Summary by Andrew O’Hagan, MD
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Based on “Principles of Addiction Medicine” Chapter by Karran A. Phillips, MD, MSc, Peter D. Friedmann, MD, MPH, FASAM, FACP, Richard Saitz, MD, MPH, FACP, FASAM, and Jeffrey H. Samet MD, MA, MPH
Individuals with substance use disorders frequently have a substantial risk of other comorbid medical and psychiatric disease, and it is not uncommon for patients with acute substance abuse issues to initially present to these other clinicians first. Conversely, psychiatric and medical symptoms can be distractions to addiction clinicians when a patient is enrolled in a standalone addiction treatment facility. Patients may sometimes feel as if they are in a “catch 22,” as their doctors may be reluctant to address care issues that may be outside their primary expertise. For example, the medical doctor may treat the toxic effects of hepatitis, but not the substance use issue that may be its etiology. The psychiatrist may be reluctant to provide treatment to a depressed patient who uses alcohol, thinking “they can’t be treated until they stop drinking.” This chapter examines linkage models among addiction, psychiatric, and medical services with regard to their potential benefits and barriers to implementation of integrated care models.
POTENTIAL BENEFITS OF LINKED SERVICES
The need for linkage of care comes from dysfunctions where care needs are not fully addressed and providers communicate inadequately. This could occur when medical and psychiatric needs are not addressed in the treatment plan of a substance-using patient or when addiction treatment is ignored by clinicians focused on solely medical or psychiatric issues. From the patient’s point of view, linkage not only provides access to addiction, medical, and psychiatric care but also leads to improvement of general health and reduction of adverse outcomes through coordinated structured care.
For the medical clinician, the benefits of linkage to addiction treatment are many: the increased breadth of care afforded to the patient, access to efficacious screening for substance misuse habits, utilization of preventative care strategies to avoid relapse, addition of substance use disorder in the differential diagnosis of patients, and enhancement of training for clinicians who may be less knowledgeable or comfortable with treatment of substance-abusing patients. Integrative care and linkage models that incorporate addiction treatment can enhance patient adherence to treatment in psychiatric and primary care offices. From the perspective of the addiction specialist, linkage models allow the addiction specialist to focus on a patient’s core problems with regard to chemical misuse and dependency as the other members of the clinical team are addressing ancillary needs. This effect can potentially provide maximal level of positive outcomes clinically. Integrated care allows addiction specialists to provide specialized training to other providers, hopefully reduce the social stigma of substance use disorder, and reinforce the notion that addiction is a treatable chronic illness, deserved of both attention from policy makers and parity of reimbursement from insurers.
From a societal perspective, enhanced efficiencies provided by linkage models may portend significant cost saving to our health care system, by both reduction of incidence of comorbid chronic medical disease and the number of high cost users of emergency services. Other noteworthy potential social effects of better addiction treatment hypothetically include reduction in incarceration rates, a decrease in burden of the criminal justice system for drug related offenses, and greater economic productivity.
BARRIERS TO OPTIMAL LINKAGE
Medical Training
Failures in training have led to medical students and residents with suboptimal clinical knowledge, which can lead to a failure of clinicians to appreciate their responsibilities to patients. It is not uncommon for clinicians to conceive of substance-abusing patients as perpetually symptomatic. Addiction educators over the last 10 years, through initiatives like COPE and CAST, have attempted to increase educational standards for health professionals with the goal of decreasing physician biases toward addiction.
Payment and Service Linkage Issues
Traditionally, addiction and mental health services were reimbursed at lower levels in comparison to other fields, and while efforts to reform these inequities have been made, parity is not yet the norm. Since 2001, many states have worked to amend the versions of the Uniform Accident and Sickness Policy Provision Law of 1950, which ostensibly provided insurers with reduced liability if their policy owners were intoxicated. This law created disincentives for thorough diagnosis and treatment of addiction, as clinicians would receive fewer dollars as a result of their labors. As of 2010, 17 states had repealed the law. Oftentimes, insurers create carve-out plans, which separate addiction and mental health services from other health-related problems, as this may benefit the insurer by controlling utilization of services. However, this may not lead to enhanced efficiency of delivery of health care and lead to adverse outcomes. Addiction and psychiatric resources as “carve outs” create inequality. Congress was only partially able to address the problem of parity with the 2008 Addiction and Mental Illness Equity Act. The Affordable Care Act of 2010 mandates addiction treatment options in the minimum plans available potentially to all Americans. Existing parity laws have not adequately addressed physician compensation of addiction treatment. Addiction treatment may be perceived as a costly endeavor, but frequently, insurers do not appreciate long-term cost savings that may be gained from successful treatment vis-a-vis comorbid medical and mental health problems. One study of usage and costs with parity, done on seven federal health plans, were mixed between the seven different plans. The authors made the conclusion that parity of addiction and mental health benefits can improve insurance protections and not necessarily lead to an increase in costs.
Concerns About Confidentiality and Stigma
One common limitation on linkage is the ability of providers to receive release of information from clients in a timely manner. While all providers must abide by the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Substance Abuse Programs must also comply with CFR 42 Part 2 and CFR 45 Parts 160 AND 164, which create an extra layer of federally enforceable confidentiality protocol. However, there exists a fundamental tension between the need to protect the privacy rights of consumers of health care services and the ability to communicate knowledge in a timely and efficient manner. Innovation in the creation of real time–oriented electronic medical records with ability to create networks of data has the potential for improving health care outcomes; however, this process is limited by the aforementioned regulatory protections afforded to consumers. From the perspective of a consumer with addiction-related pathology, privacy rights help to create a shield from the social stigma that these conditions have attached to them. Linkage and confidentially do not have to be mutually exclusive; centralized care models allow patients to get care in one place. Office-based protocols that encourage prompt signing of release of information forms can also be helpful. Further, certain treatment modalities can help maximize patient privacy as well as integrated care.
