Abstract
In 2017, more than 70 000 persons died as a result of drug overdose, making it the leading cause of injury deaths in the United States. Opioids, primarily synthetic opioids (other than methadone), that include illicitly manufactured fentanyl are currently the major drivers of drug overdose deaths. Opioid-related deaths increased by 71% per year from 2013 through 2017. 1 In 2017, approximately 19.7 million persons aged 12 or older in the United States had a substance use disorder that involved the use of opioids and other substances. According to the 2017 National Survey on Drug Use and Health, an estimated 8.5 million adults aged 18 or older had a co-occurring substance use disorder and any mental illness, and 3.1 million adults aged 18 or older had a co-occurring substance use disorder and severe mental illness. 2
The opioid epidemic is exacerbated by a lack of treatment for affected persons, sometimes called the opioid use disorder treatment gap. A 2015 study showed that nearly 80% of persons aged 12 and older with opioid use disorders in the United States did not receive treatment during 2009-2013, even though treatment can be effective. 3 For example, medication-assisted treatment, a combination of behavioral health interventions and medications (eg, methadone, naltrexone, buprenorphine), is clinically effective in treating persons with opioid use disorders. 4 -9
More than 2 million US adults aged 18-64 have opioid use disorder. National estimates from 2015-2017 showed that mental illness was common among adults with opioid use disorder; 64.3% had any mental illness and 26.9% had severe mental illness. In addition, of particular concern is the low prevalence of receiving mental health and substance use treatment services in the past year (2015-2017) among adults aged 18-64 with opioid use disorder and any mental illness (24.5%) and with opioid use disorder and severe mental illness (29.6%). 10
In recent years, public health officials have called for filling the opioid use disorder treatment gap by integrating behavioral health and primary care to expand access to treatment. Behavioral health refers to treatment for mental health conditions and substance use disorders, including providing medication-assisted treatment. 4 Providing integrated behavioral health care in primary care settings to persons with opioid use disorders has the potential to enhance the quality of treatment, improve health outcomes, and reduce health care costs. 4
In this Executive Perspective, we describe how federally qualified health centers, funded by the Health Resources and Services Administration (HRSA; hereinafter referred to as health centers), have responded to the opioid use disorder treatment gap among the most vulnerable and underserved populations in the United States. We describe HRSA’s use of the Patient-Centered Medical Home advanced primary care model for persons with opioid use disorders, and we posit that the experience of health centers can inform an expansion of behavioral health and primary care integration in other primary care settings.
Primary Care Settings
Primary care settings often serve as gateways to the health system. Thus, they may improve access to and quality of care for patients with substance use disorders, including patients with opioid use disorders. The National Academy of Sciences defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing the large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” 11 Primary care settings may include health centers, private practices, and academic primary care practices.
Traditionally, the management of mental health conditions and substance use disorders has occurred in settings that are separate from primary care settings and even separate from the medical or physical health care system. Moving the management of these disorders to primary care settings may improve access to treatment for mental health and substance use disorders, potentially improving the quality of care for the patient. Patients receiving care for substance use disorders in primary care settings may perceive more comfort and familiarity and less stigma than they perceive in specialty substance use disorder treatment programs. 4 More comfort, more familiarity, and less stigma may improve the likelihood that they will stay in treatment and succeed in the long term. 9 Compared with treatment in specialty substance use disorder programs, treatment in a primary care setting can be more comprehensive and coordinated. 4 For example, patients in primary care settings can receive preventive care and treatment for medical comorbidities along with treatment for substance use disorders and mental health conditions.
