People struggling with addiction to opioids, alcohol, or other substances are among the highest-cost users of health services, including longer and more frequent hospitalizations. Yet most of these individuals don’t receive treatment for their addiction. It can be hard to engage them, and there are severe shortages of specialty treatment centers across the nation. In this issue, we showcase approaches to increasing access to addiction treatment by integrating it into primary care settings.
By Martha Hostetter and Sarah Klein
The steady drumbeat of deaths from drug overdoses — akin to two Hurricane Harveys every day — has drawn attention to the perils of untreated addiction and exposed troubling gaps in our nation’s capacity to treat opioid and other substance use disorders.1 The problem is most pronounced in rural communities, which often lack sufficient population density to support specialized addiction treatment centers and general clinicians who are trained and willing to treat addiction. In many parts of the country, people must travel long distances to seek treatment, join waiting lists for cash-only clinics, or go without.
There are challenges to accessing addiction treatment in other communities as well: nationwide, there are only about 3,600 physicians who are board-certified in addiction medicine (and of these, most are practicing part-time).2 Just over 4 percent of physicians in the U.S. have gone through the training process that enables them to prescribe buprenorphine, one of the few forms of medication-assisted treatment for opioid use disorder available outside of methadone clinics.3 (A 2016 law enabling nurse practitioners and physician assistants to prescribe buprenorphine may help take up some of the slack.4)
The national epidemic of untreated addiction places a heavy burden on emergency departments and first responders who treat people who have overdosed. But it’s also having an impact on the health system more broadly, as addiction makes it harder to treat other health conditions, increases acute-care use, and drives up medical costs.5 The expenses do not include the costs of incarceration, foster care, and other public services linked to untreated addiction, nor do they take into account the costs of lost productivity. While these figures are hard to quantify, the National Institute of Drug Abuse estimates that substance abuse costs the nation $600 billion annually in health and social costs.6
Treatment for substance use disorder, like behavioral health care services generally, has historically been delivered outside of primary care, often in specialty facilities that may be staffed by mental health and addiction experts. But there’s increasing recognition among government leaders, medical educators, and clinicians that such specialists can’t meet the demand for addiction treatment — and that incentives are needed to encourage more primary care providers to screen for and treat addiction. “Primary care providers are the most likely to have contact with patients who are struggling with substances, yet we have traditionally avoided that responsibility,” says Miriam Komaromy, M.D., who is board-certified in both addiction and internal medicine and serves as associate director of the University of New Mexico’s Project ECHO, a distance-learning approach to training primary care providers to offer addiction treatment and other care that has traditionally been the bailiwick of specialists.
Proponents of a primary care–based approach acknowledge that there are several challenges to treating addiction: reimbursement may not adequately compensate providers for the additional time and staff needed, and patients may be more difficult or frustrating to treat. A growing body of evidence demonstrating the effectiveness of medication-assisted treatment together with the scientific recognition of addiction as a neurobiological disease — not a lack of will power — may help convince more providers to offer treatment. Still, stigma and concern about managing complex cases of addiction remain significant barriers.
In this issue of Transforming Care, we examine four distinct models of delivering addiction treatment within primary care: a state-led model in which designated primary care practices receive additional resources and support; a model pioneered in rural community health clinics in which group visits make it feasible; a “low-threshold” approach to treating addiction in an urban setting; and a model developed to treat complex patients in an integrated primary and behavioral health care clinic.7
Research in neuroscience has greatly increased our understanding of the disease of addiction. When you don’t understand something, it’s mysterious, it’s scary. You want to distance yourself from it. But once you have an understanding, it’s much easier to accept and to feel compassion and to realize these people are suffering from the disease of addiction. You get past the stigma and are even more motivated to try to help them and their families.
Models of Addiction Treatment in Primary Care
One approach that’s being replicated by other states is Vermont’s “hub and spoke” model of addiction treatment, launched in 2013 to reduce long waiting lists for treatment.8 Using a state plan amendment, which allows for higher federal matching payment for Medicaid patients, Vermont designated addiction treatment “hubs,” which are specialized drug treatment centers that serve the most clinically complex patients, and “spokes,” which are primary care offices willing to provide medication-assisted treatment (MAT) to less complex patients. The spoke practices receive additional resources to hire new staff, typically nurses to help manage the treatment protocols and social workers to help patients find counseling and social services. Primary care clinicians in the spokes can take part in learning collaboratives to hear from experts and their peers about successful strategies for assessing and managing addiction, and can consult with addiction treatment experts at the hubs on an on-demand basis.
