That gap, between what the chart said, and what I read in the room, is where much of the work happens in primary care.

Universal screening with validated tools, brief intervention, referral to treatment (e.g., SBIRT) has a robust evidence base, and at the population level, it works. A well-resourced implementation trial across 22 primary care practices and more than 330,000 patients found that combining EHR decision support, performance feedback, and practice facilitation increased alcohol screening from 21% to 83% and documented brief interventions fivefold (Lee et al., 2023). Primary care treatment for alcohol dependence is non-inferior to specialist care for patients with low to moderate severity, and any reduction in consumption carries meaningful public health benefit (Wallhed Finn et al., 2018). For patients whose drinking is habitual but not organized around anything deeper, a well-delivered brief intervention is often exactly what is needed.

The harder question is what happens with the patients for whom it doesn’t work—and why. The same trial found no increase in AUD treatment engagement, even as new diagnoses and treatment initiation rose (Lee et al., 2023). The infrastructure problem and the clinical problem are different.

The behavioral science of addiction offers a partial answer (e.g., Bandura, 1976; Hayes et al., 2006; Rollnick et al., 2023). For a meaningful proportion of patients, the substance is functionally rational (a point most integrated care clinicians would not dispute—and yet treatment design routinely ignores it). It is regulating affect that has no other outlet, managing sleep that has never been restful, quieting a nervous system that has never learned to quiet itself. When treatment addresses the substance without understanding or addressing the function it serves, the outcome is predictable. The patient is not failing to respond to treatment. The patient is solving a problem, and treatment has offered to remove the only solution the patient has.

Prolonged adverse experience produces affect dysregulation which is among the most persistent consequences of complex traumatization (Gold, 2020). For patients whose lives have included prolonged traumatic exposure, substance use is frequently less a disorder superimposed on a stable life than a behavioral adaptation to a nervous system doing what it learned to do. The chart reads AUD. The room, if the right questions get asked, reads something else entirely.

Primary care is the setting where those questions can get asked—not because it has more time, but because the BHC in the workflow is positioned to conduct a contextual assessment in the space that already exists: the warm handoff, the follow-up visit, the appointment that was nominally about something else.

I think most readers of this blog already understand that the therapeutic relationship matters. What is worth centering is that in primary care, the relationship itself is the clinical instrument—not a precondition for the work, but the work. Single encounters can produce meaningful, durable change across a range of mental health concerns (Schleider et al., 2025), and the greatest gains in outpatient care typically occur early—which means the first encounter carries more clinical weight than a treatment-episode framing suggests (Hatchett, 2020).

In primary care, a visit is not simply a unit within a treatment course. It is, in itself, complete. The BHC who enters a warm handoff oriented toward understanding this person, in this moment, is practicing a form of presence the referral pathway cannot replicate—because that encounter happens within the existing primary care relationship, the same practice where the patient manages their diabetes and brings their children, a place they already trust with people who will still be there (Robinson & Reiter, 2025).

Most patients with problematic substance use will not establish with specialty addiction treatment—not now, perhaps not ever. But the non-judgmental relationship they build in primary care becomes a resource they carry forward. When the urge to use returns, or a relapse has already happened, where a patient goes depends on what they believe awaits them. A patient who has experienced a BHC asking about their life without flinching at the answer has reason to come back—after a hard month, after the thing that finally cracked something open. That return visit is where the relational capital of primary care becomes clinically decisive.

The warm handoff does not close a loop. It opens a door that may be walked through months or years later, under circumstances no treatment plan anticipated, because primary care is the setting the patient never fully leaves (Robinson & Reiter, 2025).

What integrated primary care offers patients with substance use concerns is not a replacement for SBIRT or for brief interventions, or even intensive specialty treatment. It is the capacity to see the functional logic of the behavior, the context that explains the chart, the life underneath the presenting complaint. When the BHC and the PCP are working toward the same patient goals on the same day, primary care becomes the setting where substance use can be understood in full rather than addressed in part.

That is a different kind of care. And for a meaningful number of patients, it may be the only kind that reaches them.

I think about that patient often. The chart said alcohol use disorder. The room told a different story. What changed the encounter was not the AUDIT-C score or the DSM criteria. It was a question asked first: Tell me about your life.

The chart told me what to treat. The room told me what was actually going on. And the relationship we built in that room was still there the next time the patient needed it.

References

Bandura, A. (1976). Social learning theory. Prentice-Hall.

Gold, S. N. (2020). Contextual trauma therapy: Overcoming traumatization and reaching full potential. American Psychological Association.

Hatchett, G. T. (2020). Anticipating and planning for the duration of counseling. Journal of Mental Health Counseling, 42(1), 1–14. https://doi.org/10.17744/mehc.42.1.01

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006

Lee, A. K., Bobb, J. F., Richards, J. E., Achtmeyer, C. E., Ludman, E., Oliver, M., Caldeiro, R. M., Parrish, R., Lozano, P. M., Lapham, G. T., Williams, E. C., Glass, J. E., & Bradley, K. A. (2023). Integrating alcohol-related prevention and treatment into primary care: A cluster randomized implementation trial. JAMA Internal Medicine, 183(4), 319–328. https://doi.org/10.1001/jamainternmed.2022.7083

Robinson, P. J., & Reiter, J. T. (2025). Behavioral consultation and primary care: A guide to integrating services (3rd ed.). Springer. https://doi.org/10.1007/978-3-031-72150-2

Rollnick, S., Miller, W. R., & Butler, C. C. (2023). Motivational interviewing in health care: Helping patients change behavior (2nd ed.). Guilford Press.

Schleider, J. L., Zapata, J. P., Rapoport, A., Wescott, A., Ghosh, A., Kaveladze, B., Szkody, E., & Ahuvia, I. (2025). Single-session interventions for mental health problems and service engagement: Umbrella review of systematic reviews and meta-analyses. Annual Review of Clinical Psychology, 21, 279–303. https://doi.org/10.1146/annurev-clinpsy-081423-025033

Wallhed Finn, S., Hammarberg, A., & Andreasson, S. (2018). Treatment for alcohol dependence in primary care compared to outpatient specialist treatment—A randomized controlled trial. Alcohol and Alcoholism, 53(4), 376–385. https://doi.org/10.1093/alcalc/agx126