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Autumn 2007 | Vol 11 No 1

Focus

Sharing addiction care

Primary care settings move to the forefront of treatment

By Kim Goggins

Within the Addiction Shared Care (ASC) Service at St. Joseph’s Health Centre in Toronto, addiction clinician Robyn Little takes the time to learn about each of her clients’ struggles with alcohol and other drugs. Although the stories are different, what these clients have in common is the involvement of their family physician in their addiction treatment and the attention of a collaborative team of health care professionals.

Meanwhile, in Hamilton, Ontario, a substance use counsellor visits the Rosedale Family Medical Group as part of a pilot project that started in autumn 2006 to educate family physicians, dieticians, mental health counsellors, nurses and nurse practitioners on how to implement screening to target clients who have substance use problems while still in the early stages.

Elsewhere in Canada, physicians are brought into alcohol and drug programs outside of Whitehorse in the Yukon to provide basic medical services for clients with severe substance use issues who have no family doctor. Unlike its sister initiative in the Central Okanagan area of the Interior Health Region in British Columbia, where drug and alcohol counsellors meet with clients in family practice settings, many of these doctors in rural areas of the Yukon provide medical care where clients are treated for their substance use problems.

These moves reflect the emerging concept of collaborative addiction care, which involves primary care providers such as doctors, nurses and nurse practitioners who are supported by addiction and other health care professionals. The few programs available are as varied as the populations and needs of individual communities. Whatever form the collaboration takes, the key piece to this “wrap-around care,” as Little describes it, is the training and ongoing support of primary care providers to provide screening, intervention and client-centred treatment.

“Traditionally, addiction treatment has been quite separate from the health care system,” says Dr. Meldon Kahan, medical director of the Addiction Medicine Program at St. Joseph’s Health Centre. “They’re funded separately, they have different procedures for admission, they’re on different sites, and they don’t really talk to each other,” he says. “But this system makes no sense because patients with addiction problems go to their family doctor first. Or they go to the emergency department. Many patients will not go to a formal addiction treatment system, and even if they did, the system does not have enough resources.”

According to a recent cohort study based on the ASC service, where Kahan is the director and one of seven physicians, of the 1,084 Ontarians who participated in a population survey, only 36 per cent with a history of alcohol dependence had sought help for their condition. Of those, 30 per cent sought their physician’s help and only seven per cent accessed a formal substance use program.

But although primary care providers may be the first point of contact for people with substance use issues, many are reluctant to address addiction issues because they feel ill-equipped to do so. In a survey published in 2000 by the Ontario College of Family Physicians, 65 per cent of family doctors reported that it was “often to always difficult” to diagnose and treat clients with addiction issues. Given this situation, integrating primary care providers like family physicians into addiction care makes sense.

That’s the driving force behind the ASC. Once clients are referred to the service by their physician, an appointment is made to see Little, who meets with the client within three weeks for a comprehensive assessment. The client then sees an addiction medicine doctor within two weeks for further assessment. “Consult summaries are based on all of this information and sent to the family physician,” says Little, who has been with the program since it launched in 2005. “Treatment plans may include pharmacotherapy or ongoing counselling, based on individual need. If there are additional referrals, we’ll include them in the summary.”

As with the ASC service, providing support and education to primary care providers is a key component of the Increasing Substance Use Focus in Primary Care pilot project in Hamilton. One of its main goals is to help Family Health Teams (FHT), which bring together different health care professionals to support primary care providers (click here for more about FHTs), detect and treat the 18 to 20 per cent of clients who drink over the recommended low-risk drinking guidelines before the problem becomes chronic.

“This group costs a lot in terms of social, medical and family consequences,” says the program’s substance use co-ordinator, Carol Melnick. “Our pilot project is targeting that group, not just the group with alcohol dependency. They’re easier to access in a doctor’s office because they often don’t self-identify as having alcohol-related problems so they probably won’t go to an addiction agency.”

Since autumn 2006, the Rosedale Family Medical Group has participated in the pilot, and initial work has begun with two other other medical practices that are part of the Hamilton FHT. Melnick recruits a lead physician, who will take on more responsibility within the group of physicians, and brings together a multidisciplinary team to form a steering committee that meets regularly to discuss the needs of the primary care providers and their clients.

Routine screening at annual physicals and when flags are raised are conducted by the primary care providers. The brief intervention screening – a series of questions that can take anywhere from two to 10 minutes – determines whether further involvement is needed. A substance use counsellor with a background in concurrent disorders also works part-time in the practice to answer doctors’ questions and assist with more serious addiction cases.

“We ask primary care providers to calculate the weekly number of drinks and to then ask their patients questions around alcohol abuse and dependency,” explains Melnick. “Depending on where the clients fall in that continuum, the primary care provider will provide feedback, invite a response, offer psycho-educational material and follow up with that.”

On the other side of the country is the BC/Yukon Collaborative Care Initiative (BCYCCI), launched in 2001 to improve the effectiveness and accessibility of primary health care for clients with concurrent disorders by enhancing co-operation among the health care providers who treat them.

The BCYCCI has implemented a system change process that works to improve links and working relationships among mental health, alcohol and drug and primary health care services in the Central Okanagan area of the Interior Health Region and in the Yukon Territory. While services in both areas focus on providing client-centred care in a collaborative model, the programs are unique to the different needs of the two areas.

“In Central Okanagan, key components of the model are the ongoing deployment of clinicians from addiction services into family practice settings,” says Dr. Julian Somers, director of the Centre for Applied Research in Mental Health and Addiction, BC/Yukon. “Services are intervening with a much larger number of individuals when they’re practising in that setting than they would when they’re in their offices back at alcohol and drug services,” he says.

In the Yukon, alcohol and drug services became the hub sites for the collaborative work because people would be brought in for withdrawal management or other kinds of acute services, but many of those clients had no other health care. To fill this need, a collaborative model was developed where general family practitioners visit the substance use treatment centres on an ongoing basis to work with clients, particularly those without a family physician.

Studies and collaborative care initiatives have found that most clients prefer to talk about their problem with their family doctor if he or she is interested or able to help them. “Partly, it’s because walking through the door of an addiction clinic is like admitting to an addiction, which carries a lot of stigma, as opposed to just expressing a problem to the family doctor where there’s no stigma,” explains Kahan. “It’s also easier to talk to a family doctor than it is to get into an addiction program. And there aren’t the long assessments and having to confide in strangers.”

Clients are also more likely to keep appointments and be more engaged throughout the process because they know their health care professionals are working together, says Little.

The ASC service is also seeing positive changes among physicians. “Community physicians who at one time were reluctant to address addiction issues at all are now very involved,” says Little. “They’re much more willing to acknowledge addiction within their own patients. They’re asking the right questions, and when they flag an issue, they have more confidence and understanding dealing with the issue and aren’t afraid to refer to us, knowing they’ll get support.”

This collaborative effort between primary care and addiction services is the wave of the future, says Kahan. “The tools that have been developed work,” he says. “The Centre for Addiction and Mental Health here in Toronto has had a big role over the years in developing simple clinical protocols for treating withdrawal and for brief advice interventions. Now it’s a matter of getting them to the people who can deliver them. With the revolution in primary care that has happened, especially in Ontario with family health teams, it’s a good time to help primary care clinics get up to date on addiction.”