The Substance Use Connection
The interface between substance abuse and mental illness is more pronounced than most people realize. The Substance Abuse and Mental Health Services Administration (SAMHSA) sites clinic reports that 50 to 75% of persons in substance abuse treatment programs have co-occurring mental illness, while 20 to 50% of those treated in mental health settings experience substance use disorders.
SAMHSA’s Administrator Charles Curie gave a succinct argument for integrating behavioral and substance abuse treatment in SAMHSA’s 1/31/05 Press Release:
All too often individuals are treated for only one of the two disorders, if they receive treatment at all. If one of the co-occurring disorders remains untreated, usually both get worse….Since people with co-occurring disorders cannot separate their addiction from their mental disorder, they should not have to negotiate separate service delivery systems.
SAMSHA’s Treatment Improvement Protocol (TIP), provides guidelines for the treatment of substance abuse. Geared to addiction counselors and other practitioners, Tip 42, entitled “Substance Abuse Treatment for Persons With Co-Occurring Disorders” provides advice for effectively dealing with this population and describes practices that have proven successful. SAMHSA also recently published a tool kit, “Integrated Treatment for Co-Occurring Disorders”, intended to help substance abuse and mental health administrators develop a collaborative structure. Another SAMHSA TIP, Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders, “equips clinicians with practical guidance and tools for treating chronic pain in adults with a history of substance abuse.” SAMHSA’s Incorporating Alcohol Pharmacotherapies into Medical Practice provides clinical practice guidelines in the medication assisted treatment of alcholism.Increasingly, primary care is playing an important role in treating substance abuse disorders by prescribing medical assisted treatment (MAT). California’s Medi-Cal program categorizes MAT as a medical service; thus counties and private substance abuse treatment providers are seeking to partner with primary care to provide this evidence-based practice. Other resources, including implementation instructions for medication assisted treatment (MAT), can be found on their website.
NIDA (the National Institute on Drug Abuse) maintains an informational website on all aspects of substance abuse including treatment approaches. According to NIDA, 23.6 million people over the age of 11 needed treatment for alcohol or illicit drug use in 2006 and only 2.5 million of these received it at a specialty facility. In January, 2009, NIDA issued a research report “Comorbidity: Addiction and Other Mental Illness“, exploring the correlations between the two and explaining how substance abuse can exacerbate mental disorders and how mental disorders can lead to substance abuse. One quick reference they published, “Screening for Drug Use in General Medical Settings” contains questions to ask and steps to initiate depending on risk level.
SAMHSA has also launched SBIRT, a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with, or at risk of developing substance use disorders. Screening, brief intervention and referral take place at primary care centers, hospital emergency rooms, trauma centers, and other community settings, providing opportunities for early intervention with at-risk substance users before more severe consequences occur. California’s implementation of this program is called CASBIRT.
SBIRT services became a Medi-Cal benefit beginning for alcohol use only (no drug related services) as of January 1, 2014. Providers eligible to screen and provide brief intervention may be reimbursed for both the alcohol screening and for the brief interventions. Additional resources can be found on the Center for Integrated Health Solutions (CIHS) site or on the California Department of Health Caresite. Clicking on an interactive map can bring up billing codes for SBIRT reimbursement by state. A fact sheet put out by the Department of Health and Human Services further explains the SBIRT process.
CIHS has also released a document to share insights and perspectives from addiction providers that are ‘early adopters’ of integrated primary care services. Innovations in Addictions Treatment: Addiction Treatment Providers Working with Integrated Primary Care Services encapsulates the experiences and knowledge of addiction providers and their partners that have integrated primary care services. SAMHSA’s Dual Diagnosis Capability in AddictionTreatment (DDCAT) Index is an assessment instrument used to determine a program’s ability to provide co-occurring services. It examines seven areas: program structure, program milieu, assessment, treatment, continuity of care, staffing and training. The Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) is similar, but tailored to assess addiction treatment capabilities in mental health programs.
In January, 2010, Northern California Kaiser Permanente published the findings of a substance abuse cost-related study they conducted in their facilities. Their Powerpoint presentation outlines prevalence of physical symptoms and mental disorders in this population, medical costs and cost-offsets and clinical outcomes. Other Powerpoint presentations about integrating substance use treatment in primary care can be found in the “Archives” section accessed on the home page.
