Elizabeth A. Wells, University of Washington School of Social Work
Health policy in the U.S. is moving toward bringing behavioral health into the mainstream healthcare system. Achieving such integration is an enormous job, requiring changes in funding streams, organizations, and individuals. Facing such a large task, with all of its probable pitfalls, makes resistance tempting; but before opposing this course, one must examine the potential benefits of service integration, especially for individuals and families affected by substance use or alcohol use disorders (SUD/AUD). Keeping in mind what is possible to achieve through integration may also help us design systems that maximize potential benefits for patients. What follows is a brief discussion of possible advantages for both patients and society.
Integrating care would increase access to SUD/AUD services. Results from the 2012 U.S. National Survey on Drug Use and Health (NSDUH) indicate that only 2.5 million (10.8%) of the 23.1 million people age 12 or older classified as needing SUD or AUD treatment received treatment at a specialty care facility (SAMHSA, 2013). This translates into an unmet need for SUD/AUD treatment for 7.9 percent of the U.S. population age 12 or older. This large discrepancy between need and service constitutes one of the primary arguments for both parity in SUD/AUD treatment coverage and integrating treatment for these disorders into our mainstream medical system. It is widely held that more people in need of treatment can be reached in this way, especially with the Affordable Care Act’s (ACA) expansion of health care coverage. Prior to implementation of the ACA, many of those in need of treatment lacked coverage1. A proportion was also not receiving regular primary care, and was likely to use emergency or urgent care clinics for any medical needs. Whether in emergency, urgent, primary, or specialized care, the number of substance users who can be treated would be greatly expanded by the integration of SUD/AUD services.
Integrating care would reduce stigma associated with substance use and seeking treatment. In a variety of situations, those who abuse drugs or alcohol are stigmatized because of their substance use. This is likely exacerbated by criminalization of drug use. While stigma has a function, in that it may serve to deter drug use in society, it also produces stress and may have detrimental effects on both mental and physical health (Ahern et al., 2007). In addition, stigma can act as a barrier to participation in needed treatment; worry about negative effects on employment or social distancing from neighbors or one’s community are reasons given for not seeking treatment1. Stigma acts as a barrier when it keeps individuals from seeking care out of fear of being identified or labeled as a substance user. Mere attendance at a SUD/AUD treatment facility may be resisted due to fear of such labeling. Integration into mainstream medical care has the potential for reducing both the stigma associated with having a SUD and stigma associated with receiving treatment.
Treating substance use problems like other health problems has the potential to reduce fear and marginalization of substance users. People with chronic health conditions, such as high blood pressure or asthma, are generally not avoided or discriminated against because of these conditions. To the degree that society can adopt a similar view of SUD, stigma will be reduced, lessening its negative effects on physical and mental health and lowering barriers to seeking treatment. In addition to changing people’s views of substance use, locating SUD treatment in the settings where flu, broken bones, high blood pressure, cancer, and heart disease are diagnosed and treated could lessen the fear of being labeled simply by participating in SUD services.
The goal of reducing stigma can only be achieved, however, if stigma attached to substance use is not carried into mainstream medical settings. A number of studies have documented that health care providers are not immune to societal attitudes toward substance users (Skinner et al., 2007; Lloyd, 2013). If I believe that doctors and nurses will treat me badly if “alcohol dependence” appears in my electronic medical record, I will tend not to disclose my level of alcohol use to my family physician. To the extent that marginalization occurs or is anticipated in medical settings, use of such setting will lack effectiveness in both assessing and treating SUDs/AUDs. Perceptions of SUD/AUD problems and the patients presenting with them are, therefore, critical to address at all levels in any attempt at integration.
Integrating care will improve treatment of co-occurring SUD/AUD and medical problems. It is well known that dependence on drugs or alcohol is often associated with physical health problems, such as injury, infections, high blood pressure, asthma, heart disease, chronic obstructive pulmonary disease, liver cirrhosis, and Hepatitis C (Mertens et al., 2008). Substance use places individuals at greater risk of developing certain kinds of medical conditions; some medical conditions may be exacerbated by alcohol or drug use; and some medical conditions, while not made worse by use, may improve if use is decreased or stopped. When SUD/AUD treatment is delivered in specialty care that is not coordinated with medical care, both care systems may be operating in the dark. They lack a complete picture of their patient’s needs and are likely not providing optimum treatment. Medical conditions may go undiagnosed because the patient’s risk factors are not known. Addiction may be exacerbated by prescribing that is done without knowledge of the patient’s substance dependence. Although communication is possible between separate treatment systems, it is costly in provider time and is therefore far less likely than would be the case with a shared medical record. The ideal of treating the whole person has yet to be realized but is in sight if current policy initiatives within the ACA can be implemented.
Integrating care will improve treatment of co-occurring SUD/AUD and psychiatric problems. SUD and mental health treatment programs have largely operated separately due to historical differences in philosophy and training. Given these differences, merging the two behavioral health disciplines has proven difficult; but there have been some successes. As is the case with physical health problems, co-occurrence of SUD/AUD with other psychiatric disorders is common, with the depression, anxiety and PTSD among the most prevalent. Currently, primary care and emergency care are common sites for mental health treatment, and only the seriously mentally ill are seen in specialty mental health centers. Integrating both behavioral health disciplines into medical care creates an opportunity to have treatment of each disorder informed by treatment of others, improving patient outcomes.
Integrating care will increase access to medication-assisted SUD/AUD treatment. Effective medications are increasingly available as primary or adjunct addiction treatments for a growing number of substances of abuse. Yet, many smaller specialty care clinics are not able to employ medical providers who can prescribe and provide adequate monitoring of these medications. Providing state-of-the-art treatment requires medical and behavioral health staff trained in evidence-based interventions, including medications. When SUD/AUD treatment is co-located or coordinated with mainstream medical care, this capability is expanded.
Integrating care will improve monitoring and intervention of addiction as a chronic condition. Single episodes of time-limited treatment do not adequately address what is increasingly understood as requiring a chronic care model. Many individuals with SUD/AUD return to treatment multiple times in order to achieve sustained recovery. Because it includes regular and preventive visits, mainstream primary care is in a better position to provide long term monitoring of substance use problems and service as needed than are specialty care programs. Chi and her colleagues (2011), studying Kaiser Permanente patients entering SUD treatment in a managed care health plan over 9 years, found those who had “continuing care”, i.e., yearly primary care and specialty SUD or psychiatric services when needed had twice odds of SUD remission at follow-up as those without. One difficulty is getting SUD patients involved in primary health care; integrating SUD care into a health care system increases the possibility of doing so.
Integrating care will reduce healthcare costs. Duplication of administrative costs and the additional provider time needed for coordination of care across systems are one source of the high price of U.S. healthcare. Greater integration and coordination among services, including integrated electronic health records, are expected to increase efficiency and improve patient care. Integration of behavioral health records with other medical records raises concerns about privacy, and this is associated with the problem of stigma, discussed above. However, the potential gains, in terms of better and less costly treatment, provide a strong rationale for working to eliminate such stigma throughout health care settings.
The advantages of integrating care outweigh the challenges. Accomplishing this policy initiative will require, at the very least, new collaborations among disciplines, new financing and administrative models, development of integrated electronic health records, and changed attitudes and openness to new perspectives among providers on all sides. Progress on these fronts has been made, and a number of successful models exist (SAMHSA-HRSA, 2013). For SUD/AUD patients and families, the ultimate pay-off is a future in which access is increased to cost-effective state-of-the-art treatment.