By Joji Suzuki, M.D.
As a fellow in Harvard Medical School Center for Primary Care's Innovation Fellows Program, Suzuki is implementing a collaborative model of care through which a team of clinicians will work with primary care physicians to treat opioid addiction.
Opioids, found in prescription pain medications like oxycodone or morphine, are extremely important in helping to alleviate pain and suffering. They are dangerous, however, if misused. Once addicted, users find it extremely difficult to stop due to the intense cravings and withdrawal. Also found in heroin, opioids are very expensive, costing as much as $100 to $200 a day for a moderate habit, and even more for heavier users. Many users resort to stealing, dealing, or prostitution to support their addiction. Particularly for users who transition to intravenous use, health problems also begin to accumulate, such as HIV, hepatitis C, abscesses, heart problems, overdoses and death. In Massachusetts, opioid-related overdose deaths were the leading cause of injury deaths in 2007 and the third leading cause of death overall behind heart disease and cancer. As can be imagined, someone living this life will have difficulty maintaining employment, raising a family, and contributing to society.
As an addiction psychiatrist, I have seen how addiction can wreak havoc not only on patients’ lives, but also on the lives of members of their family and community. Adding insult to injury, though many chronic conditions – such as HIV, cancer, obesity, diabetes and hypertension – result in part from personal lifestyle choices, patients dealing with addiction, as well as their families, face particular stigma for their circumstances.
The good news is that effective treatments are available for opioid addiction. A medication called buprenorphine can be used to suppress withdrawal and cravings, allowing patients to begin rebuilding their shattered lives. Patients usually require more than just a prescription, however, so the medication is used in conjunction with an array of psychosocial treatments.
The bad news is that in any given year, only about 10% of patients with addiction receive any kind of formal treatment. And we simply wouldn’t have enough facilities to handle the other 90% of patients who don’t or can’t access care. Furthermore, though addiction, like many other mental health issues, often coincides with one or more other chronic conditions, addiction treatment has always been offered outside of primary care.
In the past, perhaps it made sense to keep them separate, but that is no longer the case.
Indeed, the separation of psychiatry from primary care is frustrating to clinicians and patients alike. It decreases quality of care, drives up costs, further stigmatizes patients and further taxes the limited treatment resources available.
Asking primary care physicians to take on more work, however, is not practical or realistic. They work long hours, must have a good fund of knowledge and excellent interpersonal skills, and be able to effectively lead a team of clinicians. With this in mind, a goal of mine has been to provide my primary care colleagues with the clinical support they need to feel comfortable treating opioid addiction.
This led me to propose the project now being funded by the Harvard Medical School Center for Primary Care’s Innovation Fellows Program. As an Innovation Fellow, I am implementing a collaborative model of care through which a team of clinicians will work together with primary care physicians to treat opioid addiction with buprenorphine. Working on the team with me are a clinical pharmacist with expertise in pain management, an addiction social worker, and medical and undergraduate students. We track patients proactively through a patient registry and meet weekly to discuss them. We keep the primary care physicians informed of patient progress, and we facilitate patient referral to services such as psychiatric treatment for depression. All treatment is conducted at or very close to the primary care clinic. Only when absolutely necessary do we refer patients to outside addiction treatment.
This collaborative care model has been used to successfully treat other illnesses, such as depression, in the primary care setting. Using it for addiction is still in its infancy however.
The goals of this pilot project are two-fold. First, we want to see if this program will help primary care physicians feel more confident treating opioid addiction in the clinic. Second, we want to see if this model will indeed improve patient outcomes.
Several undergraduate and medical students play two critical functions in the project. They create and maintain the patient registry, and act as health coaches. Maintaining a patient registry is a time-consuming effort that requires a lot of attention to detail. However, the registry allows us to easily identify patients who need closer monitoring. Over time, the students will learn how to effectively interact with patients to promote behavior change, and they will learn to conduct telephone coaching with patients who need extra support. The goal is for students to become proficient in the use of motivational interviewing, an evidenced-based approach to helping patients improve their lives.
The students have already demonstrated that they are invaluable for this project to succeed. A student calling a patient who had recently been initiated on buprenorphine uncovered that the patient was incorrectly administering his medication. This significant finding prevented the team from assuming the medication was not effective or that the dose was too low. By remaining in close contact with patients, students are able to contribute in a very meaningful way. I am very grateful for their contribution.
This is just one way new models can bridge the divide between psychiatry and primary care. I suspect we will be seeing others as a growing chorus is calling for the re-examination of psychiatry’s relationship to primary care. In fact, this was the theme of this year’s annual meeting of the American Psychiatric Association: “Integrated Care—Psychiatrists working collaboratively with primary care physicians and other allied health professionals to coordinate patient care.”
It’s wonderful that the psychiatric profession is seriously re-thinking how partnering with primary care can improve the care of patients with mental illness and addiction. This integration is an important component of reforming our primary care system. Business as usual is no longer a viable option, and I am thrilled that more and more psychiatrists are choosing to work alongside our primary care colleagues.
Joji Suzuki, M.D., is an addiction and consultation-liaison psychiatrist at Brigham and Women's Hospital. His clinical focus is on the treatment of substance use disorders in medical settings. He is committed to improving the care of patients with substance-related issues.