HRSA-Funded Health Centers
Health centers provide accessible, affordable, high-quality, comprehensive primary care services, particularly to vulnerable and underserved populations. 12,13 As stipulated in section 303 of the Public Health Service Act, health centers are required to provide primary health services, preventive dental services, referrals for medical and behavioral health services, as well as patient support services, such as transportation, health education, and case management. 14 Nearly half (approximately $5.6 billion) of HRSA’s budget is dedicated to funding the health center program across the nation. In 2017, HRSA funded nearly 1400 health centers that operated approximately 12 000 delivery sites in all US states and territories. 15,16 A health center delivery site may be a fixed or mobile health care clinic or may be located in a school setting. In 2017, health centers, all located in medically underserved communities, provided care to more than 27 million persons in the United States, or 1 in 12 persons nationwide, including 1 in 3 persons living in poverty and 1 in 5 persons living in rural communities. 13,17 Given the number and locations of health centers, the number of persons who receive their services, the communities they serve, and their mission, health centers are on the front lines of the opioid epidemic. They serve populations that are substantially affected by substance use disorders and have a unique opportunity to help combat the current opioid epidemic.
Patient-Centered Medical Homes and Integration of Behavioral Health and Primary Care
Since 2011, HRSA has supported health centers with additional funding, technical assistance, and training to become Patient-Centered Medical Homes. The Patient-Centered Medical Home is a primary care delivery model in which care is oriented to the whole person, that is, addressing the medical, psychological, and social aspects of the individual. Care is delivered proactively by a multidisciplinary team that integrates and coordinates behavioral health and primary care. This integrated and coordinated care delivery model prevents the fragmentation of medical and behavioral health care that exists in the health care system. As of December 2018, more than 75% (1016/1362) 17 of health centers had been recognized as Patient-Centered Medical Homes by accrediting bodies such as the National Committee for Quality Assurance (NCQA) and the Joint Commission (Figure). For example, the NCQA criteria to obtain Patient-Centered Medical Home recognition are developed from evidence-based guidelines and best practices that focus on several concept areas (eg, team-based care and practice organization, knowing and managing your patients, patient-centered access and continuity, care management and support, care coordination and care transitions, performance measurement, and quality improvement). 18
Percentage of Health Resources and Services Administration (HRSA)-funded health centers with Patient-Centered Medical Home (PCMH) recognition, US states and territories, 2018. HRSA-funded health centers can achieve PCMH recognition by meeting national standards for primary care that emphasize care coordination and ongoing quality improvement by accrediting bodies such as the National Committee for Quality Assurance and the Joint Commission. 18 Data as of December 31, 2018.
Since 2016, HRSA has supported health centers with additional funding, technical assistance, and training to provide substance use disorder services, including medication-assisted treatment and mental health care integrated with primary care as part of the Patient-Centered Medical Home. More recently, HRSA expanded support for integrated behavioral health services at health centers. 19 In 2018, HRSA awarded $352 million to health centers for substance use disorder and mental health service expansion and quality improvement activities (HRSA awarded $200 million in 2017 and $94 million in 2016). In addition, HRSA has promoted the use of telehealth (ie, using telecommunications technologies to enhance health care) for substance use disorder and mental health treatment, particularly in rural communities. Also in 2018, HRSA awarded $25.5 million to 121 rural health organizations and communities to increase access to substance use prevention and treatment services serving rural populations. In 2018, HRSA awarded $18.5 million to enhance health centers’ behavioral health workforce by supporting training for behavioral health professional and paraprofessional students on health center multidisciplinary teams (from $4 million in 2017). 20
These actions have resulted in more patients receiving substance use disorder and mental health services. According to HRSA’s Uniform Data System, in 2017, 71% (970/1373) of health centers provided substance use disorder services, compared with 66% (838/1278) in 2014. From 2014 to 2017, the number of patients who received mental health services increased 64% (from 1 251 498 to 2 049 194), and the number of patients who received substance use disorder services increased 68% (from 100 238 to 168 508). For the same period, the number of patients who received screening, brief intervention, referral, and treatment increased 344%, from 229 228 in 2014 to 1 017 249 in 2017. The number of health center providers (qualified physicians) eligible to prescribe medication-assisted treatment increased 75% (from 1700 in 2016 to 2973 in 2017), and the number of patients receiving medication-assisted treatment increased 65% (from 39 075 in 2016 to 64 597 in 2017) (Table). 17
Number of patients, HRSA-funded health centers, and services provided, uniform data system, United States, 2014-2017a
Abbreviations: HRSA, Health Resources and Services Administration; NA, not available.
aData source: HRSA. 17
bBegan collecting data in 2016.
