Clinical Needs of Patients With Problem Drug Use
Clinical Needs of Patients With Problem Drug Use
Individuals who used illicit drugs and who were seeking primary care within a safety net medical setting had multiple coexisting social, psychiatric, and health problems, similar to observations in studies focused on treatment-seeking drug users, studies based on national surveys, and studies of such individuals presenting at EDs. This study is distinguished from previous efforts in that it was conducted in primary care clinics with patients who were not explicitly seeking substance abuse treatment. It is also distinctive in its focus on examining characteristics across the range of drug use severity as a strategy to identify clinical needs across the drug-using population.
As a group, participants in our study had significant medical needs. They had an unusually large number of chronic comorbid medical conditions, averaging 7 Chronic Illness and Disability Payment System categories; the average number for disabled Medicaid beneficiaries is <2. Although a relatively young group with a mean age of 48 years, the most frequent diagnoses reflected serious chronic conditions such as hypertension. Clearly, this is a population that will need ongoing medical care.
Patients with the highest level of drug use severity were significantly different from their less severe drug-using counterparts in ways that can interfere with seeking appropriate medical treatment as well as understanding and adhering to treatment recommendations, such as having high levels of homelessness (50%), psychiatric severity (70%), and low family support. Because of their drug use history—such as use of opiates, stimulants, and sedatives—as well as recent intravenous drug use, it is not surprising that they were experiencing more legal consequences than their counterparts with lower drug use severity; almost 24% had a recent history of ≥1 felony or gross misdemeanor arrest.
Patients with the highest drug use severity frequently treated their medical problems by using intensive and costly ED and inpatient hospital services; they had twice the number of ED visits and about double the mean ED cost relative to patients with low levels of drug use severity. They had a history of more frequent inpatient hospital admissions preceded by an ED visit—a pattern often characterized as reflecting unplanned admissions to a hospital. Almost 17% of this group had a recent history of being admitted to detoxification services with no subsequent treatment, another crisis service. It is noteworthy that costs of medical services received by participants in our study were paid almost exclusively by public funds: Medicare, Medicaid, or unsupported/uncompensated care.
Despite the multiplicity and seriousness of problems concentrated in the substantial/severe drug use severity subgroup, this subgroup had the highest proportion of patients with a goal of future abstinence from drugs (almost 61%) and also contained the highest proportion of patients admitted to CD treatment in the previous 2 years (34%). Although not conclusive, these findings open the possibility that this subset of illicit drug users may be among those most open to treatment recommendations. We recommend future research examine this.
Their multiple comorbidities suggest a need for specialized addiction and psychiatric care as well as primary care services that can address the medical consequences of substantial/severe drug use, including intravenous drug use. Access to buprenorphine or methadone treatment for addiction is particularly relevant for safety net clinics that serve patients with severe drug problems. Unstable lifestyles associated with substantial/severe drug use may require coordination with social services.
Characteristics of patients with intermediate drug use severity fell between patients with substantial/severe and low drug use severity on most measures. As such, selective application of interventions suggested for patients with high and low drug use severity may be useful with them.
Psychiatric severity was most pronounced among patients with high drug use severity (almost 70%), although the percentages of patients with low and intermediate drug use severity with high psychiatric severity were still noteworthy: 41% and 53%, respectively. In this study the most frequently reported mental health–related diagnostic code was depressive disorder (Table 3). Collaborative care approaches integrating behavioral health into primary care have shown promise in effectively treating populations who present with depression, particularly those who are among the least or moderately severe. A collaborative care approach is consistent with emphasis in the ACA on integrated services and with medical societies such as the American Board of Family Medicine, which has explicitly identified integrated behavioral health care as a core principle of the patient-centered medical home (PCMH). Despite support, evidence suggests that implementation of integrative models is still in the early stage of development. This places primary care safety net clinics in a key position to develop a range of responses that are locally effective to serve patients with problem drug use. In so doing, results of their work may have the potential to inform national efforts to establish PCMHs and to implement the ACA.
The DAST-10 was used to identify patients with problem drug use in this study. It is short, easy to administer and score, and it maps well to American Society of Addiction Medicine placement criteria. However, it bears less relationship to ICD and Diagnostic and Statistical Manual of Mental Disorders diagnoses, which may interfere with acceptance of its placement guidelines as the basis for coverage decisions by public and third-party payers. Other instruments used to screen for problem drug use include the Alcohol, Smoking and Substance Involvement Screening Test and the Addiction Severity Index.
Strengths of this study are the relatively large sample size (n = 868) and that the sample was drawn from primary care. This combination is unusual when viewed in the context of the existing literature. There are also limitations. First, we had no comparison group; thus all analyses are based on within-group comparisons. As such, they are descriptive and exploratory in nature and are best regarded as a rich source of hypotheses for the design of future studies rather than being definitive. Second, results from this sample are only generalizable to public sector health care or safety net settings, although the exclusion criteria used in this study may have inadvertently resulted in a disadvantaged sample that has milder characteristics than the target population. Third, our use of the ASI composite score to define psychiatric severity had important limitations. This measure was not designed to serve as a formal, standalone psychiatric assessment, and it does not provide psychiatric diagnostic information. Nonetheless, it provided an important opportunity to identify provisional relationships that can be more definitively explored in future studies. Finally, medical records may have been incomplete in their documentation of medical and psychiatric diagnoses; such omissions may serve to complicate care provision.
