Primary Care Moves Patients With Addiction to Self-Advocacy 

Alexandra Frost

November 16, 2022

Samuel Werner, DO, a family medicine physician in West Hartford, Connecticut, vividly remembers one patient who was struggling with a drug addiction. 

The man was having trouble holding down a steady job because of his dependence, but with Werner's guidance, he started on buprenorphine. Werner also connected him with a social worker to address housing insecurity.  

"Working together, not only was he no longer using his street drugs, but also he was able to actually develop some financial stability, to support his family," Werner, the medical director of private practice Family Osteopathy, told Medscape Medical News. "It's really amazing to be able to be a part of that transition, because you're changing not only that particular individual's life, but also every single person that is around them that might be relying on them."

Werner's approach to patients with substance abuse disorders should be more widespread, according to the results of a new study published online November 10 in JAMA Network Open.

The findings demonstrated that when people with substance abuse disorders receive training on how to engage with their doctors, they better manage their health. 

"It can be hard to focus on physical health on top of all the other challenges involved in recovery," said the study's lead author Esti Iturralde, PhD, a clinical psychologist and research scientist at the Kaiser Permanente Division of Research in Oakland, California. "Taking care of health is so important for these patients because a health setback can jeopardize their recovery, and they are already at heightened risk for chronic health conditions." 

For the study, Iturralde and colleagues assigned 252 men and women to a 3-month treatment program called LINKAGE. Patients received training on patient-clinician communication strategies, electronic patient portal navigation skills, and development of recovery- and health-related goals, with help on calling or emailing their primary care clinician to discuss their goals.

Another 251 participants received standard substance abuse programming, which included group psychotherapy, individual counseling, 12-step meetings, and routine screening for alcohol and drug use. 

The researchers followed each participant for 5 years after treatment between 2011 and 2018 from the study site, an urban, outpatient addiction treatment clinic. 

Participants in the LINKAGE program were 30% more likely to talk about substance abuse problems with their primary care providers (risk ratio [RR], 1.30; 95% CI, 1.03 - 1.65; P = .03) and 75% more likely to refill their medication online (95% CI, 1.49 - 2.06; P = .001) at the 1-year follow-up than were those who received only substance abuse programming. 

They also were 34% more likely to have sent a message to one of their health care providers (95% CI, 1.15 - 1.57 P < .001) and 34% more likely to have logged on to their patient portal (95% CI, 1.20 - 1.50 P < .001). 

Emergency department visits related to substance use also decreased by 21% per year compared with the control group (RR, 0.79; 95% CI, 0.64 -0.97; P = .03), according to the researchers. 

"We were surprised by the robust long-term effect on ER use," Iturralde said. "This is an important outcome both for patients, who it seems are not needing this high level of care, and for health systems, as ER care is a very costly drain on resources."

The improvements in outcomes in the LINKAGE group, however, were no longer statistically significant after 3 years.

Because some effects waned over time, Iturralde said a "booster" intervention may help maintain the benefits. 

"We are currently studying widespread implementation of the program and will be evaluating if wider availability of LINKAGE is associated with desirable long-term changes in healthcare use and health outcomes," Iturralde said. 

Taking Care of Overall Health Alongside Addiction

People struggling with addiction might not address other health conditions while they deal with their drug abuse. And sometimes, addiction itself leads to health issues. 

But with the involvement of primary care clinicians, patients might catch up on screenings for breast or cervical cancer, or better manage high blood pressure or diabetes, according to Deanna Wilson, MD, MPH, an internist and assistant professor at the University of Pittsburgh School of Medicine.

Primary care physicians also can help their patients connect with a social worker to address issues like housing insecurity, and referrals to a psychiatrist or pain management specialists. This coordinated approach can help patients address the root causes of their addiction, according to Wilson. 

"Until that reason is addressed, they're always going to be equally as tempted, to have a strong reason to use," she said. 

Werner and Wilson both note that primary care physicians have an opportunity to reduce the stigma of addiction. 

"I always tell patients, 'I'm not here to be a law enforcement officer and I'm not your father,' " Werner said. "I'm here to help you get from this stage of where you are on your health journey to the next." 

The study was supported by the National Institute on Drug Abuse. Co-author Constance Weisner, DrPH, LCSW, was the principal investigator of the LINKAGE study and received those funds from the center grant. Iturralde is supported by grant K23 MH126078. Co-author Derek Satre, PhD, is supported by grant K24AA025703 from the National Institute on Alcohol Abuse and Alcoholism.

Co-author Cynthia Campbell, PhD, reports receiving grants from PMR Consortium, a group of companies working together to conduct postmarketing studies required by the US Food and Drug Administration that assess risks related to opioid analgesic use, outside the submitted work. Iturralde and the other authors report no relevant financial relationships.

JAMA Netw Open. Published online November 10, 2022. Full Text 

Alexandra Frost is a Cincinnati-based freelance journalist.

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