assessments with behavioral health providers at least quarterly for counseling, relapse prevention and monitoring of treatment status.
One case example of the effectiveness of the collaborative team approach involves a patient who initially met with his primary care physician for an annual physical. At the time, the doctor reviewed his treatment plan, saw that he was on long term Methadone maintenance on a low dose, and discussed the option of switching to Buprenorphine treatment. The patient was excited at the idea of making the transition to Buprenorphine as he is a single father and was looking for work. He was tired of making the trip to the methadone clinic every day. He found the clinic to be depressing and a relapse trigger as other clients were using drugs. He was often offered pills or heroin while waiting in the dispensing line. After completing the assessment and medical visit, the patient was started on Buprenorphine. When asked about his experience, patient state he was comforted by the team approach. He received a phone call from his primary care doctor and social worker after he began taking the medication as well as the next day to see how he was feeling. He felt he was informed about the process including symptoms he would experience and how to manage them. When the patient returned a week later for follow up, the social worker met him at his PCP appointment and encouraged him to continue with weekly therapy.
It’s been a year since the patient made the change from methadone to Buprenorphine. He still attends bi-weekly therapy. He attends AA. He is still a single father and active in his daughter’s life, and he now works fulltime. He reports being very happy that he made the change to office-based treatment.
Providing comprehensive medical and substance abuse services to these individuals also enhances their recovery. Research has shown that individuals with substance abuse related medical conditions who access primary care services, are three times more likely to achieve remission over 5 years and also decreased hospitalizations by up to 30% (Weisner, C, Mertens, J, Parthasarathy, S, Moore, C, and Lu, Y. (2001). Integrating Primary Medical Care with Addiction Treatment. JAMA: The Journal of the American Medical Association, 286(14):1715-1723. doi:10.1001/jama.286.14.1715). Integrated treatment is ideal for meeting the comprehensive needs of individuals with substance use disorders.
