Integrated Care in Addiction Treatment

Philip Hemphill

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000483413
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

This book emphasizes the importance of integrative care among the healthcare professionals involved in addiction treatment and includes a plan for executing and assessing the success of the system.

Drawing on three decades of experience helping practitioners, managers, administrators, and funders understand and implement this treatment, Dr. Hemphill discusses the history and integration of coordinated care, and details how it works in practice from the medical and business perspectives. He outlines a model that encourages the expansion of detection systems and stresses the importance of behavioral health treatment in addiction treatment centers, which can reduce treatment costs and enhance care management. Resources are included for assessing organizational readiness, monitoring outcomes, and suggestions for continuous improvement to ensure a seamless transition, leading to better outcomes, patient engagement, and worker job satisfaction.

This book offers innovative solutions that any healthcare professional practicing behavioral health and addiction medicine can utilize to ensure optimal care.

1 The Ground Floor

DOI: 10.4324/9781003128571-1

All behavioral health providers learn about humanity. But those who specialize in treating professionals learn the most about human capacity. We observe the highest limits of it.

We learn what volume of stress a human can endure. We are struck by the surprising level of compassion that can be maintained over the decades of a career. We see what heights the human brain can achieve. And we observe what little support is needed to just keep a human being going as they start to burn out.

While working with healthcare providers, I thought back to the times when programming classes were taken in college. As undergraduates, we needed credits in either a foreign language or computer science. After a horrendous semester of Italian, I decided to switch to computers. In those days, that meant learning Fortran, Pascal, or BASIC. I ended up taking several languages, learning how to produce the required outcome in each.

A large percentage of a programmer's time is spent debugging the code. When a program does not produce the desired outcome, you have to go back through the code line by line to find out what is causing the “run-time error.”

Dealing with complex behavioral health and addiction problems is very similar to debugging. Albeit the human brain is, of course, endlessly more complicated.

If we think of the individual as a computer with the brain as the motherboard, the mind would be the operating system. We see the output of this operating system in the behavior of the individuals, and it is either the desired or undesired output.

If it is the latter, the system needs debugging. This means digging down into the code and finding the sections that are producing the run-time errors. Just as an OS has multiple libraries and frameworks to check, the mind and body have numerous facets that contribute to mental health and addiction. In the case of humans, debugging is a multidisciplinary task. It involves many different clinicians with many different degrees, specialties, and life experiences.

Modern addiction treatment is similar to a psychoanalytic-oriented approach, but it is much broader in scope. Psychoanalysis can be reductionistic: Say a person is suffering from addiction because they are dealing with the pain of a traumatic event. That is certainly the place to begin to unravel the threads, but such myopic perspectives fail to consider the numerous complex factors and systems that contribute to behavior.

For example, is the patient even interested in reliving, revising, and resolving their trauma? What type of trauma was it? Was physical pain involved? Can medical treatment or medications address that pain? What about the emotional pain? Has it affected the person's self-image? What other factors led them to experience the trauma in that particular way? Can we address those issues? How do society's reaction and acceptance (or lack thereof) contribute? Are there cultural variations in managing these experiences or even labeling them traumatic? Would the individual's life and those around them be enhanced by resolving their trauma?

The answers to these questions should inform all aspects of the patient's treatment. Therapists work to assure the victims that they are in no way responsible for being attacked, assaulted, and abused. This not only creates a safe environment where the patient can begin to address their experience but also makes it more likely that other victims will feel safe coming forward. Doctors also focus on trauma as an underlying issue in other conditions.

It is only in recent human history that we have healed our sick through myopic means. It is time for a pivot back to a “whole person” treatment approach. In integrated care, the staff work collectively to address all aspects of patients’ health. Coming from a variety of behavioral, medical, and administrative specialties, their pooled expertise, and efforts are central to the provision of integrated care. Their responsibilities can be broken down into five categories.

The role of the care team in integrated care is, first and foremost, to diagnose and treat illness. But unlike in traditional healthcare, in integrated care, this diagnosis and treatment occurs as early as possible and is highly individualized to the patient's psyche and life experience. The other four responsibility categories are care management, information collection, care team communication, and health promotion.

There are a variety of methods for clinically aligning behavioral health and primary care. These methods include cross-training for problem identification, formally diagnosing conditions, and treating the spectrum of disease states. Additional methods for clinical alignment include having continuous consultative services available, having strategies for increasing patient's health literacy which enhances engagement and activation by informed providers who are anticipating behavioral health care needs that are individualized, and delivering a team-based care system. Best practices include co-locating services when possible and utilizing formal assessment screenings in even trans-organizational settings.

