ASPIRE Model for Treating Cannabis and Other Substance Use Disorders: A Novel Personalized-Medicine Framework.

Abstract

Medically harmful substance use is common in the United States (U.S.), with an estimated 24.6 million Americans aged 12 years and older having used illicit drugs or engaged in non-medical drug use in the prior month, representing 9.4% of the population aged 12 years or older (1). Marijuana is the most commonly used illicit drug. In 2013, there were 19.8 million current users aged 12 years or older, 7.5% of the population in this age group (1). However, in 2013, only 2.5 million individuals in the U.S. received treatment at a specialty facility for an illicit drug or alcohol use problem in the past year, similar to numbers from 2002 through 2012 (1). Therefore, the vast majority of persons with substance use disorders (SUD) are not seen by specialty programs, and efforts to integrate SUD care with primary care in general medical settings have largely fallen short. Drug use disorders produce a wide variety of medical problems and are important contributors to years of life lost due to disability (2). A common barrier to treating individuals with cannabis use disorders (CUD) and other SUD in medical settings or successfully linking them to indicated follow-up care is inability of clinicians to engage patients in a collaborative dialog concerning the medically harmful consequences of unhealthy substance use and evidence-based treatment options aligned with patient values. Clinicians often do not use a shared-decision-making approach to discuss with patients’ different options for care personalized to risk categories and their preferences (3). Indeed, patients are often offered a single or narrow set of options for follow-up care, compromising their motivation to change their medically harmful substance use as well as engagement and initiation of treatment. Here, I illuminate a need for systematic research in medical settings to evaluate a patient-centered model for treating CUD and other SUD, which incorporates principles of shared-decision-making engaging both patients and clinicians, grounded in personalized-medicine tailored to substance use risk categories and individualized patient values/preferences. Shared-decision-making and patient-centered care (4), considering individual preferences for treatment options, are critical for patient engagement in substance use disorder care. They necessitate a collaborative dialog between patients and providers in which they discuss benefits and risks of different evidence-based treatments, as well as the importance of patients in making decisions about their care. The provider helps patients understand their medical condition in a manner in which they feel empowered to make decisions about options for evidence-based care aligned with their values, in the spirit of personalized medicine (5). Medical setting providers need to evaluate: (1) substance use disorder severity, (2) presence of co-occurring psychiatric and other medical conditions, (3) readiness of patients to change their medically harmful substance use, (4) reasons for this readiness or hesitancy to do so, and (5) how they may help patients in instituting an action plan consistent with their preferences (5). Rigorous research is needed in general medical settings testing effectiveness of primary and secondary prevention interventions incorporating principles of shared-decision-making and patient-centered care for individuals with multiple SUD (marijuana, alcohol, tobacco, or other commonly abused substances). This research is particularly needed in adolescents and young adults (age range 12–25 years old), where abuse of marijuana and prescription drugs has escalated in recent years (1). Important features of primary and secondary prevention interventions to be tested are: (1) be simple so they could be routinely delivered by clinicians at medical settings without cumbersome training and fidelity requirements, (2) utilize health information technology together with clinical decision support (CDS) tools to extend role of clinicians and simplify care delivery, (3) be either integrated with or utilize health information collected from electronic health records (EHRs), (4) use validated and brief electronic screening and brief assessment tool(s) for identifying risk categories of commonly abused substances, in a comprehensive way, (5) be sustainable and easily disseminated at conclusion of trials to applicable medical settings and stakeholders, (6) explain means of scalability and sustainability of effective secondary preventions, (7) include cost-effectiveness or other relevant cost–benefit analyses.