Generalist Physicians and Addiction Care

Abstract

FOR MANY YEARS PHYSICIANS SHUNNED ADDICTION care—traditionally the turf of chemical dependency counselors and mental health professionals. But over the past quarter century, physicians have become more involved in research and clinical care of patients with substance use disorders. Generalist physicians in particular have been drawn to the addiction field for 4 reasons. First, there is growing awareness of the epidemiology of substance use disorders. Epidemiologic studies indicate high lifetime prevalence of substance use disorders and, particularly in regard to alcohol, that persons with lowerseverity problems greatly outnumber those who meet formal criteria for abuse or dependence. Generalist physicians have long been aware of the episodic infectious and traumatic complications that bring such patients to emergency departments and of the difficulties in engaging such patients in primary care. Nonetheless, more than two thirds of individuals with substance use disorders have seen a primary care physician in the previous 6 months, offering the possibility of beginning a therapeutic relationship. Second, overwhelming evidence has emerged that drug addiction can be treated successfully, and a number of studies have revealed little difference in outcomes as a function of treatment intensity. At the same time, brief interventions appear to be efficacious and feasible within the time limits of primary care practice. Third, generalists, who with the advent of selective serotonin reuptake inhibitors became more comfortable providing the initial pharmacological treatment for some psychiatric disorders, soon discovered underlying substance problems. Finally, during the 2 decades of the HIV/AIDS epidemic, generalist physicians have directly confronted the sequelae of addiction in the management of HIV-infected patients. Increasingly, addiction is recognized as a chronic relapsing disease that requires diverse service components for successful treatment over the long term. In addition, increasing evidence supports the treatment of substance use at empirically defined levels as a “risk factor” worthy of intervention— much like clinically silent hypertension warrants treatment to prevent adverse consequences. Although in theory the model of comprehensive, coordinated, and continuous primary care suits the management of the continuum of substance use disorders, the current system delivers fragmented care. Little evidence exists to guide how primary care might fit into a better system of care for patients with addictive disorders. What is the role of the primary care physician at the various stages of substance use severity, and should this role be different for different substances? Is a wider role for primary care physicians feasible or desirable, given their burden of responsibility for an increasing number of disorders? Is a primary care focus more or less desirable than a disease management focus? Two studies in this issue of THE JOURNAL begin to answer some of these questions. In one study, Fiellin et al recruited and trained 6 primary care physicians to provide office-based methadone maintenance and primary care to a select group of opiatedependent patients. Patients stable in methadone maintenance were randomly assigned to receive methadone in their current treatment program (n=24), or through 1 of these 6 physicians (n=22). Patient eligibility criteria were strict and applied to only 12% to 14% of patients in the methadone treatment program. These criteria included having at least 12 drug-free months, as well as stable transportation, income, and living situations. At follow-up, nearly half of patients in both study groups returned to drug use, indicating the chronic relapsing nature of addiction. However, patients assigned to primary care practices were significantly more satisfied with their care than were those in the methadone program, a finding that likely has great meaning given the small sample size. These differences in satisfaction reveal as much about the burdensome nature of methadone clinics as they do about the nonstigmatizing care delivered in office practices. Satisfaction has been shown to be associated with treatment adherence in other diseases, and duration of treatment (a likely effect of satisfaction) is known to be the key to long-term addiction outcomes. As in other diseases, some patients with substance use disorders may need prolonged care from a specialist, while others can be cared for by generalists with specialist consulta-