I am not the first person to declare the importance of this approach. Experts in both behavioral and whole-health care have been calling for a multidisciplinary approach for years. I am not even the first person to implement it. And I am just one in a chorus of voices saying now is the time to scale it up.

We all have, at one time or another, failed to recognize a major historical change while it was happening. In most of these moments of significance, it is nearly impossible to seize the moment for the betterment of our lives.

I am questioning myself here—but sometimes I ask myself why I did not buy Microsoft stock at $21 when it first came out in 1986. I could code. I was relatively computer-savvy for the 80s. Why I did not see the significance of this little startup in Redmond, Washington?

I am not saying I should have fully grasped Bill Gates’ vision for the personal computer. Maybe I never could have suspected that these machines would surround us in various forms today. But maybe I could have reasonably appreciated the potential of the business model.

After buying the code for what would eventually be MS-DOS for probably $10,000, Gates had begun licensing it to IBM and others. He would pursue this market until almost 90% of the world's PCs relied on his software. Then, of course, there are the desktop applications (I am typing this manuscript in Word right now), the web browser, enterprise software, video game consoles, etc. The company is still going strong today.

I, of course, anticipated none of this. To be fair, much of it was beyond even Bill Gates' vision. But this, in a way, is the call to action I am making to healthcare business leaders in this book.

Not to buy stock and get rich. Not literally, at least. But to capitalize on the potential for an investment that all of us in the healthcare industry should reasonably have the ability to anticipate.

I am speaking to healthcare providers and healthcare business leaders. There is a better model of care out there. Investing in this model will accrue tremendous benefits for both you and your patients. And it is available to you now. The IPO is today.

The most effective model of healthcare is the one that seamlessly integrates the treatment of physical and behavioral health disorders. And if you will take steps to implement truly integrated care today, it will transform your organization into a center of excellence. It will make you a healthcare thought leader. And in three decades, you will have generated tremendous wealth—in terms of impact on the lives of your patients and their families.

Addiction is a great illustration of the impact that integrated care can have on patients, on your career, and on your business. That is because addiction is something that is easily understood as a problem with medical, psychological, and myriad other roots.

Substance use disorders reduce functioning to a simplistic state. Addiction traps people in a pattern of fundamentally under-utilizing their humanity. They lack complexity in their focus. In the worst—but unfortunately not rare—case, they are spending all their time procuring the drug, being high, or recovering from its effects. Despite this simplistic existence, addiction is an exceedingly complicated disease. It requires a diverse and coordinated range of psychosocial therapies and medical interventions to treat.

It is impossible to discuss the need for coordinated addiction treatment without establishing the fact that addiction is an “integrated disease.” It affects every aspect and cell of one's physical, mental, and spiritual life. Effectively treating addiction often means deconstructing a patient's psyche, uncovering and understanding unaddressed or repressed trauma, and building new systems of belief—all while treating the physical/genetic forces of alcohol and other substances.

Addiction and existential crisis often go hand in hand, and the disease is as much a philosophical illness as a mental and physical one. Perhaps no other field of medicine attempts to treat a more complex set of symptoms and underlying causes, and no other area of medicine requires as holistic and integrated an approach to produce successful outcomes than that of treating addiction.

Consider this latest article on the assessment of addictive disorders from a neuroscience-based framework when reflecting on the complexity of interventions required to treat such a profound disease state. To address the reality of heterogeneity of etiology, the authors identify genetic variables, environmental variables, agent use history, and impact on functionality as primary domains to consider while accounting for one's cognitive control, negative emotionality, and incentive salience. Despite this comprehensive model, they posited “given the multifactorial nature of addictive disorders, changing nature of exposure and response of human populations to addictive agents, the anticipated development of new methods for treatment and prevention, and development of new, transformative technologies, we do not anticipate that any one functional domain or imaging or genetic predictor will resolve the heterogeneity of addictive disorders or be sufficient to characterize an individual patient” (Kwako, 2015).

Clearly, addiction treatment calls for a multidisciplinary, collaborative care model that only integrated care can provide. Integrated care is your 1986 Microsoft stock. Implementing this model of care will pay dividends—both in your career as a provider and in the lives of the people you treat.

But why is the IPO today? This care model has been around for a while. What is the rush?

The need for integrated care is magnified right now by the addiction crisis in America. The current crisis is being driven by opioid use and a more recent surge in stimulants, which has increased dramatically in recent years.

The latest contributing supply and demand vectors have spiked in the past eight years with nationwide overdose deaths for cocaine and psychostimulants reaching almost 25,000 in 2017, with the rate of deaths from cocaine tripling and deaths from psychostimulants increasing five-fold. This epidemic includes both prescribed and illicit substance use disorders. Despite the high numbers of those dealing with this epidemic, they are still far outweighed by the number of people suffering from alcoholism, with roughly four times (95,000) as many alcohol-related deaths annually between 2011 and 2015 as these drug-related deaths each year. And substance use rates have increased during the COVID-19 pandemic.