The hub-and-spoke program was designed to address the concerns of primary care providers about treating addiction, says Beth Tanzman, executive director of Vermont’s Blueprint for Health, which leads the initiative. “Doctors said, we don’t have access to higher levels of care when we need to refer patients. We don’t have anyone we can call to consult like we would for treating other chronic conditions, and we don’t have the staff to provide team-based care.”
Today, Vermont’s nine hubs serve some 3,000 patients; most are insured by Medicaid and many are IV drug users and have unstable lives and/or co-occurring mental illnesses. Hubs are staffed by consulting psychiatrists and care coordinators, accommodating daily office visits and witnessed (i.e., in-office) dispensing of medication. The 77 spokes (some are federally qualified health centers, some are independent primary care practices, and some are OB practices) treat 2,700 patients; the state pays for a nurse and licensed mental health or addictions counselor for each of the practices’ 100 patients.
Katie Marvin, M.D., a primary care physician who runs one of the spokes at a federally qualified health clinic in Stowe, noted that her practice works with the sheriff’s department, recovery centers, mental health specialists, hospitals, and the health department to form a community-wide approach to prevention, treatment, recovery, and law enforcement. For example, the MAT coordinator — originally a nurse assigned to her practice and now a social worker — has helped the sheriff assess and triage patients. “We are working together for the people in our towns and families who need help and answers,” Marvin says.
Since the launch of this model, the number of Vermont providers willing to offer MAT for addiction has nearly doubled (from 114 at the beginning of 2013 to 196 at the end of March 2017). In one study, patients with opioid use disorder who received MAT had slightly lower total health care spending, on average, than those who had other forms of treatment for opioid addiction.9 Tanzman says Blueprint is still evaluating whether the cost of supporting the hubs and spokes exceeds the potential savings in health care costs, but she notes that there are likely overall savings to the state from lower rates of incarceration and higher rates of employment.
The medications commonly used to treat opioid use disorder work by occupying the opioid receptors in the brain.
Opiate agonists such as methadone bind to the receptors, displacing stronger, faster-acting opioid agonists like heroin and fentanyl. Partial agonists like buprenorphine elicit a lesser response but also act as a substitute, relieving withdrawal symptoms and cravings and allowing patients to focus on recovery. “They break the cycle of need,” says Joshua Lee, M.D., M.Sc., an internist at a primary care practice at New York City’s Bellevue Hospital. Some patients taper off these drugs over time while others remain on them for years.
Opiate antagonists like naltrexone also bind to opioid receptors, reaching them before other opioid drugs do, thus blocking the latter’s effects. Because they don’t produce stimulant or euphoric effects, as methadone and buprenorphine may do when first used, they have less potential for abuse or diversion to the black market. This is one of the reasons naltrexone may be preferred by jails and prisons offering treatment for opioid use disorder and/or preparing parolees for release. The downside is that naltrexone can be administered only after a patient has completed detox. “You can’t have someone walk into the clinic and begin treatment in a couple of hours. You have to go through a multi-week process of detoxing,” Lee says.
Open Door Clinics: Building a Sustainable Business Model
Bill Hunter, M.D., a family medicine physician and the medical director of the Open Door Community Health Centers, a group of 11 federally qualified health centers in rural Humboldt County, Calif., pursued a waiver to prescribe buprenorphine in 2002, the first year the FDA approved its use. He’d seen the toll that poverty and disability were taking on his community, where opioid use is rampant but the nearest methadone clinic is three hours away.
Open Door, now with seven physicians waivered, offers MAT to nearly 500 patients with opioid use disorders. The clinics have developed a care model that enables them to provide treatment in a way that is financially and logistically feasible within a traditional primary care clinic. The model is structured around group visits, each involving six to 12 patients. During each visit, nurses perform toxicology screenings, and drug counselors, who are often peers in recovery themselves, lead discussions, which give patients opportunities to share their stories and offer each other support. Patients are called out one at a time to meet with their prescribing physician to review their MAT dosages, talk about how they’ve been feeling, and receive their new prescription. Scheduling patients this way enables the clinics to cover the cost of drug counselors and nurses, whose services aren’t billable.
