Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
By any measure, effectively treating a primary care patient's substance abuse problem is addressing a significant "personal health care need." Alcohol-related disorders, for example, occur in up to 26 percent of general medical clinic patients, a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes
(Fleming and Barry, 1992). While not specific to the primary care setting, the most recent National Household Survey on Drug Abuse estimates that 12.8 million Americans, or 6.1 percent of the population age 12 and older, currently use illicit drugs, while about 32 million Americans (15.8 percent of the population) had engaged in binge or heavy drinking (five or more drinks on the same occasion at least once in the previous month)
(Substance Abuse and Mental Health Services Administration, 1996b). Using estimates from the Institute of Medicine
(Institute of Medicine, 1990), a Robert Wood Johnson Foundation report calculated that about 5 million users of illicit drugs and 18 million people with alcohol use problems need treatment, but only one fourth of them receive
it (Institute for Health Policy, 1993).
Accurately gauging the costs of substance use problems, like estimating costs for heart disease or cancer, is difficult. This figure grows or shrinks by billions of dollars depending on the economic assumptions used. The costs to abusers, their families, and society at large, however, are indisputably enormous and encompass health care costs, premature mortality, workers' compensation claims, reduced productivity, crime, suicide, domestic violence, and child abuse.
Some 100,000 people die each year in the United States as a result of alcohol; illicit drug abuse and related acquired immunodeficiency syndrome (AIDS) deaths account for at least another 12,000 deaths
(Rice et al., 1990;Stinson et al., 1993;Rosenberg et al., 1996). Every man, woman, and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime, and lost productivity due to substance abuse
(Institute for Health Policy, 1993). Furthermore, an "analysis of the epidemiological evidence reveals that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse"
(Center on Addiction and Substance Abuse, 1993, p. 21).
Nearly one quarter of Americans say that "drinking has been a cause of trouble in their family"
(Institute for Health Policy, 1993, p. 40). A forthcoming study based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
(American Psychiatric Association, 1994a) estimates that 52.9 percent of Americans age 18 and older have a family history of alcoholism among first- or second-degree relatives
*(Dawson and Grant, in press). In short, substance use disorders are simply too pervasive and too costly to be ignored.
Fortunately, not only is effective specialty treatment available for problem drinkers, alcoholics, and illicit drug users, but brief interventions, which can be done in a primary care setting, can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health
(Kahan et al., 1995).
In a report on the financially driven changes in health care, the Institute of Medicine highlighted the growing need for primary care clinicians to diagnose and treat a range of problems previously addressed by specialists
(Institute of Medicine, 1996). While not focused specifically on substance abuse, the report credits the "trust and partnership" that exists between primary care clinicians and patients as a key argument for expanding the role of primary care clinicians in screening for early disease detection, managing chronic diseases, and coordinating care among all those involved in providing patient services. The American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommends patient education, anticipatory guidance, and early intervention strategies to reduce adolescent patients' use of alcohol and other drugs
(Elster and Kuznets, 1994). Likewise, the American Academy of Pediatrics advises pediatricians to include anticipatory guidance on substance abuse to all children and adolescents.
In support of these recommendations, universities are implementing medical and nursing school curriculum modules while specialty organizations, including the National Nurses' Society on Addictions, the American Society of Addiction Medicine, the Association for Medical Education and Research on Substance Abuse, the American Association of Obstetricians and Gynecologists, and the Drug and Alcohol Nurses Association, are promoting faculty development and the development of core competencies and practice standards for intervening with and treating substance abuse problems.
In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol- or other drug-related service. Basic skills in identifying and diagnosing patients who are chemically dependent will become essential. Clinicians in areas with limited substance abuse resources may be responsible for assessments, while those trained in addiction medicine may be providing a range of treatment services. Regardless of how extensively involved clinicians become, those who are familiar with the medical complications of substance abuse and are able to relate them to other comorbid illnesses will be better equipped to deliver adequate care.
