Faculty Bibliography

Brain imaging and genetic studies over the past two decades suggest that substance use disorders are best considered chronic illnesses. The passing of the Affordable Care Act in the United States has set the occasion for integrating treatment of substance use disorders into mainstream healthcare; and for using the proactive, team-oriented Chronic Care Model (CCM). This paper systematically examines and compares whether and how well the CCM could be applied to the treatment of substance use disorders, using type 2 diabetes as a comparator. The chronic illness management approach is still new in the field of addiction and research is limited. However comparative findings suggest that most proactive, team treatment-oriented clinical management practices now used in diabetes management are applicable to the substance use disorders; capable of being implemented by primary care teams; and should offer comparable potential benefits in the treatment of substance use disorders. Such care should also improve the quality of care for many illnesses now negatively affected by unaddressed substance abuse.

ABSTRACT. Background: With rising rates of prescription drug abuse and associated overdose deaths, there is great interest in having accurate and efficient screening tools that identify nonmedical use of prescription drugs in health care settings. The authors sought to gain a better understanding of how patients interpret questions about misuse of prescription drugs, with the goal of improving the accuracy and acceptability of instruments intended for use in primary care. Methods: A total of 27 English-speaking adult patients were recruited from an urban safety net primary care clinic to complete a cognitive interview about a 4-item screening questionnaire for tobacco, alcohol, illicit drugs, and misuse of prescription drugs. Detailed field notes were analyzed for overall comprehension of the screening items on illicit drug use and prescription drug misuse, the accuracy with which participants classified drugs into these categories, and whether the screening response correctly captured the participant's substance use behavior. Results: Based on initial responses to the screening items, 6 (22%) participants screened positive for past-year prescription drug misuse, and 8 (30%) for illicit drug use. The majority (26/27) of participants correctly interpreted the item on illicit drug use, and appropriately classified drugs in this category. Eleven (41%) participants had errors in their understanding of the prescription drug misuse item. The most common error was classifying use of medications without abuse potential as nonmedical use. All cases of misunderstanding the prescription drug misuse item occurred among participants who screened negative for illicit drug use. Conclusions: The results suggest that terminology used to describe misuse of prescription medications may be misunderstood by many primary care patients, particularly those who do not use illicit drugs. Failure to improve upon the language used to describe prescription drug misuse in screening questionnaires intended for use in medical settings could potentially lead to high rates of false-positive results.

Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles' merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.

BACKGROUND: Dental visits represent an opportunity to identify and assist patients with unhealthy substance use, but little is known about how dentists are addressing patients' use of tobacco, alcohol and illicit drugs. The authors surveyed dentists to learn about the role their practices might play in providing substance-use screening and interventions. METHODS: The authors distributed a 41-item Web-based survey to all 210 dentists active in the Practitioners Engaged in Applied Research and Learning Network, a practice-based research network. The questionnaire assessed dental practices' policies and current practices, attitudes and perceived barriers to providing services for tobacco, alcohol and illicit drug use. RESULTS: One hundred forty-three dentists completed the survey (68 percent response rate). Although screening was common, fewer dentists reported that they were providing follow-up counseling or referrals for substance use. Insufficient knowledge or training was the most frequently cited barrier to intervention. Many dentists reported they would offer assistance for use of tobacco (67 percent) or alcohol or illicit drugs (52 percent) if reimbursed; respondents who treated publicly insured patients were more likely to reply that they would offer this assistance. CONCLUSIONS: Dentists recognize the importance of screening for substance use, but they lack the clinical training and practice-based systems focused on substance use that could facilitate intervention. Practical Implications. The results of this study indicate that dentists may be willing to address substance use among patients, including use of alcohol and illicit drugs in addition to tobacco, if barriers are reduced through changes in reimbursement, education and systems-level support.

The feasibility of long-term extended-release naltrexone (XR-NTX) alcohol treatment is unknown. Following an initial 12-week, single-arm, observational trial of XR-NTX plus medical management (MM) in primary care, we offered 48 additional weeks of XR-NTX treatment (12 additional monthly injections) in two public primary care clinics as a naturalistic extension study. Of 65 alcohol dependent adults initiating XR-NTX treatment, 40 (62%) completed the initial 12-week XR-NTX observational trial, and 19 (29%) continued treatment for a median of 38weeks total (range, 16-72weeks; median 8 total XR-NTX injections). Among active extension phase participants, self-reported rates of drinking days (vs. last 30 days pre-treatment baseline) were low: median 0.2 vs. 6.0drinks per day; 82 vs. 38% days abstinent; 11 vs. 61% heavy drinking days. Long-term XR-NTX treatment in a primary care MM model was feasible and may promote lasting drinking reductions or alcohol abstinence (clinical trial: NCT00620750).

INTRODUCTION: Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers. METHODS: Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry. RESULTS: All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage. Conclusions: Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.