Louise Haynes, Medical University of South Carolina
Neither people nor organizations welcome change with open arms. Yet, in the addictions field, change is constant. It takes a lot of effort to change, and we wonder whether the future result will indeed be that much better than the system we have today.
This article will focus on a change that currently challenges addictions treatment providers – the integration of addictions treatment into mainstream medical care. I ask the reader’s indulgence as I first provide a little personal background as my entre to this subject.
My first job after graduate school was at an academically-affiliated hospital operated by the U.S. Department of Veterans Affairs (VA). I was a social worker serving on an addictions treatment team that included a psychiatrist, a family medicine specialist, nurses, an occupational therapist, psychologists, counselors and a biofeedback specialist. We participated in team meetings every morning where one of the medical students presented a structured, detailed medical and social history on all new admissions. Having no prior experience in the field of addictions, this resource-rich marriage of medicine and addictions care made sense, and at that point in my career, I assumed it was the norm.
My next job was for the Single State Authority (SSA) for the state of South Carolina, where I encountered a very different reality. I was hired because the SSA had signed the first-ever contract with the Department of Health and Human Services (DHHS), a contract that would provide payment through Medicaid for addictions treatment.
My job was to teach addiction treatment providers how to “diagnose” substance abuse and dependence as required by Medicaid. The resistance from the field was intense and passionate. In the beginning, some providers refused to participate or to sign the contract because to “medicalize” treatment in order to collect money was akin to a pact with the devil. Labeling people with specific diagnoses, calling them “patients,” requiring credentialed staff – all were steps that were perceived with fear and as a move away from the art of recovery.
The providers asked why we, as the state’s experts in addictions, would change our system of care, and agree to keep changing it, as directed by Medicaid administrators? What did they know about addictions?? Why would we sign an agreement that required us to take orders from them? As I began to provide training to the community providers, I observed that the resource divide between addictions treatment at the VA hospital and our state treatment system was startling, and the cultural divide between a medical/academic treatment program and a system of care that had developed largely outside of medicine was equally so. They were worlds apart.
Despite the providers’ resistance and fear, we moved forward with the procedural changes required by DHHS. And, after years of effort and leadership from the SSA, bio-psychosocial assessments became the norm in South Carolina, uniform clinical records were in place, and every clinical counselor in the field of addictions was expected to have full working knowledge of the criteria for diagnosis. This change was an early initiative that would integrate a medical model into addictions treatment. Over time, the culture had changed, and the carrot that had served as the initial stimulus for that change was money.
Although the use of medications to support recovery has not been widely implemented in South Carolina, many changes have occurred, and the adoption of evidence-based treatment is now widely supported. In retrospect, that first Medicaid contract not only pushed the system toward a medical model, but it also served as the catalyst that moved the state’s treatment system toward accountability and evidence-based care. Similarly, the advent of the Affordable Care Act may drive changes that move the field further toward mainstream healthcare.
Does it makes sense, at this point in the development of the addictions field, to move addiction services into general medical practice, no longer restricting recovery oriented care to the programs that specialize in addictions services? After all of the work to “medicalize” addictions treatment, are we now ready to “addictionize” medicine? And, if so, what will happen to the culture of recovery when it is transplanted into mainstream medicine? What are the opportunities presented by such a change?
I recently saw an example of a successful transplant of addictions services into medical practice. The NIDA Clinical Trials Network (CTN) is currently conducting a study in HIV clinics. When we were selecting sites to participate in the study, I visited a number of community HIV providers across the country and was surprised to learn that despite the overlap of HIV and substance abuse, many of these clinics had little, if any, connection with addictions treatment programs in their communities.
Although there was a significant amount of substance abuse within their respective treatment populations, these clinics had elected to create their own in-house programs for substance abuse treatment, rather than referring these individuals to existing external community resources for substance abuse treatment. Why? Because their patients resisted referrals to programs that were not familiar with the issues facing people with HIV, and the patients would prefer to receive as many services as possible in one location with staff and culture that were familiar.
If the HIV clinics had not offered their own recovery oriented care within their clinics, probably most of their patients’ drug abuse would have gone untreated. Although the patients in these recovery groups faced many of the same issues that all recovering people face, the interface between drug/alcohol use and the health issues related to their HIV was a common recovery theme that was shared by all group members. The prevalence of associated problems, including housing instability, mental health issues and medication side effects, was significant. While these in-house programs definitely have addressed a need among this population, perhaps the opportunity exists for specialty substance abuse treatment programs to offer consultation and collaboration to infuse more of the traditions of recovery into these specialized HIV/addictions recovery efforts.
Through another CTN study conducted in sexually transmitted disease (STD) clinics across the country, we found that more than 50 percent of the people seeking services at the clinics reported illegal drug use in the past six months, and about one-fourth of the patients had assessment scores that were consistent with severe drug use. Yet, only six percent reported involvement with any form of substance abuse treatment.
Unlike the HIV clinics where medical care is long term with many opportunities to provide addictions treatment services, STD clinic care is typically short term, with one or two visits being the norm. Consequently, the patient flow in STD clinics does not lend itself to the development of traditional addictions treatment onsite. Yet, there is clearly a need to systematically ask questions about drug and alcohol use and have a readily available brief intervention and capacity for referral and linkage, when indicated.
The current call for change in addictions treatment offers a variety of opportunities to bring recovery services to people whose lives are negatively affected by their drug and alcohol use but who would not come to a specialty substance abuse treatment program. I believe that it is possible for the core values and principles of drug abuse treatment to remain intact as services are expanded into non-traditional treatment settings. Yet, we still have many challenges ahead as we work to determine the most effective way to integrate addictions treatment into new environments. Decisions about how to organize and deliver services are often more complex than are the decisions about what type of care to provide. As always, the devil will be in the details.
In conclusion, there is currently a broad continuum of integration of medical care and addictions treatment, but the trend is moving toward a greater level of integrated care. I do not envision a day when addictions care will be richly resourced and able to provide the level of medical and addictions treatment that I saw at the VA in 1983. But, realistically, we may someday evolve to a place where there is an expectation for medical care that includes addictions treatment, a change which has the potential to significantly decrease the stigma associated with addictions. As we move in that direction, treatment providers have the opportunity to shape the evolution of care so that recovery principles remain the foundation of addiction services. By actively seeking collaborators in mainstream medicine to explore community needs and design healthcare systems that are responsive to the needs of a broad range of constituents, many of whom seek care in settings other than traditional substance abuse programs, we may be able to keep the best of what we have by sharing our most effective recovery principles with mainstream healthcare.