How Are Substance Use Disorders Addressed in VA Psychiatric and Primary Care Settings? Results of a National Survey

To obtain a representative sample of psychiatry programs, psychiatry directors were contacted from a random sample of 100 VA medical facilities, drawn from the VA Medical Facilities Address Listing, which contains listings for all VA medical facilities; 17 facilities had no psychiatry program and thus were not surveyed. Directors of the remaining 83 psychiatry programs were surveyed by telephone between October 2003 and February 2004; all proposed interviews were completed (100% response rate).

The survey assessed the following: screening practices used to detect substance use disorders (for example, whether the program provides ongoing screening for substance use), estimated percentage of patients with substance use disorder, protocol for treating patients with a substance use disorder (for example, no protocol, treat substance use disorders within the psychiatry program, refer patients to a VA specialty substance use disorder program, or refer patients to a community treatment program), and available treatments specific to substance use disorders (for example, whether the program offered group therapy, individual therapy, case management, or contingency contracting for patients with a substance use disorder).

A national sample of 102 primary care practitioners was surveyed by telephone between October 2003 and December 2003; all proposed interviews were completed (100% response rate). To obtain a representative sample of primary care practitioners, respondents were selected through a stratified sampling procedure that ensured participation by primary care practitioners from all 21 VA regional service networks and from three types of VA facilities: community-based outpatient clinics (27 respondents, or 26%), VA medical centers located in large urban areas (42 respondents, or 41%), and VA medical centers located in rural areas (30 respondents, or 29%). Only providers who were currently following a panel of VA primary care patients completed the survey. Almost all respondents were physicians (97 respondents, or 95%); the remainder were nurse practitioners (three respondents, or 3%), a physician's assistant (one respondent, or 1%), and a registered nurse recruited at a community based outpatient clinic that did not currently have a physician on staff (one respondent, or 1%).

The survey assessed the following: screening practices used to detect substance use disorders (for example, whether the practitioner provides ongoing screening for substance use), number of patients treated in the past month with substance use disorders, protocol for treating patients with substance use disorder (for example, no protocol in place or the practitioner treats substance use disorders, refers patient to another provider within primary care, or refers patient to a specialty substance use disorder program), and treatment specific to substance use disorders that is available to veterans (that is, whether the practitioner provides ongoing counseling for substance use disorders and how much time is spent on counseling for substance use disorders). The psychiatry and primary care surveys were both part of a government-mandated study of service provision for substance use disorders within the VA; thus these surveys were deemed to be exempt from institutional review.

Prescription data for patients with a diagnosis of a substance use disorder and visits to psychiatry, primary care, or specialty treatment programs for substance use disorders were gathered from the VA National Pharmacy Benefits Database.

Psychiatry directors estimated that a mean±SD of 41%±17% of their patients had a substance use disorder. This estimate is less than the 58% rate identified in other research on veteran patients in psychiatry programs ( 4 ). Furthermore, 51 psychiatry programs (61%) provided ongoing screening for substance use.

A vast majority of psychiatry directors (66 respondents, or 80%) indicated that their protocol for treating patients with substance use disorders involves referral to a specialty substance use disorder treatment program, while concurrently treating other psychiatric disorders in their program. Seventeen psychiatry directors (20%) indicated that their staff were able to take the primary responsibility for treating both substance use disorders and psychiatric problems.

Psychiatry programs provided limited treatment services for substance use disorders. A total of 35 (42%) employed a staff member certified in addiction treatment. Twenty-eight (34%) offered group therapy for substance use disorders, 28 (34%) offered individual therapy for substance use disorders, 33 (40%) offered additional case management for substance use disorders, and nine (11%) offered contingency contracting. The 17 programs (20%) that did not routinely refer patients to specialty substance use disorder clinics were better equipped to treat patients with dual diagnoses than the 66 programs (80%) that referred patients for specialty substance use disorder treatment. Specifically, the programs that did not routinely refer patients to specialty substance use disorder clinics were more likely than those that did not refer patients to such clinics to employ a staff member certified in addiction treatment (ten respondents, or 59%, compared with 25 respondents, or 38%), offer group therapy for substance use disorders (14 respondents, or 82%, compared with 14 respondents, or 21%), offer individual therapy for substance use disorders (14 respondents, or 82%, compared with 14 respondents, or 21%), offer case management for patients with substance use disorders (nine respondents, or 53%, compared with 24 respondents, or 36%), and offer contingency contracting (four respondents, or 24%, compared with five respondents, or 8%).

In the psychiatry programs prescriptions for medications specific to substance use disorders for patients with such disorders were low, even though most psychiatry programs (70 respondents, or 84%) employed one or more physicians (mean of 5.7±2.4 physicians). Of the 82,036 patients diagnosed as having a substance use disorder in FY 2003 who received only psychiatric care, only 3,772 (4.6%) received a prescription for disulfiram or naltrexone. In comparison, of the 86,291 patients receiving specialty substance use disorder treatment, 12,229 (14.2%) were given prescriptions for disulfiram or naltrexone. Despite the significant presence of physicians in psychiatry programs, patients in psychiatry programs were three times less likely than those in specialty treatment programs to receive medications specific to substance use disorders.

