Issues related to patient eligibility, treatment capacity, understanding of options, and communication problems all contribute to gaps in referral and delays to getting treatment for patients with substance use disorders, according to the new research by Claire Evelyn Blevins, PhD, of Warren Alpert Medical School of Brown University and Butler Hospital, Providence, RI; Nishi Rawat, MD, of OpenBeds, Inc., Washington. DC; and Michael Stein, MD, of Boston University and Butler Hospital.
Obstacles to Treatment
The ongoing opioid crisis has drawn attention to the widening gap between the high need and limited access to substance use treatment in the United States. A recent Substance Abuse and Mental Health Services Administration report found that of 21.7 million Americans in need of substance use disorder treatment, only 2.35 million received treatment at a specialty facility. Yet there is little information on the organizational-level barriers to treatment for substance use disorders.
To address this issue, Dr. Blevins and colleagues performed a series of interviews with 59 stakeholders in the treatment referral process. The study gathered input from those who make referrals for substance use treatment, including emergency medicine physicians, addiction specialists, and other medical providers; as well as those who receive referrals, including substance use treatment facility staff and administrators.
Four Broad Themes
Analysis of the interviews identified four broad themes:
Patient Eligibility. Healthcare providers face difficulties in determining whether patients meet criteria for admission to a particular treatment center, including the application of treatment eligibility criteria. "Eligibility requirements may prevent a patient from entering a treatment center," the researchers write.
Treatment Capacity. Even if a patient is eligible, providers have trouble finding out whether space is available. "Despite the need for services, treatment centers may not run at capacity, because of frustrations encountered and time wasted on the referral and admission process."
Knowledge of Treatment Options. Providers may not understand the levels of available care for substance use treatment, and how to select the best treatment for their patient. "After determining the appropriate level of care, a provider must then find a program that meets the patient's needs, which becomes more difficult with the differences in terminology and program guidelines."
Communication. Difficulties in communication between referring providers and treatment facilities can contribute to delays to starting treatment. The need for direct referral - "from the emergency department to a bed" - is particularly high for patients with opioid use disorders.
System Needs Improvements
"Access to substance use disorder treatment is often a maze that can be difficult to navigate for both providers and patients," Dr. Blevins and coauthors write. Based on the themes identified, they make recommendations for improvement in the referral process, including a database of clear eligibility criteria, real-time information on treatment capacity, and increased education and training for providers on substance use treatment.
They also propose ways to improve communication and reduce treatment waiting times, including new information technologies. The researchers write: "By improving systems that enhance communication across organizations, patient referrals may be more easily completed, improving access to care and expanding the use of appropriate treatments for the many patients in need."
In an accompanying commentary, David L. Rosenbloom, Ph.D., of Boston University School of Public Health discusses the underlying reasons for the current "dysfunctional referral system." He notes that referrals for other chronic diseases "may be more effective because they are to 'in-house' affiliated providers." Dr. Rosenbloom writes: "The standard of care should be to stabilize, initiate treatment, and provide a hands-on transfer to an entity that can complete a diagnostic assessment and provide evidence-based treatment" for patients with substance use disorders.