Since more Americans abuse alcohol than illicit drugs, primary care clinicians will encounter substantially more patients with alcohol problems than with drug problems (although many patients who abuse alcohol also abuse illicit drugs or prescription drugs and vice versa). Though most people who consume alcoholic beverages do not experience problems related to their use, primary care clinicians can expect that 15 to 20 percent of their male patients and 5 to 10 percent of their female patients will be at risk for or already are experiencing related medical, legal, or psychosocial problems. These problems include unresponsive diabetes, arrests for "driving under the influence," problems with job or school, or family or marital difficulties.
Figure 1-1 presents the current prevalence of alcohol use and problems in primary care settings for patients over the age of 18
(Manwell et al., in press).
The nature and intensity of alcohol-related problems vary according to consumption: Above two to three drinks a day, there is a clear dose-response curve. The higher the levels of consumption, the greater the risk of negative health effects including cirrhosis, cancer, heart disease, stroke, traumatic injury, and depression. For this reason, the National Institute on Alcohol Abuse and Alcoholism recommends that patients who currently drink adhere to the following:
It is important for primary care clinicians to know patients' drinking levels in order to gauge their potential risk for developing problems. Levels also can be discussed with patients in the context of general health problems where they provide a nonstigmatizing opportunity to share valuable risk reduction information
For example, just as a clinician may point out to patients with blood pressure higher than 140/90 that they are at risk for cardiovascular problems secondary to hypertension, people who consume more than two drinks per day should be told that they are at risk for heart and liver disease. When presented this way, information about levels may help motivate nonproblem drinkers and abstainers to maintain healthy habits, while offering those at risk for problems an incentive to reduce the amount of alcohol they consume.
To determine a patient's risk level, however, the clinician must consider more than consumption levels. Definitions of low-risk and at-risk use are based on the relationship between a given quantity of alcohol used and a number of health effects. Recognizing at-risk drinkers in particular can be difficult. Researchers have investigated indicators other than consumption levels in an effort to determine other risk factors.
Low-risk drinkers consume less than an average of one to two drinks per day, do not drink more than three to four drinks per occasion, and do not drink in high-risk situations (e.g., while pregnant, driving a car, or taking medication that interacts with alcohol). At-risk drinkers occasionally exceed recommended guidelines for use. While they are at risk for such alcohol-related problems as burns, motor vehicle crashes, or falls because of their drinking habits, at-risk drinkers may never experience negative consequences as a result of their alcohol use and represent a prime target for preventive, educational efforts by primary care clinicians. A number of environmental, interpersonal, psychobehavioral, and biogenetic risk factors (e.g., social norms conducive to use, family and marital conflict, early onset of use, and inherited susceptibility) have been identified and are summarized in Figure 1-2(Hawkins et al., 1985;Kandel et al., 1986;Newcomb and Bentler, 1988;Heath et al., 1989; *Brook and Brook, 1990; Landry et al., 1991a;Landry, 1994).
The American Psychiatric Association's DSM-IV classifies mental disorders (including substance-related disorders) to help clinicians make useful diagnoses and to guide scientists' research. Although this approach works best when there are clear boundaries between types of disorders, categories within disorders cited in the DSM-IV are not necessarily discrete or static. Moreover, all individuals suffering from the same disorder are not necessarily alike (American Psychiatric Association, 1995). When the DSM-IV refers to such diagnostic levels as substance abuse and dependence, it views them as points on a continuum on which patients' use may vary. The DSM-IV's dependence is roughly equal to the term alcoholic, and abuse is synonymous with problem drinkers. The latter is seen more than the former in primary care
(Kahan et al., 1995). These nondependent but problematic drinkers account for the "majority of alcohol-related morbidity and mortality in the general population"
(U.S. Preventive Services Task Force, 1996, p. 567;Institute of Medicine, 1990).
As a group, problem drinkers experience a range of alcohol-related problems from a "driving under the influence" citation to loss of job or family disruption. It is important for clinicians to understand, however, that problem drinkers, unlike alcoholics, often respond to clinician counseling and brief intervention efforts (see Chapter 3) and do not always require a referral to specialized treatment.
