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What If Your Doctor Asked About Your Opioid Use?

A new program tries to catch would-be opioid abusers early. Very early.

By Francie Diep


(Photo: Susan Sermoneta/Flickr)

There’s an interesting experiment launching soon among a series of clinics that serve low-income individuals in Santa Barbara, California. In a few months, a patient who visits a Santa Barbara Neighborhood Clinic may find a new set of probing questions from his doctor, beyond the usual paperwork asking for insurance information and smoking history. The clinics are implementing a 20-point survey that asks questions such as “Have you used drugs other than those required for medical reasons?” and “Do you ever feel bad or guilty about your drug use?” If a patient answers “yes” to enough of those questions, his doctor will ask whether he wants to see a drug counselor before treating him for anything else — including a cold, diabetes, or whatever he originally came into the clinic for.

The aim of the new policyis to find and treat those who are abusing addictive drugs, especially prescription opioid painkillers, which mimic the effects of opium, morphine, and heroin. Over the past several years, Americans have increasingly used these drugs recreationally, and they’ve paid the price. Since 2000, the rates at which Americans have died from overdosing on opioids, including prescription and street drugs, has doubled. In Santa Barbara County in particular, more people die of opioid overdoses than the state average. The Centers for Disease Control and Prevention has declared an opioid-abuse “epidemic” in America.

Over the past year, the Obama Administration tried to tackle the problem with a lot of money and several programs, including $94 million in grants to clinics that see low-income, migrant, homeless, or otherwise underserved folks. The Santa Barbara Neighborhood Clinics received one such grant, to the tune of $325,000, which they plan to use to hire a behavioral health specialist and to train their staff to screen all of their patients for drug abuse, says Charles Fenzi, CEO of the Clinics, which has six locations in town. The science on whether this effort will work — on how many would-be opioid addicts doctors will be able to identify and re-route — remains uncertain. Still, experts Pacific Standard talked to said it’s worth trying.

“This really is a move in the right direction.”

The Santa Barbara Neighborhood Clinics are among the frontrunners in a movement for primary-care doctors to screen for mental disorders in the same way they already ask patients about their history with cancer, heart disease, and other physical conditions. The movement is driven by doctors like Fenzi, who believes ensuring his patients are treated for mental problems is key to keeping them healthy overall. Perhaps someone who’s pre-diabetic but not sticking to her diet, for example, is actually suffering from depression or addiction, which is sapping her willpower.

“If a patient is addicted, they’re going to be focusing their energy on getting their next dose. They’re not going to be engaged in taking responsibility for controlling their blood sugar,” Fenzi says. “To get the patient engaged with other problems, you may have to deal with these big problems, first.” The Affordable Care Act is also pushing the trend, because it mandates that mental and physical health care receive equal attention.

“This really is a move in the right direction,” says Stephen Strobbe, a researcher and nurse who studies addiction at the University of Michigan. In 2014, Strobbe published a paper urging doctors’ offices like the Santa Barbara Neighborhood Clinics to use a drug-screening program called Screening, Brief Intervention, and Referral to Treatment, or SBIRT. That’s exactly the program Fenzi plans to implement. “The worst that could happen from this is nothing and the best that could happen from this is people could receive the appropriate level and intensity of care to address a substance use disorder,” Strobbe says.

To be clear, SBIRT is not a drug-testing program. It doesn’t require a urine sample. Instead, at least once a year, any Santa Barbara Neighborhood Clinics’ patients 12 or older will fill out a survey about their drug use. (Although 12 may seem young, experts agree it’s reasonable.) Patients’ answers will determine whether doctors should intervene. Patients can lie on the survey, of course, just like they can lie to their doctors about any of their habits. Still, there’s good evidence SBIRT works to catch and prevent alcohol abuse.

And while there isn’t much research on whether SBIRT works to catch abusers of opioids or other drugs, researchers insist that is by no means a reason for pessimism. “Absence of evidence isn’t evidence of absence,” says Matthew Young, a policy analyst for the Canadian Center on Substance Abuse.

Still, it’s unknown how effective the Santa Barbara Neighborhood Clinics’ program—or any other clinics’ SBIRT programs, for that matter—will be. And the Santa Barbara Neighborhood Clinics plan to use a screening questionnaire that explicitly leaves out alcohol use, which means it won’t catch the one addiction for which there’s the best evidence that SBIRT works.

Young thinks SBIRT could work well to identify people who might have started by taking a prescribed opioid painkiller for something like lower back pain, and since became gradually (and unknowingly) addicted. “The strength of the SBIRT model is identifying individuals who may be beginning to experience harms and then having a conversation with them about that,” he says. “Early identification, that’s the key thing here.”

Although the evidence on this isn’t clear yet, Young thinks SBIRT might not work as well on people who use drugs like heroin or cocaine—the harsh consequences of which are better known by the public. Overall, he was supportive of the idea of clinics trying SBIRT. “I think it’s really great that they’re doing something about this issue,” he says. “If they catch some people and they’re able to help them onto a trajectory into treatment, I think that’s laudable.”

That the Santa Barbara Neighborhood Clinics is pioneering this program does create an odd dynamic in a city that is notable in part for its wealth. The most common job description in town is “executive”; the median house is worth more than $800,000. Unless private doctor’s offices are on the cutting edge of drug screening policy, however, only the poorest Santa Barbarans will get SBIRT-ed annually. Maybe their richer peers should hope for it though. As Strobbe says, “Clinicians aren’t doing their more affluent patients any favors by not asking them about this important aspect of their health behaviors.”