Right Time and Place: Substance Use Discussions and Primary Care

Big solutions depend on asking the right questions. Treatment for substance use problems languishes due to poor funding, enduring stigma and the delivery of care in an isolated silo. Our approach to care is stuck because we are asking the wrong questions. One question overshadows all others because it is repeatedly asked by consumers: Where should a loved one go for treatment?

Addiction is often well advanced by then, and this question is fostered by a realization that the quality of addiction care varies greatly. The industry remains focused on improving services within its existing silo. Yet the best questions tend to challenge the status quo. Tom McClellan’s question about the chronicity of addiction is an example. He exposed the absurdity of an acute illness model for addiction.

Chronicity highlights the need for continued care, well beyond the initial, intensive treatment focus. Yet we must move beyond a focus on diagnosable disorders and on the long-term needs of people with chronic conditions. We must also focus on the endless stream of hazardous drinkers and early-stage compulsive users. This is commonly framed as a detection problem.

Those stressing detection emphasize the need for Screening and Brief Intervention (SBI) protocols and brief assessment tools like the CAGE. These efforts are well-intentioned but odd in practice. This approach to detecting problematic use resembles an awkward approach to dating. Questions are abruptly posed with little context or personal connection. It is more off-putting than engaging.

Screening may be less jarring in a questionnaire format, but the process remains an impersonal clinical assessment. Screening is neither therapeutic nor likely to put a person at ease to open a conversation. It is based on a misunderstanding. We do not have a detection problem, but instead a conversation problem. Who is participating in it? Can the key issues be explored in depth?

People cannot easily navigate siloed care. Those with severe problems are more likely to end up in jails than treatment centers. So where should the conversation start? We must start with primary care, but not as we know it today. Screening solutions like SBI are accommodations to a dysfunctional status quo where PCPs are overly burdened and ill at ease with topics like addiction. They need our help.

Behavioral health problems should become one of the top areas of focus for primary care. Why? They are pervasive, impair functioning at subclinical levels, complicate medical disorders, and cause more disability than other diagnostic groups. PCPs are good communicators, but they are not therapists. Until therapists are incorporated into primary care, behavioral health problems will grow unchecked.

We must make the status quo seem peculiar, like the absurdity of viewing addiction as an acute problem. Let us imagine a day when advancing to later stages of addiction is the exception, not the norm. We must hasten the time when people are amazed that waiting to “hit bottom” was once a serious plan. This will not be easy. A new and better approach rests on integrating separate fields.

The integration with primary care imagined here is comprehensive. It involves transforming primary care, not inserting a few therapists into it. The justification for that transformation is the same whether the clinical issue is depression, obesity or addiction. Primary care is reimagined and restructured as a setting with therapeutic alliances, empathic listening, and behavior change methods in wide use.

Let us return to the conversation problem. PCPs could improve their comfort and skill talking with people, but they have no desire to become therapists. Yet patients need primary care to be grounded in more of a therapeutic culture, and therapists should be readily available for brief discussions. A variety of behavioral health issues should be talked about routinely and casually.

A casual discussion evolves over time. It might start with the fun of social drinking, then move to a focus on occasional misuse, and finally to a series of red flags that need exploration. This is a conversation, not a detection protocol or a diagnostic interview. It guides people with interventions that just seem like talking. Primary care builds extended relationships. It allows for monitoring over time.

Our current healthcare system waits for addiction to be like late-stage cancer before intervening. Let us help people get on a better path while more of their social and economic resources are intact. Growing the number of specialty outpatient programs is not the best solution. People will still resist crossing that threshold. The nature of addiction contributes to this reluctance, not just our healthcare system.

When primary care was taking shape in the 1960s, psychotherapy was new and limited in its focus. Decades of evidence now supports therapy as a broadly effective healthcare service. There are many reasons for reconstituting primary care with behavioral health as a key dimension, and addiction is one. A new primary care experience is a big solution. It requires more people asking the right questions.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.