MODELS OF LINKED SERVICES
Substance-abusing patients tend to use health care–related services in an inefficient manner, that is, without continuous, longitudinal, and comprehensive care. These patients frequently represent high utilizers of emergency services rather than outpatient care. Integrated care models tend to be of two archetypes: a centralized approach where services may be delivered in one specific site or a distributed model based on effective referrals to other sites.
Centralized Model
The effect of single location delivery of integrated care is to create for the health care consumer “one stop shopping.” Studies conducted with medically ill alcoholics who received centralized integrative care (e.g., where a primary care doctor monitored biologic markers of disease and provided basic motivational interviewing with associated mental health care within the same site) have shown better outcomes over patients who received split treatment.
Office-based addiction treatments from primary care clinicians have become more common since 2000, when the Drug Addiction Treatment Act became law. This law helped pave the way for the 2003 approval of sublingual buprenorphine in combination with naloxone, or Suboxone. Not only have studies shown that Suboxone is as efficacious as methadone for mild-to-moderate opiate dependence, but patients on Suboxone tend to have higher treatment retention rates and a lower percentage of opiate-positive urine toxicologies. While methadone is also an effective treatment for opiate dependence, medical methadone maintenance continues to be heavily regulated.
Centralized linkage also is an effective strategy for management of comorbid medical illness. In a 2012 Centers for Disease Control report, the CDC stated that linkage would improve quality, reduce duplication of service, and improve access and delivery of care for individuals with HIV, viral hepatitis, sexually transmitted diseases, and tuberculosis. Methadone clinics that offered centralized linked care found that around 90% of individuals assigned to the centralized model used medical services, whereas only 35% of methadone-using patients without linked care receive medical care. Some addictive processes may not require a high degree of linked services and can be addressed with office-based practices (i.e., low severity illicit drug use, at-risk drinking, nicotine dependence), but the goal of care continues to be delivery of primary and preventative health care.
Distributive Model
While centralized linked care provides high degree of efficiencies for delivery of care and can help modulate long-term health care costs, barriers to linkage such as lack of reimbursement parity frequently mean providers lack the ability to provide centralized services. When centralized models fail, another option can be the distributive model, which is based upon the concept of the successful referral. Referring patients to other providers without a system of reinforcement leads to treatment failures. For example, around 45% of providers in one study were unaware that their patient had a chemical dependency issue. In another, around 45% of drug users had used the local health care system in a given year, but only around 10% of that group was referred by medical or mental health providers for addiction. Distributive linkage models usually utilize case management to help patients access existing resources within the community, and it is not uncommon that they need to follow up with patients to make sure they attend appointments and liaise with the referred provider. Another way services can be linked is through a hybridized model of centralized and distributed health care.
Disease Model Management
Chronic disease management is a model of integrated care delivery that links primary and specialty care. It is commonly thought that this model has yet to be adopted for substance dependence, as it requires highly motivated patients and treatment teams. A substance-dependent chronic disease model should address integration of care systems, medical, psychiatric, and social problems and provide addiction-specific treatments such as ambulatory detoxification, motivational interviewing, relapse prevention counseling, and appropriate referral.
Vulnerable Populations
Certain populations, such as individuals who are HIV positive, homeless, or incarcerated, represent those patients who may benefit the most from linkage of care. These groups may have high barriers to access of care and suffer high rates of nonadherence to treatment and relapse of symptoms. Therefore, providing integrated care can improve overall health and reduce negative metrics of health, such as rates and length of inpatient hospitalization. These populations again benefit from coordinated care from a case manager when a distributive linkage model is utilized. Incarcerated substance-abusing individuals suffer poor rates of referral to outpatient addiction treatment upon release. When parole officers and treatment counselors of the incarcerated are provided with interventions from a collaborative behavioral management model, it is not surprising that attendance at parole sessions increased on days when treatment also occurred, and these inmates were less likely to violate parole when released. Inmates retained in treatment were less prone to illicit drug use and showed improvements in basic biologic markers of disease, as management of associated medical illness was improved.
PROSPECTS FOR IMPROVEMENT OF LINKAGE
The continued high economic and social costs of the interplay between addiction disorder and medical and mental illness require health care practitioners and policy makers to think about these problems in an innovative manner. Ideally, the goal of linkage, as identified in an Institute of Medicine report, is the free flow of information and maximized cooperation between clinicians. Chronic disease and primary care models are not effective when used solely by physicians, but require a broad-based multidisciplinary team.
KEY POINTS
1. Linkage of addiction to medical and psychiatric care provides incentives for the clinicians and customers by increasing health benefit and controlling costs. These benefits also have tremendous social benefit and positive effects on the general public.
2. Clinician bias toward addiction patients, problems with reimbursement parity, and regulatory/privacy issues can limit the free flow of health care information and prevent effective integrated health care.
3. Models for linkage include the centralized model, where the consumer effectively has “one stop shop” for their health care needs. Since fully using this archetype can be costly, many organizations utilize a distributive model where patients are referred to outside clinicians in the community.
REVIEW QUESTIONS
1. A patient with long-standing opiate use disorder and untreated anxiety disorder completes an intake evaluation with a primary care doctor experienced in prescribing Suboxone. The internist recommends office-based opiate agonist therapy and makes a direct referral and brief case presentation with the patient in the room to a psychiatrist with whom he works collaboratively. Which model of care does this represent?
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