A Place for Primary Care

If you haven't yet read details of the COMBINE study that examined treatments for alcohol dependence at 11 academic sites, this partial list of the study's research team should make you take notice: Bankole Johnson, MD, PhD; Raymond Anton, MD; Stephanie O'Malley, PhD; David Gastfriend, MD; William Miller, PhD; Allen Zweben, DSW; Robert Swift, MD. An all-star lineup indeed.

Some media reports on the study, published in the May 3 Journal of the American Medical Association, have zeroed in on its finding that the medication naltrexone significantly outpaced the drug acamprosate in improving abstinence outcomes and reducing risk of heavy drinking days. (This certainly lends weight to Mark Publicker, MD's comment related in this space in the March/April issue, that naltrexone is “the most effective medication not being prescribed in this country.”) Yet what may prove even more significant to the field over time is the study's confirmation of primary care physicians' ability to treat alcohol dependence successfully in the office setting.

This finding, based on research involving nearly 1,400 patients, could carry huge implications for closing a pervasive treatment gap. And the specialty addiction sector should welcome the prospect of more individuals receiving care through their primary care provider, given the potential this would have for bringing about referrals and further legitimizing addiction treatment with the public.

Clearly this has been one area in which addiction professionals' brethren in mental health have achieved more progress. For years now, mental health field leaders have urged specialty provider organizations to partner with primary care clinics, especially since that amounted to “following the money” as the federal government increased support of federally qualified health centers. Primary care and specialty mental health services under one roof have become more prominent in recent years as a result.

In the meantime, much of the discussion of primary care in the addiction community has centered on physicians' distrust of addicts and unwillingness to address their issues. But the COMBINE results, in which naltrexone in combination with medical management topped the list of studied interventions, seem to call into question the assumed dearth of physicians willing and able to help the alcohol-dependent.

The COMBINE study merits a careful read because it examines nine separate treatment protocols representing variations of antialcohol medications, placebo, behavioral therapy, and medical management. In perhaps the best news of all to come of this, all treatment groups showed some level of improvement from their 16-week course of treatment, confirming that the road to recovery can have any number of starting points.