Open Door clinicians have access to a consulting psychiatrist, who can clarify diagnoses and help identify other issues that may fuel addiction. “He’s been really helpful in raising our game in terms of trauma,” says Hunter. “Most of the people we treat have experienced some trauma. The group discussions help patients work through these issues.”
Most patients initially come to the clinics weekly. Once they’ve had clean urine tests for three to four weeks they come in monthly, then much less often as they stabilize. The clinic’s success rate — measured by the number of patients who remain in treatment for three to six months — is about 50 percent, Hunter says. “I’ve been a country doctor for close to 40 years now. There are few things that make such a difference. We had people who were struggling; every waking thought was how not to get sick and what they needed to do to get the drug to not be sick. You give them buprenorphine and in a few days they are showered and shaved and figuring out what they need to do next, including getting a job.”
In spite of these successes, Hunter cautions that addiction treatment is a long-term proposition, given the chronic nature of the disease, and some people may need to stay on a maintenance dosage for costly MAT drugs for years. The clinic has had some patients relapse when their physicians have tapered down their buprenorphine dosage too quickly, he says.
Bellevue Hospital: Offering “Low-Threshold Care”
Joshua Lee, M.D., M.Sc., an internist at a primary care practice at New York City’s Bellevue Hospital, provides what he and others have described as “low-threshold care.” The Substance Abuse and Mental Health Service Administration’s guidelines for office-based buprenorphine treatment endorse in-office, observed induction, frequent follow-up, and concurrent psychosocial counseling.10 By contrast, Lee’s patients with opioid use disorder — nearly all are heroin users and many are homeless and/or unemployed — undergo an initial screening and then receive a one-week prescription for buprenorphine-naloxone. Although it is encouraged, patients are not required to receive counseling, nor is treatment automatically suspended if they fail a screening for illicit substances.
A study of 485 Bellevue patients who received this treatment found small numbers of adverse events (e.g., unanticipated medication side effects), with a median retention rate of more than nine months and diminishing opioid misuse over time.11 Lee points out that this level of engagement and success is on par with or better than that achieved in many chronic-disease management programs. “We do opioid treatment like we do other chronic medical treatment for conditions like diabetes, hypertension,” he says. “Patients see their doctor regularly, they can get help when they need it. We think that works well for alcohol or opiate addiction treatment.” Lee notes that the national success rate for MAT for opioid use disorder is about 50 percent (defined as still in treatment between six and 12 months later); by contrast, an abstinence-only approach that emphasizes detox plus 12-step meetings has rates closer to 10 percent to 20 percent. At Bellevue, about 45 percent of patients are still in treatment and meeting some definition of success after a year. “That doesn’t mean they are all completely opiate-free. People will continue to struggle with heroin or other substance use, such as cocaine. But without treatment, the success rate is around zero,” he says.
The low-threshold approach may encourage more people to seek treatment, including those who may be ambivalent about giving up substances that help them cope with emotional distress.
Massachusetts General Hospital established the Bridge Clinic, with drop-in appointments, in part to help patients who haven’t fully committed to abstinence and have trouble keeping appointments in traditional primary care practices. “Patients come in whatever shape they are in and we really try to engage with them and meet them where they are, with a long-term goal of stabilizing them and transitioning them back to community-based care,” says Sarah Wakeman, M.D., medical director of the hospital’s Substance Use Disorder Initiative. For more detail on the clinic, see our Q&A with Dr. Wakeman.
Center for Integrative Medicine: Treating Addiction as Part of Complex Care
Spectrum Health’s Center for Integrative Medicine, in Grand Rapids, Michigan, is an integrated behavioral health and primary care clinic that was designed to treat patients who repeatedly turn up in the health system’s emergency department. About 70 percent of these patients have a substance use disorder, though it often hasn’t been diagnosed, according to Scott Haga, a physician assistant there. “Many patients come with chronic pain or anxiety,” he says. “We find out they are getting large numbers of controlled substances or multiple prescriptions. Some knew they had a substance use disorder, but many didn’t.” Haga provides MAT to such patients, though he typically starts by trying to understand the sources of the pain and/or psychosocial issues that may be fueling their substance abuse.
