You look at your clinic schedule, and there they are: some patients you’ve known for years who are going to challenge your inner clinician. Perhaps you have been talking with them about their alcohol use for decades, and they say they want to quit but get too shaky to stop. Perhaps the challenge comes from their prescribed opioid doses creeping higher and higher and for longer periods than you would like.

You know that recent public attention to problems caused by prescription and nonprescription drugs and the pressures on clinicians to solve these problems have intensified enormously over the past few years. You also feel the tension between the awareness of these serious problems and the needs of patients facing challenging situations and health conditions.

While you appreciate that guidelines for care issued by multiple agencies give you tools to discuss substance use with your patients, you also know these may be very difficult discussions. Like other busy practicing clinicians, you feel the mounting pressure to intervene by screening, counseling, initiating medication-assisted treatment (combining medication with behavioral health services), and tapering high-risk medications.

PCPs Shoulder Responsibility

It would be great if every community had a comprehensive substance use treatment program, easily accessible to both patients and clinicians regardless of insurance or type of drug used. That’s the kind of system that many California counties are working on building for their Medi-Cal populations through the Drug Medi-Cal Organized Delivery System pilot. These programs will offer a comprehensive array of treatment options for substance use disorders and will be coordinated with Medi-Cal managed care plans and primary care providers.

But the reality is that right now, much of the responsibility for treating these patients falls on the shoulders of primary care clinicians, with or without integrated substance use treatment in primary care settings. And many patients say they prefer to have their substance use needs and mental health treatment managed by their primary care providers. In that setting, advice from an experienced clinician who can share the latest approaches, explore complexities of each case, and help navigate treatment discussions is essential. Whether it is identifying those who should be reconnected with an opioid treatment program or advising on a safer strategy to adjust opioid and benzodiazepine doses, expert support can often help guide us to the best options.

Help Is Here

This free and confidential help is now available from the Clinician Consultation Center (CCC) Substance Use Warmline, based at Zuckerberg San Francisco General Hospital. For 25 years, the CCC has provided focused education and decision support to clinicians across the country of varied backgrounds and experience levels, mainly addressing HIV and viral hepatitis prevention and care. This year, through a partnership with the US Health Resources and Services Administration (HRSA) Bureau of Primary Health Care, the center expanded its services in an effort to complement the many new clinical education initiatives surrounding substance use disorders and high-risk medication combinations. The CCC’s multidisciplinary team of dedicated substance use experts and educators includes Addiction Medicine-certified physicians, clinical pharmacists, and advanced practice nurses.

The Substance Use Warmline has assisted callers across a wide range of topics, including concurrent use of multiple opioid formulations, outpatient alcohol detoxification and benzodiazepine tapers, opioid addiction treatment with buprenorphine during pregnancy, urine drug toxicology interpretation, approaches to addressing methamphetamine use, and drug interactions between prescriptions used for medication-assisted treatment and HIV/hepatitis C. More than half of the calls have involved patients using multiple substances.

Service Used by Physicians, Nurses, Counselors, and More

The Warmline has provided consultation to primary care physicians as well as substance use counselors, nurses, physician assistants, and psychiatrists in locations ranging from Pennsylvania to Georgia to Illinois, with many calls from California — especially rural practices with limited community-based treatment infrastructure. Every caller has been a busy clinician providing a broad range of patient care. Some already had a buprenorphine waiver under the Drug Addiction Treatment Act of 2000 (DATA 2000) but were seeking real-time assistance in putting it to its first use.

Calls have included:

• A 42-year-old with extensive history of opioid use agrees to try decreasing oxycodone. Would it be better to try buprenorphine or methadone first? What about prescribing rescue naloxone?
• A 67-year-old with alcohol use disorder who has also received pain medications intermittently from various local emergency departments for severe arthritis. What are some options to address risky alcohol use and pain?
• A 38-year-old who gets benzodiazepines for sleep has a urine screen positive for cocaine. What would be a reasonable approach?

One recent caller, a primary care clinician, said: “My conversations with [the Warmline] have helped clarify my patient plans, and that clarity alone has been so valuable. Because addiction affects so many aspects of my patients’ lives, including the ways they relate with me as their PCP, it’s been very helpful to feel assured by an expert that I am taking appropriate steps that may be beneficial to their recovery.”

The Warmline can support the work of primary care providers in applying evidence-based and compassionate approaches to the complexity of problems facing patients with opioid use and substance use disorders. We hope to help increase clinicians’ capacity to prevent and recognize substance use disorders, provide appropriate treatment, and deliver the best overall care for their patients.

The Clinician Consultation Center offers free, timely, clinician-to-clinician telephone consultation. Our expert team helps callers identify patient-centered, evidence-informed options based on established treatment guidelines, up-to-date scientific findings, and clinical best practices. To reach a Substance Use Warmline consultant, please call 855.300.3595 from 7 AM to 3 PM PST on weekdays. Voicemail is available during off hours. For more information, visit us online.

Carolyn Chu

Carolyn Chu, MD, MSc, is clinical director of the Clinician Consultation Center. She is an American Academy of HIV Medicine-credentialed HIV specialist and clinician educator who has conducted health services research examining the integration of HIV treatment into community-based and primary care settings.

Ron Goldschmidt

Ron Goldschmidt, MD, is professor and vice chair of the UCSF Department of Family and Community Medicine. He provides primary care for adults and children in the Family Health Center at San Francisco General Hospital, where he also attends on the Family Medicine Inpatient Service. Goldschmidt is founder and director of the national Clinician Consultation Center, which provides free consultation and advice to clinicians using the Warmline, PEPline (HIV Post-Exposure Prophylaxis Hotline), PrEPline (Pre-Exposure Prophylaxis Hotline), Perinatal HIV Hotline, and Substance Use Warmline.