The patient, pleading for pills, set off alarm bells in the doctor’s head.
When abused, the anti-seizure drug the patient was seeking can produce a euphoric high. Was the patient battling an addiction?
On a computer, the doctor searched a database for the patient’s electronic record, including any recently prescribed narcotics.
Compiled by the Hawaii Prescription Drug Monitoring Program, the database tracks the 1.4 million controlled substance prescriptions Hawaii doctors and pharmacists are expected to dispense to patients this year. The information helps prescribers detect and prevent prescription drug abuse.
The patient had no recent prescriptions for a controlled substance, the database revealed. This assuaged the doctor’s concern. She wrote him the prescription.
“It helped me in deciding to give him what he was lying on the floor begging for, which triggered something in my mind that, uh-oh, this might be an addiction,” said Kelley Withy, a medical doctor and professor at the University of Hawaii’s John A. Burns School of Medicine.
For people in Hawaii with mild to moderate substance abuse or mental illness, the road to treatment often ends at the office of the family physician.
Barriers to getting psychiatric care from a specialist include Hawaii’s rural geography, a statewide shortage of psychiatrists, insurance coverage restrictions and the stigma of mental illness.
But doctors in the primary care setting are better equipped to treat the body parts below the head. How to help a person who announces an intent to kill themself or the chemistry of antipsychotic drugs are subjects best understood by specialists.
Now a new digital learning platform is connecting an interdisciplinary team of psychiatric experts to local primary care providers. The result is that patients are receiving better care for illnesses ranging from anorexia to anxiety.
ECHO Hawaii is a free webinar that schools doctors on behavioral health treatment during the Tuesday lunch hour. Topics range from the side effects of antidepressants to the art of weaning a patient off pain medication.
Doctors can also present specific patient cases that are troubling them, engaging in a peer-to-peer problem-solving discussion with local specialists, including psychiatrists and pharmacists.
“Primary care doctors have different levels of comfort with treating things like depression,” said Withy, who helped bring the video conferencing platform to Hawaii and recently presented her case about the patient who flat-out begged for anti-seizure medication.
“If it’s mild to moderate depression, probably your primary care provider will be able to treat it — if they have the time and they don’t feel so stressed that they can’t,” Withy added. “If it’s psychosis, that’s a little harder because the drugs are more dangerous and it’s harder to work with someone who has lost touch with reality. So this is a great model to provide these doctors with support.”
It is not a panacea.
But Hawaii Medicaid Director Judy Mohr Peterson, who said she is seeking avenues for Medicaid to support ECHO Hawaii, described the program as an important tool to help primary care doctors boost their skills and agility in treating drug and alcohol abuse and common mental health disorders.
“Usually these situations end with the physician saying to the patient, ‘Well, here are all the mental health specialists that you can call and good luck to you,’” Peterson said.
“But often the patient doesn’t follow up or they can’t get in with the specialist. But yet we know that if we don’t start to look for ways to support our primary care doctors to do this integration with behavioral health, we’re never going to change the tide.”
Nearly 57 percent of American adults with mental health disorders receive no treatment. In Hawaii, the situation is even worse. A 2017 access-to-care study ranks the islands second-to-last in the nation, with 66 percent of adults with mental health disorders failing to receive treatment.
Launched in 2016, ECHO Hawaii is the local iteration of an initiative born at the University of New Mexico to train primary care clinicians to provide specialty care services, especially in rural and underserved communities. In New Mexico, the program claims it saved 539,000 travel miles for patients in 2009 by training primary care providers to administer specialty care in their communities.
The program has more than 175 U.S. and international partners offering mentorships and education in areas including liver disease, bone health and opioid addiction.
Hawaii participants numbered 323 last year, plus a handful of medical professionals from Micronesia and American Samoa.
Withy said the program is growing but so-far underutilized, probably because many primary care physicians are too overwhelmed with patient care and administrative work to participate in the lunchtime call.
Joseph Kohn, an internal medicine doctor on Maui, described ECHO as a valuable resource. But he notes that continuing education can only be so helpful when many primary care doctors lack the resources to use it.
“How does a doctor deal with emotional problems when they have about 8 to 15 minutes for a follow-up visit with a patient?” Kohn said.
“I love sitting there and listening to my patients and finding out what’s going on in their lives and what’s important to them and developing a strategy to deal with whatever problems they’re facing,” he added. “But after you’ve said hello and figured out what’s going on with the patient’s medications, how are you supposed to do comprehensive care like that in five minutes?
“I love ECHO and I think it’s useful, but I’m disgusted with our healthcare system.”
ECHO Hawaii (ECHO is an acronym for Extension For Community Healthcare Outcomes) is sponsored by the Hawaii State Rural Health Association, the state Department of Health, the Hawaii Area Health Education Center and the Pacific Basin Telehealth Resource Center.
In addition to the behavioral health curriculum, the program offers a webinar series on geriatric care.
Helen P. Bressler, a registered nurse and counselor who participates in the behavioral webinar from her practice on Oahu, said she appreciates the opportunity to share strategies from her background as a marriage and family therapist.
“A psychiatrist might have different ideas than a family and marriage therapist who may have different ideas from a medical doctor,” Bressler said. “And so we can glean information from all of these different approaches.”
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