Haga also provides medication-assisted treatment for alcohol use disorder, which is more widespread and, in aggregate, causes more deaths than opioid use disorder.12 The medications used to treat alcohol addiction, including acamprosate and naltrexone, work by reducing people’s desire to drink. “If you have someone who is drinking 10 beers a night, think of what might happen if they cut it down to two-and-a-half beers a night: they’re less likely to be hung over and miss work, to be drunk-driving, and less likely to be involved in domestic violence,” Haga says. “From a primary care perspective, this is a great way to intervene with patients who say, I am drinking a little more than I would like, but I am not going to rehab or treatment. This is stuff primary care can do.” Haga says many doctors aren’t aware of medication’s potential: “When I go out and talk to primary care providers, I ask how many have patients who say they’re drinking too much. It’s 100 percent. When I ask what they do about it, they say, ‘I tell them to drink less.’ Unfortunately, that isn’t going to be very effective.”
Barriers to Expanding Addiction Treatment in Primary Care
Despite the promise of medications and new models of addiction treatment, there’s no shortage of barriers to their use in primary care. Many primary care providers are already overwhelmed, seeing 30 patients a day, says R. Corey Waller, M.D., M.S., senior medical director for education and policy for the Camden Coalition for Health Care Providers. It’s difficult to take on patients experiencing addiction without modifications to practices that allow for longer visits, more frequent follow-up, and testing to ensure that prescribed medication is taken as directed, Waller says.
Financial incentives may be lacking for this additional work, given that providers may not be adequately compensated for the time it takes to evaluate addiction and monitor its treatment. As part of an effort to treat substance abuse disorders like other chronic conditions, the insurer Cigna recently scrapped the requirement for physicians to secure prior authorization to provide MAT — a common hurdle faced by prescribers that may stem from a desire to prevent the diversion of buprenorphine to the black market.13 Cigna was also the first carrier to create a separate billing code for MAT induction, increasing reimbursement for it to 150 to 200 percent of a typical office visit, in recognition of the additional time required.
Some physicians fear that patients grappling with addiction will be disruptive to their practices. Those with experience in treating addiction acknowledge that there is some basis for such concerns: patients with severe addiction often have experienced trauma and may have comorbid mental health problems; many have lost their jobs and homes, and have little social support. Any of these circumstances can make it much harder to engage and retain them in treatment. But given how common addiction is, most primary care providers are probably already seeing these patients, even if they are unaware of their substance abuse. “Providers still hold this idea that they don’t want those patients in their waiting room,” says Marvin. “They’re already there; they’re just not telling you. My patients are the same people I see in the grocery store. They’re professionals. They are people I already knew. I just didn’t know they had issues. Now I see it everywhere.”
Providers may also have particular qualms about engaging in medication-assisted treatment, starting with fears that the drugs they prescribe will be diverted for illicit use or merely create a new dependency. Some patients have died from the misuse of buprenorphine, although experts say it is much safer than heroin or other prescription drugs. In addition, high demand for treatment has attracted some unscrupulous doctors: one investigation found that a relatively high proportion of buprenorphine-waivered physicians have been sanctioned for excessive narcotics prescribing or other offenses.14
And, in addition to having to pursue special training, those prescribing buprenorphine may receive surprise visits by a Drug Enforcement Agency officer. “Physicians can feel a bit like criminals. It’s not a great feeling to have that hanging over you,” says Penny Mills, executive vice president and CEO of the American Society of Addiction Medicine.
Levers for Overcoming These Barriers
Building a Better-Prepared Workforce
Experts say training — during medical school and residency and via continuing medical education programs — is a key to ensuring that primary care providers have the skills they need to screen for addiction and then intervene. In response to the opioid epidemic, many medical schools and residency programs have been bolstering their addiction treatment curricula in addition to strengthening their attention to appropriate prescribing practices. A Johns Hopkins University School of Medicine student and professor recently argued that such opportunities are important in that they counteract the negative opinions formed by many medical students and residents working at urban academic medical centers, where they tend to see the most severely addicted patients and may develop a grim view of their prospects for recovery.15
The University of Central Florida College of Medicine recently revamped its curriculum to include a greater focus on how to screen for and diagnose addiction, and how to use techniques like motivational interviewing to engage patients in evidence-based interventions, including medication-assisted treatment.16 It is now working with the eight other Florida medical schools to develop shared core competencies for pain management and substance use disorder treatment.
