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Lift patient- and system-level barriers to care

November 28, 2018

When it comes to addiction treatment services, there are two major types of barriers to entry that are keeping potential patients from receiving the care they need. The first are patient-level barriers, which are personal, individual barriers preventing patients from seeking treatment. These include financial limitations, motivation, insurance, wait times, anxiety and nervousness. The other major hurdles are system-level barriers. System-level barriers are failures of the industry to function under certain circumstances, such as gaps in coverage, weak referral systems, ignoring potential addiction treatment, acute treatment, and providers who simply don’t believe in treatment.

Patient-level barriers are much more difficult for us to overcome. Patients who are comorbid with various addictions, or with other mental health concerns, are statistically less likely to be motivated to seek addiction treatment. Addiction is time-sensitive, so having a strong network of referrals is critical to getting patients into care while they are still safe and motivated to seek treatment. Improving services offered, such as through peer specialists, can help us talk to patients in a more comfortable, relaxing way that can reduce anxiety and give them faith and a sense of control in the process.

A lot of patient-level barriers are related to factors out of our control, such as drug policies and the unique economies of our neighborhoods. In these cases, strong informational systems, such as relationships with local schools, primary care doctors, religious groups and other nonprofits, can be critical in long-term change for the benefit of our patients, while at the same time helping to overcome some of the lesser barriers by reducing stigma and creating stronger networking.

System-level barriers can be solved with a lot of the same practices. Many patients with substance use disorders are often identified through primary care doctors on unrelated visits. Someone who is in the ER from a car crash might have been intoxicated, and sent to rehab after stabilization. An unconscious patient might have been dehydrated from a recent drug binge. Yet, the common practices for these cases, such as Screening, Brief Intervention and Referral to Treatment (SBIRT), “were found to be ineffective at bridging the gap” between addiction disorders and other health concerns. In these situations, adequate follow-through and case management was one of the most effective solutions at getting patients into the care they need after the acute health concern is “resolved.”

Too often, addiction is treated as an acute problem in and of itself, like a broken arm or a fever. Patients are stabilized and sent on their way. The issue is that addiction is a blend of physical, mental and behavioral health. Treating the physical aspect doesn’t take care of the long-term behavioral patterns that have led them to an ER or primary care office, let alone any underlying mental health issues. The reasons for this failure to provide adequate services here are twofold.

Primary care doctors are often not equipped to handle addiction care services. Only 3% of primary care doctors and 16% of psychiatrists have waivers for prescribing buprenorphine-naloxone, which is one drug for treating and/or detoxing patients from opioid addiction, most of whom work in urban areas. It is often used for maintenance with little follow-up, and most physicians don’t prescribe in a variety of ways that best meet the individual’s needs. This shows a clear sign that doctors do not feel or understand the need for addiction care services and are limited in their scope and use of medication. To get the full spectrum of care for their patients, doctors need to make adequate assessments and referrals, because most are not well versed in all recovery avenues, which limits their ability to make the best recommendation.

Second, doctors have a weak referral system for addiction care. As providers, we haven’t established value in the eyes of rural and urban primary care doctors, who are the trusted go-to for the majority of healthcare consumers in the U.S. Failure to convey importance to these providers means failure to provide our services to their patients.

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