Integrated Primary Care and the Opioid Crisis
The comparative flood of new users of opioid medication and heroin in the population has led to a crisis. That it is a crisis is agreed to by politicians, medical professionals, substance abuse professionals, and the public in general. I am told that the Chinese character for “crisis” is made up of a combination of the characters for “danger” and “opportunity.” I recently heard a report from Beth Tanzman, the Assistant Director of the Vermont Blueprint for Health that Vermont has taken the opportunity presented by this danger to respond with a distinctive approach to creating integrated behavioral health in primary care. Instead of small changes in payment or regulation, they simply funded salaries for behavioral health clinicians in primary care. The chief duty of these clinicians is to address substance abuse concerns, but they are inevitably addressing a broader array of behavioral concerns.
I think there are two important points that this example brings to mind.
1. Whether the impetus for adding behavioral health in primary care is to treat people with serious depression, to provide better care for people with trauma histories, to attempt to intervene before people are involved in the criminal justice system, or to address serious substance abuse is a choice based on administrative and funding opportunity, because as a population THEY ARE MOSTLY THE SAME PEOPLE.
2. If you only target serious substance abuse with your behavioral health resources, you are seeking to intervene in the process too far downstream. Unless you are offering behavioral alternatives in chronic pain therapy, so that physicians have some way of helping their pain patients other than opioid pain medications, you are not helping stem the tide of new addicts. (To see a 24-minute interview with a patient who got off narcotic pain meds after 18 years with the help of behavioral health in primary care, click on “watch in Vimeo” and use “pillman” for the password http://umassmed.edu/cipc/resources/videos/.
And, today only, you get 50% more important points than promised:
3. If you define the role of a behavioral health clinician that you put in a primary care practice (a “general medical setting”) as only addressing substance abuse, you make your program fall under the strictures of 42 CFR (the Federal statute regulating the exchange of information about a patient’s substance abuse care). The clinician and physician cannot exchange information without further releases. If you define the role as a behavioral health generalist, though they may do a good deal of work with substance abuse, 42 CFR does not apply. (Your state may have other regulations that do apply.)