Residency programs that give trainee physicians opportunities to see how addiction medicine is practiced in primary care are also important, says Stephen Martin, M.D., associate professor of family medicine and community health at the University of Massachusetts Medical School. Martin helps train residents at the Barre Family Health Center, a community health center in rural Massachusetts that provides MAT to about 250 patients with opioid use disorder using an integrated model of care that combines primary care and behavioral health services.
Medical residents have grown up with the opioid epidemic and are motivated to help, says Marvin, who has trainees rotating through her practice in Vermont. “When they come and spend a couple of days with me, most walk away saying ‘That didn’t seem complicated or overly taxing. What is everyone all worked up about?’”
Creating Financial Incentives and Supportive Policy
Policymakers and health care payers also need to make the provision of addiction treatment a financially attractive proposition for primary care providers. A growing body of evidence demonstrating the effectiveness of MAT in treating addiction may help make the case for investment. More research is needed to understand how treating addiction can yield savings on other health care costs, as well as the costs of incarceration for drug-related offenses.17 Greater measurement may also be necessary to establish which treatment modalities and provider models are the most effective. “One of the gaps in substance use disorder treatment is the lack of national standard quality metrics, which makes it difficult to compare outcomes,” says Doug Nemecek, M.D., M.B.A., Cigna’s chief medical officer for behavioral health.
Cigna offers case management services that help patients who are seeking addiction treatment to find in-network providers that have better outcomes, including lower readmission rates. The insurer is also partnering with the American Society of Addiction Medicine and with Brandeis University to validate what may become national measures, and has been tracking cost savings (e.g., from reduced hospitalizations and emergency department visits) that result when patients receive evidence-based MAT.
The Medicaid program and waivers that grant states flexibility in testing new ways of delivering and/or paying for services may also prove to be useful tools for enhancing access to care and encouraging addicted patients to seek treatment. New Hampshire and New York have both relied on the Delivery System Reform Incentive Payment Program and other waivers to fund their efforts. After decades of underinvestment, New Hampshire now covers a wide array of services through its Medicaid program, says Tym Rourke, director of substance use disorders grantmaking for the New Hampshire Charitable Foundation. “It covers the full gamut from early screening to peer-based recovery programs. As a result, we’ve seen the stabilization of the treatment system and an expansion in capacity,” he says. New funding for states to fight the opioid epidemic may also help support models that expand access to evidence-based treatment.18
However they proceed, policymakers venturing into this area must recognize that addiction is a chronic disease that requires long-term treatment. Polling data suggest that there is uncertainty among the public as to whether substance use disorder requires only onetime treatment, says Robert Blendon, Sc.D., professor of public health and health policy at the Harvard T.H. Chan School of Public Health. “There is not a great deal of understanding that this may be closer to diabetes than an acute condition like many types of cancer,” he says.
The Annals of Family Medicine recently devoted an issue to articles exploring ways in which primary care settings can be used to increase access to addiction treatment, including by leveraging proven models of chronic care management.19 “Our nation will not be able to adequately respond to the current epidemic without addressing it in primary care,” Richard Saitz, M.D., and Timothy P. Daalerman, D.O., write in an introductory editorial, “and there is no question that the time to do it is now.”
1 Preliminary data show that at least 59,000 people died from drug overdoses in 2016, or an average of 162 a day. See https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html?mcubz=0&_r=0. As of September 14, 2017, 82 people were known to have died as a consequence of Hurricane Harvey according to the Washington Post. See https://www.washingtonpost.com/national/texas-officials-hurricane-harvey-death-toll-at-82-mass-casualties-have-absolutely-not-happened/2017/09/14/bff3ffea-9975-11e7-87fc-c3f7ee4035c9_story.html?utm_term=.c2d3cf67fad9.
2 Personal communication with American Board of Addiction Medicine and the Addiction Medicine Foundation, Sept. 22, 2017. This number is likely to increase with the American Board of Medical Specialties’ 2015 recognition of addiction medicine as a new subspecialty and the decision by the American Council for Graduate Medical Education to accredit fellowship training programs in addiction medicine.
3 According to the Substance Abuse and Mental Health Services Administration, 40,552 physicians in the U.S. are waivered to prescribe buprenorphine. Nearly 70 percent are limited to serving 30 patients. See https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/physician-program-data. As of April 2017, there were 923,308 active physicians in the U.S. See http://www.kff.org/other/state-indicator/total-active-physicians/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
4 See https://www.samhsa.gov/medication-assisted-treatment/qualify-nps-pas-waivers. Over 2,000 waivers have already been distributed to physician assistants and nurse practitioners as part of the Comprehensive Addiction and Recovery Act, which granted buprenorphine prescribing privileges to these professionals until October 2021. See https://www.asam.org/resources/practice-resources/nurse-practitioners-and-physician-assistants-prescribing-buprenorphine.
