Zachary Sartor, MD, began practicing as an addiction medicine specialist after he saw an uptick in behavioral health disorders among his patients, a trend he found grew exponentially after the COVID-19 pandemic.
“We have reports that show the stress of COVID potentially increased unhealthy substance use, particularly among alcohol and opioids,” the director for primary care addiction medicine at the Waco Family Medicine Residency Institute said. “In 2022, nearly 110,000 people across the country died from opioid or drug overdose, including a tragic loss of 5,500 Texans. That number is the highest it’s ever been in a single year.”
But what he calls a “concerning lack of resources” in the primary care setting makes it difficult to evaluate and treat patients with behavioral health needs that contribute to substance misuse.
This dearth includes limited understanding among patients and physicians about effective treatments and intervention options, a lack of access to mental and behavioral specialty services, and a shortage of mental health professionals in the area. (See “Coming Up Short,” page 12.)
“Primary care often does not have the structural support to provide care to the amount of patients with depression, anxiety, or other behavioral health conditions. And the numbers of patients who need that care grow every day,” he said.
That need drove Dr. Sartor and his team at Waco Family Medicine to reframe such challenges as an opportunity. The result? The Waco Guide to Psychopharmacology in Primary Care, a free app for clinicians that provides hundreds of clinical decision support materials for managing common and complex mental and substance use disorders, including psychopharmacologic treatment.
The “Waco Guide,” for short – which Dr. Sartor co-edited and created in consultation with the faculties of the Massachusetts General Hospital Psychiatry Academy and Waco Family Medicine – is designed to aid primary care physicians in making behavioral health treatment decisions at the patient’s initial point of care. His practice also adopted an integrated behavioral health care model into its primary care setting.
“Primary care is a key player in treating the behavioral health of our communities,” Dr. Sartor said. “We’ve tried to adapt and develop in such a way as to meet that need. That’s what this guide is intended to do as well.”
The Waco Guide
According to the 2022 National Survey on Drug Use and Health, 32.9% of U.S. adults experienced both a mental health condition and substance abuse in 2022. And while up to 75% of primary care visits include mental or behavioral health components, according to a 2021 American Academy of Family Physicians study, Dr. Sartor says primary care clinicians still lack access to mental and behavioral specialty services.
He points to systemic challenges in his own community as an example. In 2023, Waco closed one of its only psychiatric hospitals, leaving area family medicine clinicians “scrambling” to find comparable care for their patients.
“We’re witnessing both our community and primary care as a whole buckle underneath the weight of behavioral health care [needs],” he said.
Since its creation in 2017, the Waco Guide has aided over 60,000 users across the country. The guide provides:
- • Patient-centered algorithms based on age, comorbidities, and other special populations;
- • Recommendations for first-, second-, and third-line pharmacotherapy options, complete with dosing and monitoring recommendations, augmentation options, titration schedules, and potential side effects; and
- • Strength of recommendation ratings assigned for specific tools using the strength of recommendation taxonomy.
Dr. Sartor says providing these resources via an easy-to-access platform gives physicians the opportunity to provide care without adding research to their already heavy workload.
“You don’t have to be an addiction medicine specialist to treat addiction in your clinic. It is firmly within the scope of primary care, or just physicians at large,” Dr. Sartor said. “But the guide works to break down the barrier between an over-burdened physician and behavioral health services.”
Integrated care
In addition to the guide, Waco Family Medicine’s integrated behavioral health care model seeks to increase behavioral health screenings among patients as well as collaboration between mental health professionals – like psychiatrists and clinical social workers – and physicians.
“For example, patients who have depression or anxiety and see a primary care clinician for that complaint can then visit with a licensed clinical social worker for non-pharmacologic support, like mindfulness training or relaxation techniques,” Dr. Sartor said.
The practice also formed a behavioral health subgroup to disseminate evidence-based resources and best practices to other clinics and worked to integrate addiction medicine within the scope of primary care behavioral health.
Dr. Sartor said the “monumental” changes provide interventions at a patient’s initial point of care and target misinformation about addiction and mental health disorders.
“Integrating behavioral health with primary care allows patients to start addressing those issues in a place where they already have relationships and feel comfortable,” he said. “And it allows us in the primary care sphere to evolve as clinicians to provide multifaceted care.”
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469