Alcoholic or dependent drinkers meet at least three of the seven DSM-IV criteria for substance dependence: drinking more than intended; wanting to stop drinking; spending a great deal of time procuring alcohol; giving up social or occupational activities because of alcohol; drinking despite the physical or psychological problems it causes; and, in some cases, experiencing physical dependence as manifested by tolerance to alcohol's effects and withdrawal symptoms.
Figure 1-3 illustrates the relationship between level and frequency of use and the development of alcohol problems
(Skinner, 1992).
Since unauthorized drug use is illegal, patients who use illicit drugs are considered drug abusers. While primary care clinicians can discuss approaches for reducing the amount of alcohol consumed as an acceptable goal with patients who are problem drinkers, such approaches will collide with the law if the substance being abused is illegal. For illicit drug abusers, abstinence is the ultimate goal. However, the primary care clinician should recognize that quitting "cold turkey" may initially be untenable for some drug abusers and should encourage any steps the patient makes in that direction.
In 1995, 6.1 percent of Americans age 12 and older had used an illicit drug in the previous month (Substance Abuse and Mental Health Services Administration, 1996b).
Figure 1-4 shows the percentages for specific drugs.
Since 1991, there has been a continuing rise in marijuana use among adolescents. Nearly 1 in 20 (4.9 percent) of high school seniors uses marijuana daily, while young people's disapproval of marijuana continues to decline
(Johnston et al., 1996). Although the crack cocaine epidemic appears to be stabilizing, an estimated 1.4 million Americans are current cocaine users, with rates of use highest among 18- to 25-year-olds
(Substance Abuse and Mental Health Services Administration, 1996b). Reports from medical examiners, hospital emergency departments, treatment programs, and others who participate in the National Institute of Drug Abuse Community Epidemiology Work Group indicate that a small but growing number of young people are using heroin. Crack users increasingly are combining crack with heroin, and older intravenous drug users are shifting to intranasal use
(Community Epidemiology Work Group, 1996).
Over-the-counter and prescription drugs also are abused. An estimated 2 million adults age 65 and older, for example, are addicted to or are at risk of addiction to sleeping medications or tranquilizers
(Hanley-Hazelden Center, 1991;Chastain, 1992). Health care professionals are especially at risk for prescription drug abuse
(Sullivan et al., 1990).
Like alcohol-related problems, drug abuse problems also occur along a continuum from nondependent use to addiction. Knowing where patients are along this continuum is as important for effective intervention with drug abusers as it is for alcoholics.
Substance use disorders share many characteristics with other chronic medical conditions like hypertension. Among the similarities between the two are late onset of symptoms, unpredictable course, complex etiologies, behaviorally oriented treatment, and favorable prognosis for recovery
(Fleming and Barry, 1992).
Clinical problems related to substance abuse develop slowly and may remain undetected for a long time unless a traumatic injury, problem in the workplace, confrontation with the police, or other serious event calls attention to it before physical symptoms become apparent. As with hypertension, routine screening for substance abuse is necessary to identify problems in the early stages of development.
At this time, it is difficult to predict with any certainty which subset of heavy drinkers and drug users will develop serious substance abuse problems. Further, it is not possible to predict whose problems are situational and transient and whose will remain chronic and progressive. Therefore, it is important to monitor each patient's status regularly, just as clinicians do for hypertension.
The interplay between genetic familial predisposition and lifestyle influences the development of substance abuse disorders just as it influences hypertension
(Gordis and Allen, 1994;McGue, 1994;Landry, 1994). Many now believe that individuals may inherit a genetic susceptibility to substance abuse that may be fueled or quelled by a combination of family and social norms (parental use of drugs, community or peer acceptance or rejection of drug use, or equation of heavy drinking with masculinity), traumatic events (death of a loved one, divorce, childhood physical or sexual abuse, or war), pharmacodynamic effects (affinity for developing tolerance or withdrawal or positive reinforcing qualities of the drug used), or environmental factors (poverty or easy availability of drugs)
(Collins, 1986; Yokel, 1987;Koob and Bloom, 1988;Gardner, 1992;Johnson and Muffler, 1992). At the same time, people without inherited susceptibility may develop problems as a response to external stresses or internal discomfort if they continue using alcohol or other drugs over time. Individual patients, for example, may use alcohol and other drugs to ameliorate or "self-medicate" psychiatric symptoms or to titrate medications
(Landry et al., 1991a;Meyer, 1986).
