Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.

The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper

Behavioral health care includes care for patients around mental health and substance abuse conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. Mental and substance use disorders alone are estimated to surpass all physical diseases as a major cause of worldwide disability by 2020. The literature recognizes the importance of the health care system effectively addressing behavioral health conditions. Recently, there has been a call for the use of the primary care delivery platform and the related patient-centered medical home model to effectively address these conditions. This position paper focuses on the issue of better integration of behavioral health into the primary care setting. It provides an environmental scan of the current state of conditions included in the concept of behavioral health and examines the arguments for and barriers to increased integration into primary care. It also examines various approaches of integrated care delivery and offers a series of policy recommendations that are based on the reviewed information and evidence to inform the actions of the American College of Physicians and its members regarding advocacy, research, and practice.

Preconsultation exchange in the United States: use, awareness, and attitudes

OBJECTIVES

Demand for specialty care exceeds supply in many healthcare systems in the United States. Preconsultation exchange has the potential to increase access to specialty care, and increase its timeliness and efficiency, by triaging need and urgency and streamlining the previsit workup. We sought to characterize attitudes toward, use of, and concerns regarding preconsultation exchange among US internists.

STUDY DESIGN

Prospective cross-sectional survey.

METHODS

We administered a Web-based survey to a large national panel of US internists maintained by the American College of Physicians.

RESULTS

Response rate was 55% (N=451) with minimal differences between responders and nonresponders. Of responders, only 13% were initially familiar with the term "preconsultation exchange," but once defined, 28% were classified as frequent users, 40% as occasional users, and 32% as rare/never users. Internists used preconsultation exchange to: guide the prespecialty visit workup (78%), answer clinical questions without a patient visit to the specialist (71%), triage referral urgency (67%), and transfer referrals to a more appropriate specialty (47%). Responders supported multiple benefits of preconsultation exchange, but also reported concerns regarding reimbursement, liability, physicians taking personal responsibility for patient care, and inadequate exchange of clinical information. Compared with primary care physicians, specialists recognized more benefits of preconsultation exchange, but also expressed more concerns. The majority of responders reported increased willingness to use preconsultation exchange if specific remedies were applied.

CONCLUSIONS

Most US internists participate in preconsultation exchange and agree with its potential benefits. However, important concerns and barriers exist. Methods to reduce barriers to preconsultation exchange should be identified.

Specialists/subspecialists and the patient-centered medical home

This article provides an overview of the Patient-Centered Medical Home (PCMH) care model. It provides a history and definition of the concept, a discussion of its growing acceptance by the health-care community, and a review of current public and public-private demonstration projects testing the concept. The role of specialty/subspecialty practices within the PCMH model is described, with a focus on the potential for these practices to serve as a PCMH for a subgroup of patients or, alternatively, as a PCMH "neighbor" that interfaces effectively with PCMH practices. The authors conclude that the model for effective connections between the PCMH and specialty/subspecialty practices requires further development, including the cross-specialty establishment of guidelines and processes regarding referrals, information flow, transitions in care, and accountability. The efforts of the American College of Physicians' Council of Subspecialty Societies PCMH Workgroup to further develop this model are described. The authors encourage involvement from all interested stakeholders to ensure that the issues and challenges identified are addressed through collaboration and consensus based on available evidence.

Mapping of Alport syndrome to the long arm of the X chromosome

Five X-chromosome DNA markers were typed on 261 members of three large kindreds with Alport syndrome (hereditary glomerulonephritis). Lod scores greater than 3.0 for linkage between the disease locus and two of the markers confirmed X-linked inheritance of the disease. A decreasing gradient in the estimated recombination fractions observed when the markers were ordered on the basis of their map locations suggested that the disease locus is on the long arm distal to all the markers typed in this study. Using three-locus analysis we rejected all but three map orders for the six loci (the disease locus and five markers). In all three the Alport syndrome locus was on the long arm of the X chromosome distal to all the markers. Two types of Alport syndrome were represented in the three kindreds. Affected males in one kindred developed deafness in addition to nephritis; deafness did not occur in members of the other two kindreds. Although larger recombination-fraction estimates were obtained for all five markers in the kindreds without deafness, the difference was significant for only one marker. Evidence of heterogeneity was not found in tests using two markers. Markers distal to the disease locus are needed to determine whether two loci are responsible for the two types of Alport syndrome.