Primary care practitioners reported treating a mean of 215±135 patients in the past month, of which they estimated 9%±8% had a current substance use disorder. These estimates are considerably lower than the actual rate of 29% among veterans who use VA health care ( 3 ). Furthermore, 62 primary care practitioners (62%) stated they had not monitored substance use in an ongoing fashion (for example, urinalysis for drug abuse) for even a single patient in the past month.

When primary care practitioners detect patients with substance use disorders, they typically refer such patients to specialty treatment programs. Specifically, 59 primary care practitioners (59%) indicated that their typical approach to managing patients with substance use disorder involves referral to an outside mental health or specialty program; 75 (75%) reported making at least one such referral during the past month, and 27 (27%) indicated that they usually refer patients with substance use disorders to another provider within the primary care clinic. Fewer still (12 respondents, or 12%) indicated that they typically provide specific treatment services for substance use disorder themselves. The typical primary care practitioner in this category reported providing such treatment services to three patients in the past month, which was less than 2% of their patient caseload.

Almost all primary care practitioners (90 respondents, or 90%) reported telling at least one patient in the past month how substance abuse affects physical health. However, more intensive interventions for managing patients with substance use disorders were rarely provided. For example, 34 (34%) indicated that they had not provided ongoing counseling to any patient with a substance use disorder during the previous month. Among the 66 (66%) who reported providing ongoing counseling in the past month, the modal number of patients counseled was two, which was less than 1% of their patient caseload. Those who provided ongoing counseling reported being able to devote only small amounts of time to this activity: 42 (42%) spent less than five minutes per patient on counseling, and only 15 (15%) spent ten minutes or more per patient on counseling.

Of the 141,927 VA patients diagnosed as having a substance use disorder in FY 2003 who received all of their health care in the primary care setting, only 206 received a prescription for any substance use disorder-specific medication; this is less than one quarter of 1%. For substance use disorders, patients who were treated in primary care were more than 28 times less likely than the patients in specialty treatment programs to receive substance use disorder-specific medications.

Contraction of specialty treatment programs for substance use disorders is not necessarily problematic if a health care system is simultaneously expanding screening and intervention options in nonspecialty settings. Accordingly, this study examined the extent to which VA psychiatry programs and primary care practitioners detect and treat substance use disorders. We found that psychiatry programs and primary care practitioners typically underestimated the prevalence of substance use disorders among their patients. Comparison with known rates of substance use disorders indicates that psychiatry programs may not detect substance use disorders as much as one-third of the time and primary care practitioners fail to detect substance use disorders in two-thirds of patients with these disorders. These findings replicate other work conducted in VA and non-VA samples that suggest that substance use disorders are underdetected by health care providers ( 11 ).

Even when substance use disorders were detected, intervention was the exception rather than the rule. It is worth noting that studies that used patient reports and audiotapes of doctor-patient interactions have also shown that primary care practitioners do not routinely offer evidence-based care for substance use disorders ( 12 ) and rarely give advice to change substance use behavior ( 13 ). As psychiatry and primary care visits are important opportunities for initiating interventions to address substance use, increased use of screening and diagnostic tools should be encouraged in these settings. Toward this end, the VA has recently mandated annual screening for alcohol use disorders with the Alcohol Use Disorders Identification Test, making it a performance measure in primary care ( 10 ).

We found that when substance use disorders are detected in psychiatry and primary care, patients were usually referred to specialty treatment programs for substance use disorders. Notably, an absence of specialty care for substance use disorders at the treating facility did not influence the standard treatment protocols in psychiatry programs for substance use disorders. This would indicate that the reduction in specialty substance use disorder treatment has not been compensated for by a systematic increase in substance use disorder treatment offered in psychiatry and primary care clinics and raises concerns that substance use disorders are increasingly going untreated.

Two obvious solutions to the problem of untreated substance use disorders are available. One is to increase specialty programming for substance use disorders. Alternatively, increasing substance use disorder treatment in psychiatry programs and primary care would remedy the gap in treatment availability. This survey suggests that this second option cannot be accomplished without increasing appropriate resources. Only 42% of psychiatry programs had a staff member certified in addiction treatment, whereas more than 50% of patients in these programs have substance use disorders. Thirty-seven percent of programs did not offer any treatment services for substance use disorders. Primary care practitioners were unlikely to detect substance use disorders, and one-third did not provide brief counseling to even a single patient. Psychiatry and primary care providers will require additional training, time, and staff resources to provide quality care for substance use disorders to patients without access to specialty treatment programs.

Very little substance use disorder treatment is occurring in VA psychiatry and primary care settings, and these providers typically rely on specialty care. As VA specialty services for substance use disorders continue to contract, a problem may arise: providers can refer patients to specialty programs only if such programs exist. Caring for veterans with substance use disorders may require increasing the capacity of existing specialty programs, establishing new specialty programs, or expanding the ability of psychiatrists and primary care practitioners to provide such care. Because VA psychiatry programs and primary care practitioners serve as a critical channel by which patients are directed into specialized treatment for substance use disorders, proper screening and detection of substance use disorders is essential at these clinics.

The VA Mental Health Strategic Healthcare Group provided support to the Program Evaluation and Resource Center for this study. The authors thank Thomas Holohan, M.D., for his comments on an earlier version of this article. Views expressed in this article are the authors' and do not necessarily reflect official VA policy positions.

The authors report no competing interests.

The authors are affiliated with the Program Evaluation and Resource Center, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025 (e-mail: [email protected]).