Discussion
Individuals who used illicit drugs and who were seeking primary care within a safety net medical setting had multiple coexisting social, psychiatric, and health problems, similar to observations in studies focused on treatment-seeking drug users, studies based on national surveys, and studies of such individuals presenting at EDs. This study is distinguished from previous efforts in that it was conducted in primary care clinics with patients who were not explicitly seeking substance abuse treatment. It is also distinctive in its focus on examining characteristics across the range of drug use severity as a strategy to identify clinical needs across the drug-using population.
As a group, participants in our study had significant medical needs. They had an unusually large number of chronic comorbid medical conditions, averaging 7 Chronic Illness and Disability Payment System categories; the average number for disabled Medicaid beneficiaries is <2. Although a relatively young group with a mean age of 48 years, the most frequent diagnoses reflected serious chronic conditions such as hypertension. Clearly, this is a population that will need ongoing medical care.
Severity of Drug Use
Patients with the highest level of drug use severity were significantly different from their less severe drug-using counterparts in ways that can interfere with seeking appropriate medical treatment as well as understanding and adhering to treatment recommendations, such as having high levels of homelessness (50%), psychiatric severity (70%), and low family support. Because of their drug use history—such as use of opiates, stimulants, and sedatives—as well as recent intravenous drug use, it is not surprising that they were experiencing more legal consequences than their counterparts with lower drug use severity; almost 24% had a recent history of ≥1 felony or gross misdemeanor arrest.
Patients with the highest drug use severity frequently treated their medical problems by using intensive and costly ED and inpatient hospital services; they had twice the number of ED visits and about double the mean ED cost relative to patients with low levels of drug use severity. They had a history of more frequent inpatient hospital admissions preceded by an ED visit—a pattern often characterized as reflecting unplanned admissions to a hospital. Almost 17% of this group had a recent history of being admitted to detoxification services with no subsequent treatment, another crisis service. It is noteworthy that costs of medical services received by participants in our study were paid almost exclusively by public funds: Medicare, Medicaid, or unsupported/uncompensated care.
Despite the multiplicity and seriousness of problems concentrated in the substantial/severe drug use severity subgroup, this subgroup had the highest proportion of patients with a goal of future abstinence from drugs (almost 61%) and also contained the highest proportion of patients admitted to CD treatment in the previous 2 years (34%). Although not conclusive, these findings open the possibility that this subset of illicit drug users may be among those most open to treatment recommendations. We recommend future research examine this.
Their multiple comorbidities suggest a need for specialized addiction and psychiatric care as well as primary care services that can address the medical consequences of substantial/severe drug use, including intravenous drug use. Access to buprenorphine or methadone treatment for addiction is particularly relevant for safety net clinics that serve patients with severe drug problems. Unstable lifestyles associated with substantial/severe drug use may require coordination with social services.
Characteristics of patients with intermediate drug use severity fell between patients with substantial/severe and low drug use severity on most measures. As such, selective application of interventions suggested for patients with high and low drug use severity may be useful with them.
Psychiatric Severity
Psychiatric severity was most pronounced among patients with high drug use severity (almost 70%), although the percentages of patients with low and intermediate drug use severity with high psychiatric severity were still noteworthy: 41% and 53%, respectively. In this study the most frequently reported mental health–related diagnostic code was depressive disorder (Table 3). Collaborative care approaches integrating behavioral health into primary care have shown promise in effectively treating populations who present with depression, particularly those who are among the least or moderately severe. A collaborative care approach is consistent with emphasis in the ACA on integrated services and with medical societies such as the American Board of Family Medicine, which has explicitly identified integrated behavioral health care as a core principle of the patient-centered medical home (PCMH). Despite support, evidence suggests that implementation of integrative models is still in the early stage of development. This places primary care safety net clinics in a key position to develop a range of responses that are locally effective to serve patients with problem drug use. In so doing, results of their work may have the potential to inform national efforts to establish PCMHs and to implement the ACA.
Identifying Patients With Problem Drug Use
The DAST-10 was used to identify patients with problem drug use in this study. It is short, easy to administer and score, and it maps well to American Society of Addiction Medicine placement criteria. However, it bears less relationship to ICD and Diagnostic and Statistical Manual of Mental Disorders diagnoses, which may interfere with acceptance of its placement guidelines as the basis for coverage decisions by public and third-party payers. Other instruments used to screen for problem drug use include the Alcohol, Smoking and Substance Involvement Screening Test and the Addiction Severity Index.
Strengths and Limitations
Strengths of this study are the relatively large sample size (n = 868) and that the sample was drawn from primary care. This combination is unusual when viewed in the context of the existing literature. There are also limitations. First, we had no comparison group; thus all analyses are based on within-group comparisons. As such, they are descriptive and exploratory in nature and are best regarded as a rich source of hypotheses for the design of future studies rather than being definitive. Second, results from this sample are only generalizable to public sector health care or safety net settings, although the exclusion criteria used in this study may have inadvertently resulted in a disadvantaged sample that has milder characteristics than the target population. Third, our use of the ASI composite score to define psychiatric severity had important limitations. This measure was not designed to serve as a formal, standalone psychiatric assessment, and it does not provide psychiatric diagnostic information. Nonetheless, it provided an important opportunity to identify provisional relationships that can be more definitively explored in future studies. Finally, medical records may have been incomplete in their documentation of medical and psychiatric diagnoses; such omissions may serve to complicate care provision.
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