Like treatment for hypertension, behaviorally oriented substance abuse treatment requires the patient to assume primary responsibility for making difficult behavioral changes. As with any chronic condition that depends on behavioral change to improve outcome, a patient will first have to accept that he or she has a problem. Compliance with treatment is ongoing and may be difficult.
Behaviorally oriented treatment includes a number of cognitive and behavioral approaches that help patients recognize and change maladaptive behaviors, develop new or enhanced social skills that will promote and sustain recovery, and learn techniques for responding to cravings without relapsing. Motivational enhancement therapy, cognitive behavioral therapy, contingency contracting (e.g., use of positive rewards and negative consequences such as the threat of job loss to promote recovery), and cue exposure treatment are designed to promote resistance to those triggers or cues that prompt use and are among the most common behavioral therapies
(American Psychiatric Association, 1995).
Despite these problems, however, many substance abuse patients -- like patients with diabetes, elevated cholesterol, and hypertension -- do respond to clinician recommendations and modify their behavior. The rate of 20 percent of problem drinkers (those meeting the DSM-IV criteria for alcohol abuse) who successfully reduce their drinking compares favorably with the prognosis rates of many chronic health conditions primary care providers routinely address
(Kahan et al., 1995).
Data contradict the widespread belief that substance abuse treatment does not work. When treatment is available, there have been documented reductions in use, hospitalizations, medical costs and sick time, family problems, and criminal activity as well as increases in employment, job retention, income, and improvements in an array of other health indicators. For example, the National Treatment Improvement Evaluation Study (NTIES) completed in 1996 reports that clients served by federally funded substance abuse treatment programs were able to cut their drug use in half for up to 1 year after leaving treatment
(Center for Substance Abuse Treatment, 1996). A study commissioned by the Oregon Office of Alcohol and Drug Abuse Programs concluded that for every dollar spent on substance abuse treatment, taxpayers saved $5.60
(Finigan, 1996).
As with other chronic conditions, the efficacy of substance abuse treatment is helped tremendously when family and friends support patients' efforts to change their behavior, patients themselves are ready to make significant lifestyle changes, and the effects of co-occurring disorders are minimized
(Institute of Medicine, 1990;National Institute on Alcohol Abuse and Alcoholism, 1993).
When the Center for Substance Abuse Treatment convened its Consensus Panel of experts on primary care, its goal was to devise a practical approach to addressing patient substance abuse problems, one that recognized the time and resource limitations inherent in primary care practice and offered approaches that could be implemented in a stepwise fashion without disrupting normal clinic or office routine. This Treatment Improvement Protocol A Guide to Substance Abuse Services for Primary Care Clinicians describes a series of graduated approaches for responding to the substance abuse problems typically encountered by primary care clinicians.
Chapter 2, Screening for Substance Use Disorders, provides specific dialogue and recommends particular instruments for uncovering substance use disorders. The chapter also explains how to tailor screening to special populations, how to document screening, and how to discuss a positive screen with a patient.
Chapter 3, Brief Intervention, details how to perform this office-based pretreatment or prevention technique and which patients are most likely to benefit. Chapter 4, Assessment, presents the elements of an in-depth assessment, ideally performed by an addiction specialist. Chapter 5, Specialized Substance Abuse Treatment Programs, summarizes the referral process and the various forms of specialized treatment available.
Chapter 6 suggests methods for implementing change and summarizes the Consensus Panel's recommendations.
Appendix A, Pharmacotherapy, written by a leading detoxification expert, explains how to administer pharmacotherapy to aid withdrawal and to prevent relapse.
Appendix B, Legal and Ethical Issues, outlines those issues and the laws governing them concerning privacy and confidentiality for substance-abusing patients.
Appendix C reproduces selected screening and assessment instruments, and
Appendix D provides ordering information on pamphlets and brochures about substance abuse that clinicians can give to patients.
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