Substance abuse treatment generally follows a psychosocial, rather than medical, model. The most recent surveys that have examined staffing patterns confirm that the substance abuse treatment system involves little or no physician time in the treatment of patients (Office of Applied Studies, 1993; Brandeis University, 1993). Even when on staff, physicians are often addressing primary health care needs or other mental disorders, rather than providing specialized substance abuse treatment services.
Methadone treatment for heroin addiction would appear to be the most medically oriented model of drug treatment. However, the role of physicians in methadone clinics is generally small and circumscribed to initial diagnostic assessments (i.e., of heroin addiction), management of methadone dosage, and some primary health care services. Most clinic services are oriented to the behavioral and psychosocial needs of the patients, and are delivered by counselors, social workers, and, less often, psychologists (Institute of Medicine, 1990).
The 1991 NDATUS study of specialty substance abuse providers surveyed 9,000 treatment centers (out of a total of about 11,500) with 811,000 patients enrolled on the survey date. The survey identified only about 2.2 full-time equivalent psychiatrists and other physicians, respectively, per 1,000 enrolled patients. Nationwide, there were about 88,000 full-time equivalent direct care staff, including about 1,800 psychiatrists and other physicians, respectively. These estimates were not adjusted for survey and item non-response (Office of Applied Studies, 1993).
The 1990 DSRS survey focused on 7,200 "drug" abuse centers (excluding "alcohol only" centers), serving 540,000 patients with primary or secondary drug problems. That survey found that there were about 1,000 full-time psychiatrists and other physicians, respectively, on staff at the 7,200 centers, very similar to the estimates of full-time physicians from NDATUS. The DSRS also found about 4,500 psychiatrists and other physicians working part-time or on contract; however, the report does not translate these numbers into full-time equivalents or into the proportion of facilities having any physicians on staff. These estimates were not adjusted for item non-response (Brandeis University, 1993).
Involvement of private practice physicians in treating cocaine addiction is virtually negligible. Of all national expenditures for specialized substance abuse treatment services, including alcoholism, less than 1 percent are for psychiatrist visits. Only about 1 percent of all visits to psychiatrists are by patients with a primary diagnosis of substance abuse, including alcoholism; another 2 percent are by patients with a secondary diagnosis of substance abuse (Harwood et al. 1994). Of all national expenditures for substance abuse services, excluding alcoholism, 2 to 3 percent are for visits to physicians of any type (Harwood 1984; Rice et al. 1990).