Getting Addicted Patients Into Treatment
Substance use disorders are defined as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.”1 Importantly, the presence of tolerance and withdrawal alone are not sufficient to diagnose a substance use disorder. Rather, the disorders are typically also characterized by compulsive patterns of behaviors, impairment in social and occupational functioning, recurrent use in hazardous conditions, and use despite exacerbation of physical and psychiatric problems. A patient prescribed opioids or benzodiazepines during appropriate treatment, for example, can become dependent without being addicted. Substance use disorders can be mild, moderate, or severe, based on the number of criteria met and reflecting the level of impairment for the individual (Table 1).1,2
Advances in neurobiology and neuroimaging have helped shape our understanding of the interactions between genetics, environment, drug exposure, and developmental vulnerability in the emergence of addiction. The repeated use of substances has been shown to alter neuronal circuitry involved in motivation, reward, and inhibitory control, as well as to influence the expression of neurotransmitters and receptors in the brain that contribute to the consolidation of memory, saliency of cues associated with use, and learned conditioned behaviors seen in individuals with substance use disorders. These brain changes can persist even after cessation of use. In some cases, they may not be reversible, further supporting the conceptualization of substance use disorders as a chronic disease.3-5
As with hypertension, diabetes, and asthma, the treatment of substance use disorders requires continuing care that is individually tailored for the patient. Comprehensive treatment plans may include education, counseling, and medications. When treating chronic diseases, adherence to treatment recommendations is the strongest predictor of treatment efficacy.6,7
Factors that can influence treatment adherence, and thus treatment efficacy, include socioeconomic status, amount of family support, and medical or psychiatric comorbidities.6-8 Indeed, relapse rates for hypertension (50% to 70%), type 1 diabetes (30% to 50%), and asthma (50% to 70%) are comparable to relapse rates for substance use disorders (40% to 60%) with nonadherence to treatment.8 Treatment for patients with substance use disorders may vary by the substance used, medical and psychiatric comorbidities, and demographics, among other factors. Any treatment plan should be monitored, assessed, and modified continuously to ensure it addresses the changing needs of the patient.9
In 2014, approximately 22.5 million people age 12 and older needed substance use treatment, but only 2.6 million people (11.6%) with substance use disorders received specialty treatment (i.e., treatment in mental health centers, or inpatient or outpatient treatment at a rehabilitation center). Among those who perceived a need for treatment, but did not receive treatment at a specialty care clinic, the most common reasons were not being ready to quit (41.2%) and inability to afford care due to a lack of health insurance coverage (30.8%).10
Primary care physicians can play an important role in identifying patients with problematic substance use and providing continuity of care to bridge the patient to the appropriate level of care.7,9 The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model is an evidence-based approach for primary care physicians to help identify patients with problematic substance use behaviors in order to provide early interventions and referrals.11 Detecting problematic use of substances is the first step in preventing and reducing the negative medical and psychiatric consequences from excessive use of alcohol and other illicit substances. The goal of SBIRT is not to diagnose substance use disorders; rather, validated screening tools are used to stratify patients into low, moderate, and high risk categories for adverse health effects related to their substance use.
Based on the patient’s risk category, brief interventions or referral to a higher level of care may be appropriate.11,12 Brief interventions are “in-person, time-limited efforts to provide information or advice, increase motivation to avoid substance use, or to teach behavior change skills with the aim of reducing substance use and the likelihood of experiencing negative consequences.” They are typically limited to 4 or 5 sessions, with each done during a 10- to 15-minute office visit. The focus should be on a single behavioral objective and the identification of immediate goals that will reduce the risk of harm to the patient from continued substance use.12 A common model used when administering a brief intervention is the Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-efficacy (FRAMES) model (Table 2).13