Should Primary Care Docs Treat Addicts, Too?

Relapse rates plummet when treatment, regular care combined

FRIDAY, Nov. 8, 2001 (HealthDayNews) -- Addicts may have more luck getting off drugs or alcohol if their medical care and addiction treatment are combined, new studies suggest.

Traditional health care separates treatment for addiction from medical care by sending substance abusers to outpatient clinics or residential programs. But, having one source for both medical care and addiction treatment seems to triple the ability of addicts to stay off drugs or alcohol, one study shows.

And, going to a primary care physician may help heroin addicts stick with their treatments and avoid relapse, a second study says.

"There's very strong literature showing people with addiction conditions have a higher rate of other medical conditions when compared to the general population," says Constance Weisner, a psychiatry professor at the University of California, San Francisco. "One of the concerns is that many primary care physicians who are treating their patients for health care may be completely unaware of a patient's addictions and, therefore, are not assessing the patient for other related conditions."

"There is also a large body of literature that shows that primary care physicians seldom screen for addiction or substance abuse problems," Weisner says.

"We wanted to test whether integrating the two treatments would result in better outcomes," she says. "What would happen if they were being seen by a primary care physician who was involved in their addiction treatment and, therefore, involved in the … substance abuse treatment as well?"

To find out, the researchers assigned 285 people to an integrated program in which their medical care was combined with addiction treatment and managed by a primary care physician. They also put 307 people in more traditional substance abuse treatment programs, based at outpatient clinics. All participants were required to attend 12-step programs. After eight weeks of treatment and 10 months of follow-up care, the researchers looked at the abstinence rates and medical costs for both groups.

"Patients who had integrated healthcare and addiction treatment were about three times more likely to remain abstinent, which is very large in these kinds of studies," Weisner says.

Integrated health care costs about $1,500 more per patient, Weisner says, "but the potential for the long term is that there may be less medical costs down the road." More research is needed on that possibility, she says.

A second study shows that using a primary care physician also can be beneficial in treating much more serious addictions.

People who are successfully undergoing methadone treatment for heroin addiction can be transferred to their own doctors to continue treatment, with successful results and greater satisfaction, the study reports.

And that could mean more treatment resources for heroin addicts, says Dr. Richard Schottenfeld, a Yale University psychiatry professor.

"It's been very hard to expand current treatment opportunities, so one of the main impetuses of our study was to look for an alternative location to provide both access and treatment," he says.

Schottenfeld and his colleagues randomly assigned 46 heroin addicts, who were all doing well in their methadone treatment, to either stay in their program or transfer to a primary care physician to continue treatment. After six months, the addicts were tested for illicit drug use.

"What we found was that patients did comparably well when they moved to a physician's office when compared to a regular program," Schottenfeld reports. Four of the 22 participants assigned to a primary care physician started using narcotics again regularly, compared with five of the participants who got their methadone from a clinic, the study says.

"There were some advantages to primary health care in terms of patient satisfaction," Schottenfeld says. Almost 75 percent of the people given a primary care physician said they were satisfied with the office-based treatment, compared with 10 percent for those in regular treatment.

"And satisfaction is one of the things that leads people to enter and stay in treatment, so we consider that important," Schottenfeld says.

Details on the two studies appear in a recent issue of the Journal of the American Medical Association.

In an accompanying editorial, Dr. Michael Stein and Dr. Peter Friedman, both with Rhode Island Hospital, say the two studies provide necessary data on both the benefits and costs of primary care physicians' involvement in addiction treatment. The role for general care physicians may be similar to the role of those who care for people infected with AIDS, they write.

"In the HIV/AIDS arena, a relatively small number of physicians -- willing to overlook financial and administrative disincentives -- provide the great majority of care to patients with more complicated clinical pictures," Stein and Friedman write. "The system of care for substance-using patients will likely take shape in the same way as new therapies become available."

But doctors need special skills for addiction treatment to succeed, experts say.

"Physicians -- whether generalists or addiction specialists -- who provide an ongoing, trusting relationship, if they have learned the requisite skills, may be able to evoke from patients reasons for changing and commitment to change that endure," they write. "It is rewarding but challenging work. Time will tell how many generalist physicians really want a share of this turf."

What To Do: For more on addiction treatment, check the National Institute on Drug Abuse or the Addiction Resource Guide.

SOURCES: Interviews with Constance Weisner, Dr.P.H., professor, department of psychiatry, University of California, San Francisco; Richard Schottenfeld, M.D., professor of psychiatry, Yale University School of Medicine, New Haven, Conn.; Oct. 10, 2001, Journal of the American Medical Association
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