Health Centers’ Challenges
Despite these advances, health centers face challenges in implementing substance use disorder services, including medication-assisted treatment, which can be instructive. Health center directors have described challenges to HRSA leaders (J.S.), at annual listening sessions, and in commissioned reports. One challenge is recruiting and retaining (1) qualified clinicians who can treat opioid use disorder in treatment settings other than opioid treatment programs (ie, providers known as “Drug Addiction Treatment Act of 2000 waivered providers”) and (2) substance use disorder counselors. 9,21 A second challenge is the lack of important team members who can provide support for the delivery of medication-assisted treatment. A chief cause of this challenge is that the services of several important members of primary care medication-assisted treatment multidisciplinary teams, such as nurse care managers, substance use disorder counselors, and peer navigators, are often not reimbursed by public or private payers. Health center directors have told HRSA leaders that clinicians who are qualified to provide medication-assisted treatment under the Drug Addiction Treatment Act of 2000 are less likely to prescribe medication-assisted treatment or will prescribe to fewer patients if they lack the support of a team in their treatment setting.
Another challenge noted by health center directors is that health center staff members need additional technical assistance and training to implement or expand an integrated model of care that is sensitive to patients’ experiences of trauma (resulting from an event or series of events that has affected or affects the person physically or emotionally), called trauma-informed care. According to the Substance Abuse and Mental Health Services Administration, a trauma-informed system of care realizes the effect of trauma and understands the paths for recovery, recognizes the signs and symptoms of trauma among patients and staff members, and responds by fully integrating knowledge about trauma into policies, procedures, and care practices and actively resisting retraumatization. 22 Furthermore, health center directors have noted that their staff members need additional training in the safe prescribing of opioids, pain management, and the confidentiality requirements that are part of treatment for opioid use disorders (eg, sharing of patient records, extension of patients’ consent, treatment of minor patients). Health center directors also identified a need to mentor clinicians who are new to prescribing medication-assisted treatment as they gain comfort and expertise with this new service. Lastly, health centers need to work closely with their staff members and communities to engage them in supporting medication-assisted treatment as an effective approach to substance use disorder care and to overcome the stigma of substance use disorders and mental illness.
Moving Forward
Health centers’ integration of behavioral health and primary care through the multidisciplinary team of Patient-Centered Medical Homes may inform more widespread expansion of access to mental health and substance use disorder services in primary care practices of all types in the United States. Increasingly, primary care practices in the United States are being recognized as Patient-Centered Medical Homes by accrediting bodies. 23 Although more research is needed to evaluate the effect of integrating behavioral health, including substance use disorder and mental health services, and primary care, research shows that health centers that are recognized as Patient-Centered Medical Homes have performed better on clinical quality measures than health centers that are not recognized as Patient-Centered Medical Homes. 24 To facilitate expansion of this care integration model, health centers and other primary care practices would benefit from policy changes and programs that address the aforementioned challenges, such as the recruitment and retention of qualified clinicians who can treat opioid use disorder in joint efforts with their multidisciplinary team of nurses, substance use disorder counselors, and peer navigators and also expanding staff member training in the safe prescribing of opioids and pain management. Therefore, mobilizing primary health care practices of all types to integrate behavioral health, including substance use disorder services, and primary care through a team-based approach may be feasible and could improve access to and quality of care. 24
Primary care in the United States has an important role to play in combating the ongoing opioid epidemic. As the data from HRSA’s Uniform Data System indicate, mobilizing primary care to implement a Patient-Centered Medical Home model of care that integrates primary care and behavioral health may further expand comprehensive and integrated mental health and substance use disorder services across the nation. As HRSA continues to collect data in the coming years, we will understand more about how this integrated primary care model works in practice and its impact. The pain and suffering of individuals, families, and communities in the United States as a result of the opioid epidemic may be offset by integrated and coordinated approaches to care that improve access and quality. Primary care should be integral to meet this challenge.
Footnotes
Authors’ Note
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Health Resources and Services Administration or the US Department of Health and Human Services. The current affiliation for George Sigounas is Immediate Office of the Secretary, US Department of Health and Human Services, Washington, DC, USA.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
