Case-based Session to Feature Addiction Care Pearls for Primary Care

A patient complains of difficulty with concentration. Is the culprit attention deficit hyperactivity disorder or substance abuse? Another patient has hypertension and obesity, and consumes quite a bit of alcohol. Might the alcohol be triggering the hypertension and obesity? Those are examples of cases two primary care addiction specialists will present during Workshop 11 “Improving Addiction Care in Primary Care” from 10:15 a.m. to 12:15 p.m. today in Continental B, lobby level of the Hilton Chicago.

“We will address issues that primary care doctors deal with in their patents involving potential substance abuse,” said speaker Norman Wetterau, MD, FASAM, Addiction Medicine Specialist and Family Physician, Tri-County Family Medicine, Dansville, N.Y. “We will ask the audience how they would approach the cases and come up with the treatment approach, though we will offer insights and recommendations.”

Bruce Maslack, MD, Medical Director, St. Mary’s Health Care Addiction Services, Amsterdam, N.Y., also a speaker, said, “We believe a case-based approach will make this information memorable and applicable to practice.”

The key to resolving a patient’s medical problem may be to address that individual’s alcohol use, Dr. Wetterau said.

“Whether it’s sleep problems, depression, stomach pain, or hypertension, the doctor needs to connect the alcohol to the specific problem,” he said. “The patient does want to know what is causing the problem. In cases where alcohol is involved, the brief intervention is effective, and it doesn’t take that much time.”

Dr. Wetterau also will describe how to make a “no” answer into a “yes” answer. Instead of telling a patient, “No, I will not prescribe an opioid for pain,” a more effective approach is to say, “We have something I believe will work better for you.” That turns a negative into a positive and guides the patient toward addressing the pain’s source via physical therapy, physical activity, or an antidepressant.

An area ripe for redirection involves neurostimulants. Dr. Maslack will present the latest data from the University of Maryland on their use for attention deficit hyperactivity disorder. Other patients seek these neurostimulants for neurological enhancement as a means to improve themselves.

“We have an epidemic of prescribing these medications for patients who are having concentration or behavioral problems,” he said. “We are not really assessing that and screening for the patient who might have an alcohol or drug problem masking as a behavioral problem. I would like primary care physicians to look at this carefully in their practices.”

When substance use issues surface with patients, Dr. Maslack encourages primary care physicians not to abandon patients by referring them out of their practices entirely, essentially firing the patient.

“We are trying to help primary care physicians see a different

approach to patients with addiction,” he said. “Often, patients with substance use issues are not the ones we see in addiction treatment programs. They have problematic use of these substances that we may be able to do something about through a brief intervention and advice.”

Dr. Wetterau will advise primary care physicians how to get paid appropriately for these services by applying the correct evaluation and management (E/M) codes. He will teach how to upcode when the patient presents at least three problems or when a problem is unstable. For example, if a patient on buprenorphine also complains of anxiety and uses tobacco, those are three problems the physician will address, document, and subsequently upcode. As for unstable conditions, substance-positive urine tests, reports of substance-use slips, or development of constipation are indicative of instability in treating the ongoing substance use. Therefore, the primary care physician may upcode because of the additional time it will take to resolve.

“With the Affordable Care Act, we are implementing new codes and ways to bill for services in primary care settings for patients with addiction,” Dr. Maslack said. “For that reason, we need to know how to handle coding for these situations.”