The seriousness of this long-standing problem demands an integrated approach. And the effort and expense of implementing this approach is justified—even just for the benefit of bringing more attention to the public. Under integrated care, more healthcare professionals are going to be looking for the clues that a patient is abusing substances. It heightens attention to the problem.

So yes, addiction is a perfect demonstration of the impact of—and the urgency for—integrated care. In truth, however, addiction is not unique in this regard. All illnesses have a complex area of factors at play. At the beginning of the pandemic, we sought the pie-in-the-sky solution. The cure.

A year in, however, it was clear that mortality associated with COVID-19 will continue to be determined by a mixture of vaccines, various medications and other treatments, masks, social distancing, comorbidities, and lifestyle—such as diet, exercise, and tobacco use. And then you have also got to think about risk factors that are beyond our control, such as genetics and age.

If only there was some kind of investment we could make in our healthcare system! Something that would pay off in impact on as many determinants of health as possible. Again, Bill Gates comes to mind.

“If anything kills over 10 million people over the next few decades, it is likely to be a highly infectious virus rather than a war,” Gates told his audience at a TED Talk five years before the pandemic.

In Gates’ decades-long journey from a young billionaire tech entrepreneur to a major voice of global health, I wonder if he ever thought he would be accused of spreading a virus so that he could sell people a vaccine that would allow him to surveil their every move. I suspect that, too, was beyond his vision of the future.

2020 was a disaster in many ways, and one of them was the messaging around the science and public health of COVID-19. I can understand how these conspiracies spread. There was a captive audience. Everyone was very anxious. We desperately sought a feeling of control in our lives, and the pandemic confronted us every day with the fact that none of us were in control.

So, some of us attempted to assume a false mastery over information. They were seeking information that simply did not exist yet. On top of that, our political and public health leaders did a poor job of disseminating information, and so a lot of good information and expertise was discredited in the eyes of the public.

Therefore, the public sought information from many different media—television, websites, Facebook, YouTube, and TikTok. And the usual interpersonal exchanges disappeared because of social isolation. So, at the same time that we were inundated with information, it became more of a challenge for people to discern the veracity of each piece of information. That very process of vetting was overwhelming.

Simplicity and survival led straight into distortion. And the results were heartbreaking to watch.

The anxiety, powerlessness, and confusion of the COVID-19 pandemic are much like the way patients with substance use disorder feel all the time, especially when bouncing around the dysfunctional avenues of our healthcare system. Unable to get an appointment. Unable to get coverage. Unable to get transportation. Unable to get information.

But it does not have to be this way. Integrated care greatly improves the delivery of healthcare. That is not just because it addresses multiple dimensions of disease, but also because it enables early intervention. Integrated care empowers providers to diagnose earlier in the progress of a disorder when treatment is generally more effective. In addition, integrated care results in a better patient experience and patient engagement, which are powerful fuels for the business success of health systems and centers. It empowers patients in a system that makes them feel a lack of control. It reduces churn and burnout among healthcare employees.

And finally, integrated care reduces disparities that exist across racial and ethnic groups—but it is not enough. Healthcare leaders implementing this model must also consciously consider racial and ethnic bias and discrimination. The role of recurrent, systemic, and pervasive traumas experienced by individuals, communities, and societies requires a sensitive response that avoids further victimization and marginalization. So yes, the hard work of addressing bias and racism must be done as well, but integrated care is the best model of care for delivering equitable care.

The barriers are high. Implementing integrated care in your system or practice will not happen overnight. But all of these barriers can be lowered. I have done it, and you can too.

This book will focus on the barriers that primary care and behavioral health professionals can influence. And just like patients, doctors and even healthcare executives can feel powerless in the bureaucracy of healthcare. But you will be surprised what influence you have! Providers and healthcare business leaders do have some power to overcome incompatible EHR systems, insurance coverage limits, and other seemingly intractable problems.

This book will give you tools to fight back against resistance from management, providers, referral sources and support staff, and insurance companies—but most importantly, to secure buy-in from business leadership and primary care providers. I will also talk about how to tackle some myths that stand in your way with important stakeholders. One of the most widely held fallacies is that integrated care will increase PCPs’ workload and decrease the time available to spend with patients. Not true!

Another stubborn myth is that having good technology is enough to enable collaboration. Indeed, data-informed decision-making, great EHRs and communication tools, and other technology improvements are critical ingredients for integrated care. This measurement-based care model includes comprehensive assessments that generate tons of data t...