5 A 2011 study estimated that health care costs related to prescription opioid abuse amounted to $25 billion a year. H. G. Birnbaum, A. G. White, M. Schiller et al., “Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States,” Pain Medicine, April 2011 12(4):657–67. See also, S. P. Melek, D. T. Norris, and J. Paulus, Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry (Milliman Inc., April 2014) and National Center on Addiction and Substance Abuse at Columbia University, Addiction Medicine: Closing the Gap Between Science and Practice (National Center on Addiction and Substance Abuse, June 2012).
6 See https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost.
7 While many of the examples in this issue relate to opioid addiction, we do not focus solely on opioid use disorder. Experts say there are many shared lessons and approaches to addiction treatment in general, whatever the type of substance use disorder.
8 California and Pennsylvania are replicating the model. Pennsylvania will be relying on health systems and their primary care networks to act as hubs and spokes.
9 A study of the program’s impact on Medicaid expenditures found patients receiving MAT had much lower non-opioid-related medical expenditures than did patients who were receiving treatment for substance use disorder without MAT. When the cost of MAT was factored in ($2,708 per year on average), total health care expenditures were roughly equivalent for both groups. M. K. Mohlman, B. Tanzman, K. Finison et al., “Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont,” Journal of Substance Abuse Treatment, Aug. 2016 67:9–14.
10 Substance Abuse and Mental Health Service Administration, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (Center for Substance Abuse Treatment, 2004).
11 E. Patterson Bhatraju, E. Grossman, B. Tofighi et al., “Public Sector Low Threshold Office-Based Buprenorphine Treatment: Outcomes at Year 7,” Addiction Science Clinical Practice, 2017 12(7):1–10.
12 B. F. Grant, R. B. Goldstein, T. D. Saha et al., “Epidemiology of DSM-5 Alcohol Use Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III,” JAMA Psychiatry, Aug. 2015 72(8):757–66, https://www.ncbi.nlm.nih.gov/pubmed/26039070.
13 A 2013 review of Medicaid and commercial insurance policies found multiple barriers to medication-assisted treatment, including requirements for prior authorization counseling as well as limits related to quantity and duration of treatment. See: American Society of Addiction Medicine, Advancing Access to Addiction Medications: Availability Without Accessibility? Report 1: “State Medicaid Coverage and Authorization Requirements for Opioid Dependence Medications,” The Avisa Group, 2013, https://www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final.
14 A 2013 New York Times investigation found that at least 1,350 of 12,780 buprenorphine doctors had been sanctioned for offenses that include excessive narcotics prescribing, insurance fraud, sexual misconduct, and practicing medicine while impaired. See D. Sontag, “Addiction Treatment with a Dark Side,” New York Times, Nov. 16, 2013.
15 A. Ram and M. S. Chisolm, “The Time Is Now: Improving Substance Abuse Training in Medical Schools,” Academic Psychiatry, 2016 40:454–60.
16 The school has also placed a greater emphasis on pain management across care settings, focusing in part on non-pharmacological interventions.
17 Some studies among discrete populations suggest a high return on investment. For example, a longitudinal study of patients treated for addiction in Kaiser Permanente’s Medical Care Program found an average reduction of 30 percent in medical costs three years post-treatment. Significant declines were seen in areas such as the number of inpatient hospital days and emergency department visits. An analysis of data from patients in treatment for addiction involving alcohol or drugs other than nicotine in California found a benefit-cost ratio of more than seven to one: the average cost of treatment was $1,583 and the benefits were $11,487. Most of the savings were attributed to reduced crime and increased employment. Both as reported by the National Center on Addiction and Substance Abuse at Columbia University, in Addiction Medicine: Closing the Gap Between Science and Practice (New York, N.Y.: National Center on Addiction and Substance Abuse, June 2012).
18 See https://www.samhsa.gov/newsroom/press-announcements/201612141015.
19 K. E. Watkins, A. J. Ober, K. Lamp et al., “Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial,” JAMA Internal Medicine,” Published Online Aug. 28, 2017.