After nearly a decade in and out of treatment for an addiction to opioids, a patient of Daniel Lewis, MD, told him she was finally ready for permanent recovery.
"The day she said, 'That's it, I need no further,' was one of the happiest days of my clinical practice," Lewis, an internal medicine doctor with the Facey Medical Group in Los Angeles, said.
As a primary care physician, Lewis monitored his patient's progress with frequent checkups — both virtually and in person — during which he inquired about potential opioid withdrawal symptoms such as shaking, tremors, nausea, and vomiting; and adapting to pain without the use of narcotics.
Lewis is part of a larger trend of primary care physicians engaging patients with substance abuse disorders in follow-up care, which has proven effective in aiding sustained recovery.
According to the National Institute on Drug Abuse, 20.4 million people in the United States were diagnosed with substance abuse disorders in 2017. And in 2022, 29.5 million people aged 12 years and older had alcohol use disorder.
Looped In
In 2018 and 2020, the US Preventive Services Task Force released recommendations for screenings for alcohol and unhealthy drug use in adults.
Clinicians usually follow screenings with a brief intervention and referral to treatment (SBIRT), a process developed by the Substance Abuse and Mental Health Services Administration in the 1980s.
But what happens after the screening, brief intervention, and referral to treatment?
Lewis suggests follow-ups every 3 months or even monthly as a best practice for those struggling with addiction. These recovery management checkups (RMC) are provided in addition to the treatment and counseling a patient receives from substance abuse centers, which can include medication, psychotherapy, and behavioral therapy.
Lewis described "every visit as an investigative visit" to gauge how patients are progressing in recovery and how these are needed more frequently than annual checkups because of the higher risk for mortality and morbidity associated with illegal drug use.
Even if regular follow-ups are not possible, Lewis said primary care physicians must stay involved, even if the patient is receiving treatment elsewhere.
"Alcoholism and substance abuse [are] such a big, overarching part of someone's health, as a primary care physician, even if you've sent that patient to a specialist to deal with it, it's something that you follow in the background," he said.
Kendra Segura, MD, an OB/GYN with the To Help Everyone Health and Wellness Centers in Los Angeles, said she screens every patient for depression, substance abuse, and domestic violence. A physician can use their discretion in administering a drug test, though they require people who are pregnant to do so.
Segura recently tested a pregnant patient, and the results came back positive for tetrahydrocannabinol (THC), the primary psychoactive ingredient in cannabis. The positive test prompted her to dig deeper into the patient's medical record, which revealed prior methamphetamine abuse that the patient was in recovery from. Segura referred her patient to an on-site substance abuse counselor. The patient relapsed during her pregnancy but gave birth to a healthy baby.
The patient also kept up with her postpartum visits and has not relapsed.
"It just shows you the more people that are involved, the more accountability, the more support, patients can improve their health," Segura said.
In Segura's experience, patients aren't always forthcoming with their clinicians when completing drug or alcohol questionnaires. They may fear losing their jobs, children, or government-provided benefits like food assistance.
She also cited the time constraints of clinicians as a barrier to adequate recovery follow-up.
"The more follow-up they have with their healthcare providers, even with substance abuse counseling or a treatment program, there still should be communication with their primary doctor," she said, adding that healthcare providers "should be looped in."
A recent study looked at the effectiveness of using primary care settings for recovery management checkups. Using data from federally qualified health centers, the findings showed "further evidence of the effectiveness of the 'referral to treatment' component of SBIRT when combined with RMC for patients in primary care settings."
The researchers added that "results demonstrate the value of repeated checkups on longer-term treatment and substance use outcomes."
Michael Barry, MD, chair of the USPSTF and a member of the teams that wrote the two recommendations on screening, compared recovery management checkups to successful smoking cessation interventions of years past: Follow-up, praise, and repetition.
"Checking in on them and then praising them when they've done a good thing all seem good ways to keep people from relapsing into unhealthy drinking or drug use," he said.
Robert Fulton is a freelance writer living in California.
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