In September 2010, professionals at the Marworth addiction treatment organization in northeast Pennsylvania brought addiction treatment experience directly into the primary care setting. The goal was to help primary care providers more effectively treat patients who may have a problem with substance abuse. After only a few months of planning, I began assessing patients at two Geisinger Health System primary care practices.
Since Marworth is part of the Geisinger Health System, this partnership between addiction medicine and primary care came about relatively easily. Geisinger operates 39 primary care offices throughout central and northeast Pennsylvania, several of which are within 40 miles of Marworth's location in Waverly. In less than one year, the addiction medicine outreach program expanded to encompass four practices.
There are multiple challenges for all primary care providers when dealing with a patient suspected of substance abuse. First of all, their training in addiction medicine is limited. That in turn can affect their ability to diagnose a patient properly as a true addict, a pseudo-addict, or someone simply in need of more careful management of chronic pain.
“Primary care doctors are often the first to admit that we have a gap in training that puts us at a disadvantage when dealing with addiction,” says John Gardner, MD, medical director and family physician at the Geisinger-Tunkhannock primary care clinic. “Fortunately, we have a strong relationship with our colleagues at Marworth.”
Doctors at Geisinger routinely turn to the addiction experts at Marworth to learn more about treating addiction and managing prescriptions for their patients. With this line of communication already open, it was a natural next step to invite a Marworth expert into primary care practices full-time.
“Both entities view this program as a value-added service for Geisinger patients,” says Marworth vice president James Dougherty. “We all benefit from being part of a larger health system, and can now offer professional, individualized assessments and recommendations directly at the primary care level.”
Marworth's operating budget pays my salary, while Geisinger's operating budget accounts for the office space at each clinic. Counseling sessions with me are free for the patient and are available only to established Geisinger patients.
I first visited the targeted primary care sites and met with the providers, nurses and staff to assess their needs and expectations. Training in Geisinger's advanced electronic medical record (EMR) system was necessary to ensure that patients' progress would be properly recorded into their medical charts.
The first two Geisinger sites selected, Geisinger-Lake Scranton and Geisinger-Tunkhannock, vary in patient population. Geisinger-Lake Scranton is home to 10 primary care providers and is located in Scranton, the urban center of Lackawanna County. Geisinger-Tunkhannock is a seven-provider practice serving a rural patient base in Wyoming County. However, physicians at both clinics have the same issues regarding patient substance abuse problems-trouble identifying addicted patients and handling non-compliance with prescription narcotic use agreements.
I initially offered office hours at each clinic site two-and-a-half days a week. Local primary care providers now had the ability to refer a patient quickly and easily to an on-site addiction expert. If I am holding office hours when a patient in question has a primary care appointment, the doctors often are able to get the patient in to see me within minutes.
The new program grew slowly. There were more referrals at the more urban Geisinger-Lake Scranton clinic. After six months, I noticed my referrals were dropping significantly. After discussion with the medical directors at each site, they determined that each site's patient load had been “cycled through,” meaning I had seen most of their current patients with an obvious need for addiction assessment.
“Our physicians and advanced practitioners quickly identified which of their patients would most benefit from an assessment with an addiction counselor,” says Richard Martin, MD, medical director and family physician at Geisinger-Lake Scranton. “We jumped at the chance to give these patients this unique opportunity.”
This opened the door for Marworth to expand services to two other Geisinger primary care locations: Geisinger-Dallas and Geisinger-Kistler Clinic. I currently rotate my schedule among all four sites.
The two newly added locations were vastly different. A four-provider clinic, Geisinger-Dallas serves a suburban population in Luzerne County, while Geisinger-Kistler Clinic has eight providers and is located in the heart of Wilkes-Barre, the urban center of Luzerne County. As expected, I received more referrals at Geisinger-Kistler Clinic.
Categories of patients
Three basic categories emerged from the patient referrals: those with a clearly identified alcohol and/or drug addiction; patients undergoing treatment for chronic pain who seemed to be misusing or abusing their medication; and chronic pain patients who were not misusing medication but might benefit from other categories of pain management. A primary care provider without specialty training in addiction medicine or pain medicine could easily have a difficult time differentiating among these types of patients and directing them to the most effective treatment option.
I use DSM-IV-TR criteria to diagnose alcohol or drug dependency. Alcohol abuse is the most prominent issue in patients I screen.