Health Care Systems and Substance Use Disorders

While services for the prevention and treatment of substance misuse and substance use disorders have traditionally been delivered separately from other mental health and general health care services, effective integration of prevention, treatment, and recovery services across health care systems is key to addressing substance misuse and its consequences; it represents the most promising way to improve access to and quality of treatment.

There are many kinds of health care systems across the United States with varying levels of integration across health care settings including primary care, specialty substance use disorder treatment (including residential and outpatient settings), mental health care, infectious disease clinics, school clinics, community health centers, hospitals, emergency departments, and others. These systems utilize wide-ranging workforces that include doctors, nurses, nurse practitioners, psychologists, licensed counselors, care managers, social workers, health educators, peer workers, and others. They incorporate diverse structural and financing models and leverage different levels of technology. These diverse health care systems have many roles to play in providing integrated care to address our nation’s substance misuse and substance use disorder problems, including delivering prevention interventions; identifying patients with substance use related problems and engaging them in the appropriate level of care; treating substance use disorders of all levels of severity; coordinating care both across health care systems and with social services systems including criminal justice, housing and employment support, and child welfare; linking patients to RSS; and providing long-term monitoring and follow-up.

One of the recurring themes in this Surgeon General’s Report is that sound scientific knowledge about how to address substance use disorders effectively has outpaced society’s ability and, in some cases, willingness to implement that knowledge. Recent health care reform laws, as well as a wide range of other trends in the health care landscape, are working to address this gap. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that the financial requirements and treatment limitations imposed by most health plans and insurers for health and substance use disorders be no more restrictive than the financial requirements and treatment limitations they impose for medical and surgical conditions (commonly referred to as “parity”). At the same time, the Affordable Care Act is greatly expanding the number of people covered by health insurance, and requires the majority of United States health plans and insurers to offer prevention, screening, and treatment for substance use disorders. Additional policy measures are increasing the scope of substance use disorder treatment services covered under Medicaid, widening access to care for those who are most economically disadvantaged and disproportionately at risk for substance use disorders. At the same time, health care organizations are recognizing that substance use disorders must be detected and treated like other health conditions and that it is in their best economic interests to do so. This is leading to growing integration of behavioral health and general health care and increased efforts to screen patients for substance use disorders and address them through early intervention or referral to appropriate levels of treatment.

Substance use disorders are strongly intertwined with other medical conditions, making an integrated approach to care essential. Challenges to such integration include insufficient training of health care professionals on how to identify and treat substance use disorders, an underdeveloped infrastructure, and some ingrained attitudes. For example, methadone and buprenorphine treatment remain surrounded by misconceptions and prejudices that have hindered their delivery. Similar attitudinal barriers hinder the adoption of harm reduction strategies like needle/syringe exchange programs, which evidence shows can reduce the spread of infectious diseases among individuals who inject drugs.53

Increasing the number of insured Americans and integrating substance use disorder services with mainstream health care has the power to improve outcomes for individuals, reduce overall health care costs for them and their families, reduce health disparities among high-risk groups, and reduce costs for health care systems and communities. Studies show that greater investment in treatment will also reduce costs associated with criminal justice; child welfare, educational, and social services; and lost productivity.2,3 The benefits may also be felt more broadly, as the evidence suggests that improving substance use treatment can help to improve treatment success for other conditions, reduce hospital readmissions, reduce the spread of infectious diseases like HIV and hepatitis, and reduce drug-related accidents and overdoses.


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References: 

2. Sacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E., & Brewer, R. D. (2015). 2010 national and state costs of excessive alcohol consumption. American Journal of Preventive Medicine, 49(5), e73-e79.

3. National Drug Intelligence Center. (2011). National drug threat assessment. Washington, DC: U.S. Department of Justice.

53. Polcin, D. L., Korcha, R., Bond, J., & Galloway, G. (2010a). Eighteen-month outcomes for clients receiving combined outpatient treatment and sober living houses. Journal of Substance Use, 15(5), 352-366.