According to the 2017 National Survey on Drug Use and Health, of the 21.5 million people aged 12 or older who had a substance use disorder (SUD) in the prior year (2014), 20.2 million were 18 or older—accounting for 94.2 percent of those with an SUD.
These figures reflect that the vast majority of those with an SUD—as well as those who binge or otherwise misuse substances—never receive professional help at the primary care level or otherwise. In order to understand how this disturbing trend can be reversed, it's important to consider the possible reasons why so many don't get help, despite the effectiveness of interventions for SUD.
Lack of Access
Despite the existence of specialized treatment centers, there aren't enough to go around and access to them is limited, depending on availability, location, and cost for potential patients. This is particularly common in less-populated areas that can't support the costs of specialized addiction clinicians. In such cases, those in need have to travel long distances—often after being on a waitlist—or forego treatment altogether.
Add to this the lack of specialized addiction physicians at the primary care level, and addicts or heavy users often have nowhere to turn for help. As of 2017, an estimated 3,600 physicians were board-certified in addiction medicine, through the American Board of Medical Specialties. However, this number will likely increase due to the recognition of addiction as a subspecialty by the same board.
When someone reaches the point where they know there's a problem and they may need help, getting over the fear of what people will think can be extremely challenging. Fortunately, many employers today allow leave for addiction treatment, but this isn't always the case.
Stigma may not only prevent people from seeking treatment, but also cause them to conceal how much they actually drink or abuse drugs from their primary care physician, friends, relatives, and co-workers.
Underuse of Available Medications
Although there are effective medications for the treatment of an SUD, many are unaware of them and aren't being introduced to them at the primary care level. According to Markus Heilig, director of the Center for Social and Affective Neuroscience at Sweden's Linköping University and co-author of a study led by the Centre for Addiction and Mental Health (CAMH), "Approved medications for alcohol use disorders are no less effective than other widely used medical treatments... Yet they are only prescribed to a small minority of patients. This needs to change."
To really get patients the help they need when they need it, waitlists need to be minimal and patients need care at the primary care level before and after any in-patient treatment.
Not only are the limiting factors for seeking treatment affecting those with SUD—as well as their loved ones—they also place a heavy burden on ER departments and first responders.
The Burden of Untreated Addiction
In addition to increased ER visits and 911 calls for overdoses, the healthcare system is affected in broader ways, including addiction, making it more difficult to treat other health conditions—both physical and mental—and increased acute care costs due to a shortage of specialized treatment centers.
The National Institute on Drug Abuse estimates that addiction costs the US $600 billion yearly in both health and social costs. These costs don't take into account any expenses for foster care, incarceration, court costs, and other public services related to untreated addiction.
The Past, Present and Future of Primary Care in Addiction
Historically, treatment for addiction has been delivered outside of primary care, often in specialized treatment centers, emergency departments, and mental health facilities. However, increased recognition among medical educators, clinicians, and government leaders that these options for addiction treatment can't meet the current demand for it makes this dilemma much more hopeful.
These prominent leaders in addiction medicine are recommending incentives that encourage primary care providers to screen patients for misuse or addiction and treat accordingly.
Mirian Komaromy, director of the University of New Mexico's Project ECHO, which provides distance learning training for primary care providers to offer addiction care and treatment, believes that it's time to shift some of the responsibility from specialized facilities to the primary care level. "Primary care providers are the most likely to have contact with patients who are struggling with substances, yet we have traditionally avoided that responsibility,” Komaromy said in an AristaMD article.
Today, there are 4 main models for expanding care and treatment of addiction within the primary care setting, designed for both clinically complex patients and less complex cases, located in various areas of the country. These models address the need for open door clinics, medication-assisted-treatment (MAT), "low-threshold care" and treating addiction as part of complex care. All of these models indicate increased awareness for the need for addiction treatment at the primary care level.
Imagine a health system where everyone feels comfortable and safe addressing their substance use with their primary care physician and knowing that they are talking to a medical professional who has been educated and trained in addiction and will know the signs of misuse, dependence, or addiction in case you need help.
This would also mean that physicians could begin preliminary care when patients drink daily, but small amounts. If a doctor knows a patient drinks two drinks every day, they can make asking about alcohol intake a regular part of every visit.
Fortunately, it looks like primary care in addiction might be headed in that direction.