By Paul Roman, Editor
For this issue of The Bridge, our editorial board members were presented with this challenge: What are the advantages (or disadvantages) of integrating SUD/AUD treatment into mainstream medical care? This is an issue of substantial prominence today, and an issue that has huge implications for the future of the treatment of SUDs.
If one looks at some aspects of the history of this field, having this question “on the table” might seem like a parallel to the discovery of the Holy Grail. The “alcohol side” of SUD treatment first made such integration its mission statement as early as 1943. The driving assumption was “alcoholism is a disease like any other,” a clear call for mainstream medical attention and the inclusion of both diagnostic and treatment attention to alcohol dependence in all areas of medical care. The campaign, launched by the ancestor organization of today’s National Council on Alcoholism and Drug Dependencies (NCADD), began with the formation of local “chapters” across the country and with steady lobbying efforts aimed at “recognition” of alcoholism by the American Medical Association (AMA). This led to one of the first uses of a majority vote to assert a scientific truth: After several unsuccessful attempts, in 1956 lobbyists led by Dr. Marvin A. Block brought a motion of the floor of the AMA business meeting that was passed by majority vote, with the result described in AMA’s own historical timeline as “AMA declares alcoholism an illness.” This perhaps anticipated later actions where in 1973 the American Psychiatric Association voted homosexuality out of its Diagnostic and Statistical Manual, and in 2013 an influential committee voted to transform the definition of the scope of autism spectrum disorders.
The relative influence on medical practice and public attitudes of the scientist’s “Eureka!” versus the chairman’s “the motion passes” remains to be measured. Yet it is clear to any observer that while the 1956 action was a definite step toward change, the implementation of integration remains an issue 58 years later.
The “drug side” of SUD treatment did not follow a similar path. There has never been a grassroots national organization pressing for the medicalization of drug issues, save for the efforts of NCADD to simply stretch its blanket of coverage by changing its name, or the current recovery movement, which does not distinguish in any way between alcohol and drugs, but the mission of which is unclear relative to the medical community. Nonetheless, the home base of the National Institute on Drug Abuse within the National Institutes of Health is a powerful societal signal of medicalization as well as a potent platform for promoting that perspective.
Considering the integration of treating substance use disorders (SUDs) into other forms of medical care raises the initial question of “what is the problem?” Many different perspectives can shape the response to this question. The obvious “problem” is that treatment for SUDs is heavily delivered within a specialty treatment sector. So what?
Well, many problems have been identified with the SUD treatment specialty sector. First is the apparently tiny percentage of those needing SUD treatment who actually receive it. This strongly suggests defects in the current design of treatment, and the need for a re-design that would generate more patients. It also highlights the fact that while specialty sectors exist throughout medical care, the pattern of referral and service usage is generally referral from the general, primary care sector. This applies only to a small minority of treatment entries of patients in SUD specialty care.
Second is the observation that the current specialized treatment design is inadequate to address the multiple needs of patients, particularly their co-occurring mental and physical disorders. With a little reflection, this issue points to the importance of “medical homes” where knowledge of all of the patient’s needs is readily available, as well as ready access to appropriate services.
Third is the fairly nebulous concern with treatment quality, presently reflected in outcomes commonly viewed as less than optimal. Some of the quality concerns seem to come from a perspective that is highly critical of the prominence of 12-step ideologies and practices in SUD treatment. Linked to this is an implicit definition of “quality” in SUD treatment as being all things medical. Within these definitions and assumptions about quality improvement, it is quite clear that greater interaction, integration and involvement of other medical treatment personnel in the overall regimen provided to SUD patients would enhance treatment quality.
If integration has such promise, why don’t we just go for it? Obviously there are barriers upon barriers, as well as considerations not mentioned here that stand in the way. What follows are the ideas of a mixture of academics and practitioners whose work puts them up against these matters on a daily basis.
Holly Hagle first offers an enthusiastic endorsement of the integration processes, focusing on the potential range of health problems that could be effectively addressed. Mike Boyle follows with equal enthusiasm, but based on his assessment of the current status of SUD treatment and its potential for implementation of the policies embedded in the ACA. This is followed by Betsy Wells’ tempered enthusiasm, also pointing to potential pitfalls associated with the changes associated with integration into general medicine. Bringing in real-world examples, Louise Haynes builds on Boyle’s concerns about the readiness for change within the current SUD treatment system. At the editor’s invitation, Steve Martino exposes the “dark side” of integration, and does yeoman duty in producing empirical evidence for the many barriers to effective transition and implementation. Finally, carrying the theme of complexity, Dennis McCarty and Traci Rieckmann provide an overview of their developing research project in Oregon that promises to provide answers to many of the issues raised by the other commentators.
We welcome Dr. Elizabeth (Betsy) Wells of the University of Washington for her debut presentation in The Bridge.
Paul M. Roman
Editor in Chief
We invite readers to respond to these materials, including the workgroup report itself. To the extent they are appropriate, these reactions may be included in future issues of The Bridge. Please address your comments to Paul Roman at the University of Georgia (firstname.lastname@example.org).
The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.