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Recognition and Management of Substance Abuse in Primary Care

The US Substance Abuse and Mental Health Services Administration (SAMHSA) released the results of the 2016 National Survey on Drug Use and Health on September 7, 2017. In 2016, approximately 20.1 million people aged 12 or older had a substance use disorder (SUD) related to their use of alcohol or illicit drugs in the past year, including 15.1 million who had an alcohol use disorder and 7.4 million who had an illicit drug use disorder. An estimated 2.1 million people had an opioid use disorder, which includes 1.8 million with a prescription pain reliever use disorder and 0.6 million with a heroin use disorder.2 This survey supports the estimate that one out of every ten patients treated for pain with opiates develops an opiate use disorder.

Although the United States Preventive Services Task Force (USPSTF) finds insufficient evidence to recommend generalized screening of any age group for misuse of any addictive substances other than alcohol and tobacco3, some major primary care organizations do recommend routine periodic screening e.g. American Academy of Pediatrics (AAP)4, and American College of Obstetricians and Gynecologists (ACOG)5. USPSTF does recommend that anyone seeking treatment for substance abuse, mental health disorders, accidents, or violence should be screened. A single question screening test has been validated in a primary care setting. “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” If clarification of “nonmedical reasons” is needed: “For instance, because of the experience or feeling it caused.”6

If screening is positive, brief intervention and referral for treatment (SBIRT) has been the recommended model for a primary care approach to substance abuse by SAMHSA, https://www.samhsa.gov/sbirt. SAMHSA has developed a SBIRT tool for interactive use at their website https://www.drugabuse.gov/nmassist/ which has an application programming interface for EMR systems.

The National Institute on Drug Abuse (NIDA) supported a controlled clinical trial of collaborative treatment of opioid and/or alcohol abuse in primary care vs SBIRT and has shown statistically increased efficacy when treatment was given in a patient-centered medical home rather than referral.7 DEA and FDA have rigid requirements for prescribers of the opiate abuse agents methadone and buprenorphine/naloxone which make it impractical to treat just a few substance abuse patients in a general medical practice. One of the possible consequences of declaring a public health emergency may be to allow prescription of opioid maintenance medication in a primary care setting by telemedicine rather than patients having to go to a drug treatment center. NP and PA providers may also be permitted to prescribe medications for opioid use disorders. A systematic review of published research on primary care medication management of opioid use disorders has been published by University of Michigan researchers8.

References

1Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013 Jul 15;88(2):113-21. http://www.aafp.org/afp/2013/0715/p113.html

2Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

3https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/drug-use-illicit-screening

4https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Recommends-Substance-Abuse-Screening-as-Part-of-Routine-Adolescent-Care.aspx

5https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Alcohol-Abuse-and-Other-Substance-Use-Disorders-Ethical-Issues-in-Obstetric-and-Gynecologic-Practice

6Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010 Jul 12;170(13):1155-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911954/

7Watkins KE, Ober AJ, Lamp K, Lind M, Setodji C, Osilla KC, Hunter SB, McCullough CM, Becker K, Iyiewuare PO, Diamant A, Heinzerling K, Pincus HA. Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial. JAMA Intern Med. 2017 Oct 1;177(10):1480-1488. https://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2017.3947

8Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A (2017) Primary care models for treating opioid use disorders: What actually works? A systematic review. PLOS ONE 12(10): e0186315. https://doi.org/10.1371/journal.pone.0186315

Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA
csneiderman@culmoreclinic.org

Published on 12/4/17


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