One of IBHP’s primary care grantees, Sierra Family Medical Clinic, has forged an on-site collaborative arrangement with Common Goals, a substance use treatment facility. Their flow chart tracks the procedures for intake and cross-referrals. In concert with UCLA’s Integrated Substance Abuse Program, the Los Angeles County Department of Mental Health has launched the Co-Occurring Disorders Project as a homebase for health and legal professionals to access trainings, events and webinars.
The Minnesota Evidence-based Practice Center developed a paper, “Integration of Mental Health/Substance Abuse and Primary Care“, which describes models of integrated care in the U.S. and accesses how integration impacts outcomes.
A 2011 paper by Dr. Joan Dilonardo, titled “Workforce Issues Related to Physical and Behavioral Healthcare Integration: Specifically Substance Abuse Disorders and Primary Care” explores what substance abuse treatment integration looks like in primary care settings.
In November 2008, the New York State Health Foundation funded the Center for Excellence in Integrated Care to help substance abuse and mental health outpatient programs across New York State improve their capability to provide integrated care services for co-occurring disorders. For the 4-year life of the initiative, CEIC technical assistance specialists will work with providers, free of charge, to help each program achieve a higher level of integrated care.
The Little Hoover Commission explored addiction in California, along with approaches to treat co-occurring disorders in their “Addressing Addiction: Improving and Integrating California’s Substance Abuse Treatment System” in 2008.
In May 2013, the Center for Integrated Care Solutions released a paper entitled “Addiction Treatment Providers Working with Integrated Primary Care Services” which details building partnerships, information-sharing, and adminstrative issues among other areas germane to this topic. With the advent of the Affordable Care Act, several changes in the delivery of substance use treatment are anticipated. A 2013 article by Tai and Volkow discusses them.
The 2012 Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, put out by the Centers for Medicare and Medicaid, deals not only with behavioral counseling but also billing for alcohol intervenitions.
Innovations in Addictions Treatment for Providers Working in Integrated Primary Care Services, published in 2013 by the Center for Integrated Health Solutions, gives examples of approaches throughout the country.
Funding Substance Abuse Treatment in Primary Care, a 2014 paper written by the CalMHSA Integrated Behavioral Health Project (this website’s host) in partnership with AGD Consulting, is based on surveys by, and site visits of high volume substance abuse treatment centers in California. Case Study Highlights: Substance Abuse Treatment is a 2014 companion paper by the same authors.
The Bay Area Addiction Research and Treatment (BAART) Program is a multi-service organization providing drug treatment and rehabilitation for patients across the country. They offer treatment for addiction to prescription medications and other opioids, using methadone and buprenorphine (Suboxone) treatment among other evidence-based methods. In addition to drug addiction treatment, BAART programs provide primary medical care and mental health services through a network of fixed sites and mobile vans serving five states. A recent presentation to CPCA gave an overview of what’s involved in providing substance use services and considerations for partnering with primary care vs. becoming a full scope substance treatment provider. BAART is making its standard memorandum of understanding available for agencies that are considering partnering with substance use treatment providers.
“A Window into Addiction Treatment and Primary Care Integration” includes a checklist for addiction providers to consider when planning to integrate treatment systems with primary care. “Coalitions and Community Health: Integration of Behavioral Health and Primary Care“, a publication of the Center for Integrated Health Solutions, aims to “educate and motivate substance abuse prevention coalitons to engage in local integration efforts.”
CIHS’s 2014 “Expanding the Use of Medication to Treat Individuals with Substance Use Disorders in Safety Net Settings” outlines lessons learned from a year long collaborative with safety net providers. A companion checklistcontains issues to consider before undertaking MAT (medically assisted treatment).
Integrating Substance Abuse Treatment Staff and Reducing Stigma highlights case studies done by IBHP (this website’s host) and discusses the importance of peer staff. Integrating Subtance Abuse and Primary Care Services in Community Clinics and Health Centers (2015) is another of IBHP’s briefs exploring how this treatment works in a community clinic setting.
Medication for the Treatment of Alchohol Use Disorder, a free booklet put out by SAMHSA, summarizes approved medications and discusses screening, patient assessment and treatment planning.
For on-line substance use screening and intervention training, go to the Learn More section of this website. For some screening instruments to identify type and level of substance abuse problems, go to the Screening section and for resources about the confidentiality laws surrounding substance abuse treatment, go to the Confidentiality section .