July 2015
Jessica Yen, MS
Northwest ATTC
Substance use disorders continue to be under-diagnosed and under-treated, even though the individual and societal consequences are well known. In 2013, 22.7 million people aged 12 or older needed treatment for an illicit drug or alcohol use problem, yet 20.2 million of these people did not receive it (U.S. Department of Health and Human Services, 2014). Use of various substances has been linked to increased risk for developing cancer, heart disease, stroke, HIV/AIDS, and hepatitis C (Schulte & Hser, 2014), and untreated alcohol and substance use disorders cost the criminal justice, social welfare, and healthcare systems hundreds of billions of dollars (U.S.Department of Justice, 2011, Center for Disease Control, 2014; Bouchery, Harwood, & Sacks, 2011). Treatment of substance use disorders often takes places in residential and outpatient specialty care settings, but these settings can face long wait lists, stigma, and limited funding to serve the uninsured.
To address these limitations, experts have begun focusing on primary care as a setting for screening and treating people with substance use disorders. Roughly four in five Americans visit a health professional at least once per year (Blackwell, Lucas, & Clarke, 2014), and several evidence-based practices for screening and treatment are suitable for primary care settings (SAMHSA, 2009, Fudala, et al., 2003; O, Malley & Froehlich, 2003; SAMHSA NREPP, 2007.) However, the integration of substance use treatment and primary care remains underdeveloped and underutilized.
There are three general ways that substance use treatment is currently integrated into primary care. In the first, the primary care clinic conducts a universal screening for substance use disorders among all its patients, and those who screen positive are provided with a brief intervention or a referral to more extensive treatment. This is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, and various members of the care team might perform the different steps, depending on the clinic (Babor, McKee, & Kassebaum, 2007).
In the second model, substance use services are offered within a health clinic, however these services are not integrated with health services (Parthasarathy, Mertens, & Moore, 2003). For example, a community clinic might realize that a high proportion of their patients experience substance use disorders, and may therefore hire staff who provide individual counseling, group therapy, or outpatient treatment programs. These programs might be housed within the same building as the clinic or they may exist in separate buildings. In the third model, substance use treatment and healthcare services are integrated. A behavioral health clinician may participate as a member of the care team to provide substance use and mental health services, or a primary care provider may be embedded within a larger team that serves clients with substance use disorders (Parthasarathy, Mertens, & Moore, 2003)
The evidence base for successful models is still nascent. For example, SBIRT shows promise for reducing alcohol use within a primary care setting, but mixed results for its impact on illicit drug use. Several observational studies have shown reductions in drug use or increased use of specialty addiction treatment services(Madras, et al, 2009; Krupski, et al., 2010), but a review of randomized controlled studies found little or no efficacy (Saitz, 2014). For the second and third models, one study found promising results within a health maintenance organization clinic, but recommended modifying the model to improve its efficacy (Parthasarathy, Mertens, & Moore, 2003). Thus, little is known about successful implementation models, the high impact components of each model, or whether specific models are more useful for certain populations.
Case Scenario
In light of this evidence gap, this article presents one high-performing case scenario. Southcentral Foundation (SCF) is an Alaska Native-owned, non-profit healthcare organization that serves nearly 60,000 Alaska Native and American Indian people through 65 programs in Anchorage, Matanuska-Susitna Valley, and 60 rural villages in the Anchorage Service Unit. SCF supports wellness through medical, behavioral, dental, and traditional practices. A critical component of SCF is the Nuka System of Care, which is the “name given to the whole health care system created, managed, and owned by Alaska Native people to achieve physical, mental, emotional and spiritual wellness.” Clients or patients are called “customer-owners,” which highlight’s Nuka’s emphasis on placing the customer-owner, and the relationship between customer-owner and staff, at the center of all they do.
SCF’s approach to substance use integration combines the three approaches described above. “Access to substance treatment exists everywhere,” says Shane Coleman, MD MPH, Division Medical Director of Behavioral Health Services. Within primary care, masters-level clinicians (called Behavioral Health Consultants or BHCs) and psychiatrists are integrated into the care team. The BHCs engage customer-owners around SBIRT screenings, provide motivational interviewing-based brief interventions, assess customer-owner readiness for more intensive interventions, and match them with the substance use services they need. SCF is currently integrating Suboxone prescribing throughout primary care.
Primary care is the first tier of treatment, but if customer-owners need a more intensive level of substance use services, other programs are available. These include several behavioral health clinics, where behavioral health and substance use treatment are fully integrated. SCF also has an outpatient substance use treatment center and a residential treatment program for customer-owners who need additional support. Acute or urgent care services are available via BHCs who specialize in urgent mental health care and consult liaison work in the hospital or emergency room (ER). These BHCs are based within the outpatient program where they provide urgent care services. They interface with primary care to help determine if a patient should go to the ER or to urgent care, and they also consult with ER providers. Finally, SCF has a reverse integration project that embeds a primary care team within a larger team that focuses on customer-owners with severe and persistent mental illness, often with co-occurring substance use issues. Thus, SCF works with customer-owners at a variety of levels of service in an integrated continuum of care.
SCF has developed a number of internal trainings that support this work. The organization has a SBIRT curriculum and they also provide training on motivational interviewing for all BHCs. All staff members participate in a three-day communication and storytelling training to facilitate interactions with customer-owners and also between staff. “It covers the importance of stories in native culture, how to create a safe space for stories, how stories can help us understand someone else’s interpersonal work style. It’s really helped our interprofessional team approach by breaking down communication barriers between teams and disciplines,” says Fred Kopacz, former Director of Planning for SCF.
In general, one obstacle that is frequently encountered during integration is resistance from primary care providers who fear that patients will relapse or experience other complications, and that they will be ill-equipped to deal with this. As SCF integrates Suboxone prescribing into primary care, they’ve used this step as an opportunity to reframe these kinds of fears. Instead of viewing such instances as failures, leadership instead frames this as an opportunity to think about matching patient needs to an appropriate level of care. The customer-owner might need to be referred back to a higher level of service, for example to a collocated psychiatrist or to the outpatient substance use treatment program. As mindsets have started to change, this has further facilitated connections between primary care and substance use services.
SCF regularly solicits feedback through continuous surveys and focus groups, and the CEO gives out her email to customer-owners. The organization uses this information to help ensure programs are responsive. The project focused on severe and persistent mental illness has seen the health impact of integration: when the team lost their primary care provider for a few months ER visits rose dramatically, and when the team regained its provider, ER visits dropped once more. The organizational culture now embraces integration. When behavioral health clinicians were first embedded within primary care to perform SBIRT screenings, many primary care providers questioned the utility of adding these new team members. Eight years later, when SCF opened a new clinic space, a major concern of primary care providers was whether or not the new site would include behavioral health clinicians on their team.
For clinicians embarking upon the integration journey, the SCF experience highlights the importance of understanding the culture of primary care in order to successfully adapt to this new environment and thus engage in a fruitful partnership. “You’ll need to rethink the boundaries and specifics of what you do,” says Dr. Coleman. “Be able to capitalize on good, efficient, pointed consults and recommendations, and realize that you’ll need to adapt an outpatient consultant liaison mentality. Flexibility is key in a consultant role. You need to understand primary care in order to be a good consultant to primary care.”
For more information on integrated care, visit:
ATTC Network: Advancing the Integration of Substance Use Disorder Services and Health Care
About the author: Jessica Yen is a science writer and editor based in Portland OR. Previously, she spent five years working with community clinics on healthcare systems transformation and assessing and addressing the psychosocial factors that impact health. She has a Masters from the Harvard School of Public Health and a Bachelors in Chinese Literature from UC Berkeley.