The segregation of addiction treatment and medical care is an unfortunate consequence of policies and practices that have developed in the United States over many years. New research points toward the benefits of integrating these 2 systems of care, and the development of new behavioral and pharmacologic treatments for addiction is destined to render their separation increasingly untenable. However, movement toward integration faces substantial regulatory and political obstacles.

Powerful historical trends have led to and perpetuated the treatment of addiction in isolation from medical care. In the most extreme example, physicians have essentially been prohibited from treating opioid-dependent patients with methadone in their offices.1 Funding for addiction treatment is often excluded from medical insurance coverage, and even public funding under Medicaid “entitlements” is often unavailable. Specialized addiction treatment programs seldom provide medical care, while medical care sites treat the complications of addiction but rarely address, let alone treat, addiction problems.2,3

One solution to this disjunction has been to bring medical services into substance abuse treatment programs. Model programs that integrate HIV care into methadone maintenance programs have shown positive results,4,5 and randomized trials in addiction programs comparing on-site medical services to referral found increased access to medical care6 and improved addiction outcomes among those with substance abuse–related medical conditions.7

Some of the first large-scale observational data addressing the impact of integrating medical services into addiction treatment programs is presented in this issue of JGIM. Friedmann et al. study the effects of primary care availability on addiction outcomes using the National Treatment Improvement Evaluation Survey of substance abuse treatment programs.8 Patients in programs with on-site primary care services were found to have improved scores on an unvalidated measure of overall addiction severity at follow-up compared with patients in programs that did not offer such services.

Bias could have resulted from unmeasured program features associated with both the availability of on-site medical services and better overall addiction treatment quality. In addition, the lack of separate analyses for patients in methadone programs compared with other modalities is problematic, given differences in medical severity and treatment duration. Although the magnitude of the effect of primary care availability appears small, these results add to a growing body of research suggesting benefits for integrated medical and addiction treatment.

The authors further hypothesized that improvements in addiction severity might be mediated by improved medical status, but found no effect of primary care on a medical severity index they created. However, this measure did not change from admission to follow-up and may have been insensitive to a true effect. The index was based on patients' self-report of problems related to a variety of mostly chronic medical conditions, and the availability of primary care may not have affected these conditions, or may have increased patients' awareness of medical problems by making new diagnoses of hepatitis, hypertension, or HIV. No single variable emerged that mediated the effect of medical care on addiction outcomes, highlighting the need for further study, including measurement development.

A second strategy to integrate addiction and medical care is to develop addiction interventions within medical care settings. This approach may allow earlier identification of addiction problems and serve patients who are not ready to enter specialized addiction programs. Primary care screening followed by brief physician counseling of patients with less-severe alcohol-related problems has been shown effective in clinical trials.9 A novel model of intensive primary care for medically ill patients with alcohol dependence has been shown to improve abstinence rates compared with conventional addiction referral.10 These and other interventions in the medical setting—applied across the spectrum of patients from those merely at risk to those with apparently intractable addictions—stress physicians' efforts to relate drug or alcohol use to patients' current medical problems, such as the effect of alcohol on liver disease, the effects of drug use on adherence to medical therapy, or the benefits of continuing methadone maintenance while treating hepatitis C.11

In addition to promising behavioral interventions, medications for addiction treatment are becoming increasingly available. One recently approved medication, buprenorphine, offers an alternative to methadone for the pharmacological treatment of opioid dependence.1,12 Recent legislation allows physicians in office-based practice to prescribe buprenorphine to a limited number of patients after appropriate training. Regulatory changes now also allow methadone to be provided by physicians, although such programs are limited to physicians who partner with a formal opioid treatment program in treating patients who are in long-term remission on methadone. Physician office–based treatment of new patients with methadone still faces policy obstacles.1

Other medications for addiction treatment are being developed, spurred by a rapidly evolving understanding of the neurobiology of addiction.13,14 Knowledge of the genetic underpinnings of vulnerability to addiction and the brain changes that occur during addiction is certain to multiply targets for medication development. These treatments will accelerate the need for physicians to become more involved with addiction medicine in settings that can provide both behavioral and pharmacologic treatment approaches.

The movement toward integration of addiction treatment and medical care is impeded by rigid regulatory policies, the paucity of addiction education for physicians, and the lack of parity in insurance coverage for addictions. However, progress is being made toward an era of managing addiction as a chronic medical disease,15 and physicians can be increasingly confident that their ministrations, while providing no certain cure, can have important and measurable benefits for their patients' struggle toward recovery.—Joseph O. Merrill, MD, MPH,Division of General Internal Medicine, Harborview Medical Center, Department of Medicine, University of Washington, Seattle, Wash.


  1. Top of page