Does addiction behave like diabetes? In some ways, yes. The two are common, acquired conditions influenced by genetics and environment. In the UK, diabetes is managed in primary care using the chronic care management model. Changes in legislation in the USA mean that there will be more focus on chronic disease management in the future. Thomas McLellan and colleagues suggest that, because addiction does behave quite like diabetes, primary care is the ideal place to manage substance use disorders using similar techniques. The authors point out that substance use disorders (SUDs) produce:
Generally poor adherence to medications; poor control of hypertension and diabetes; increased risk for a host of cancers and medical illnesses; and decreased effectiveness of treatments for chronic pain. More severe and chronic addictions exact a high toll in preventable death.
Despite the same medical consequences from addiction here it’s clear that the UK and the US are quite different when it comes to healthcare provision. We have a much more developed primary care model with a long history of evidence-based management of chronic health conditions. The GP contract is built on this.
What do the authors mean by the ‘chronic care model’ (CCM) and how does it stack up with what we do on this side of the pond? Six components are identified:
- Changing from acute and reactive care to preventative, continuing and patient-oriented practice. You need interdisciplinary teams do this and a shared health record. Interventions would vary from alcohol brief interventions (already widely happening in Scotland) to prescriptions of anti-craving medications or ORT through to referral for more intense treatment, but with good communication with the treatment agency and an aftercare component on discharge provided in primary care. Arguably happens here.
- Improving healthcare organisation support through investment in teams, information systems and outcome monitoring. An economic case needs to be built. Again, I think we are doing this.
- Expert-informed decision support for providers, given through training, facilitated expert consultation, standardised assessment tools and evidence-based treatment guidelines and algorithms. Again, this happens in many places.
- Improved clinical information systems. GPs here have good electronic record systems. They need to talk better to secondary care.
- Fostering patient self management. This is well developed in diabetes here at least in concept, but I would say poorly developed in addictions. The authors say: As is true in diabetes management, research on the management of SUDs has shown little behavioral change from simple disease education and even less from scolding or confrontation. Instead, clinical techniques such as Motivational Interviewing—an empathic, respectful, collaborative approach to promoting behavior change—has reliably produced significant and long lasting reductions in substance use and related unhealthy behaviors
- Linking people to community resources. Now we are talking. This is the ‘quick hit’ and an evidence-based way to help folk move on to the next stage of their recovery. The authors describe this as ‘a critical component of managing SUDs…Among the easiest to arrange and most effective community services a primary care team can provide to patients with any type of substance use problem is linkage to free, easily accessible sober social networks such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or SMART Recovery. Research shows that participation in these peer-support activities is associated with decreased substance use, enhanced psychosocial adjustment, and lower health care costs.
McLellan and colleagues come to three conclusions in their paper:
- It’s possible, practical and worthwhile to manage SUDs in primary care.
- The chronic care model is likely to be an appropriate way to do it
- That we can learn directly from diabetes models of care
My own take is that in the UK, we are way ahead of the game on this one which was nice to see. The three recommendations that follow in the paper are pretty much in place here. We already have multidisciplinary care teams in general practice, screening of primary care populations for alcohol use disorders is the norm and we have good examples of ‘shared care’ models or extra support from specialist teams (like the Primary Care Facilitation Team here in Lothian). It’s odd that the researchers don’t look outside of the USA for evidence of where this kind of practice has been going on for some time. We might have been able to teach our American friends something!
What we are still working on in primary care settings in Scotland is moving towards a recovery-orientation for those on opioid replacement therapy. GPs are not experts in abstinence-oriented approaches. They are the biggest providers of ORT, know the social circumstances and families of their patients and are ideally placed to make the links to community recovery resources. Although GPs and their teams are potentially great agents to catalyse change for recovery and while they are already doing almost everything that is recommended in this paper, we are still looking for evidence that they are grasping the importance of the practice of assertive referral to recovery communities.
A. Thomas McLellan, Joanna L. Starrels, MD, MS, Betty Tai, PhD, Adam J. Gordon, MD, MPH, Richard Brown, MD, MPH, Udi Ghitza, PhD, Marc Gourevitch, MD, Jack Stein, PhD, Marla Oros, RN, MS, Terry Horton, MD, Robert Lindblad, MD, & Jennifer McNeely, MD, MS (2014). Can Substance Use Disorders be Managed Using the Chronic Care Model? Review and Recommendations from a NIDA Consensus Group Public Health Reviews, 34