Chapter 3. Integrate Treatment for Substance Use Disorders into Mainstream Health Care and Expand Support for Recovery
Chapter Table of Contents
The Administration calls for broader integration of substance use disorder services within primary care, mental health, criminal justice, child welfare, housing and homeless services, and other systems. In 2009, an estimated 23 million Americans had active substance use disorders and yet, only about 10 percent of this population received specialty treatment.
Recovery, like addiction, is multi-dimensional and progressive in nature. It involves not merely abstinence from substances, but rather a process through which individuals actively pursue and achieve health, wellness, and accountability to self and others. Recovering individuals are responsible parents, neighbors, and citizens. They serve their communities and share the gift of recovery with others in need. The Obama Administration is committed to spreading the promise of recovery across the Nation.
In 2011, HRSA and SAMHSA’s joint technical assistance and training centers will educate healthcare providers on effective approaches for identifying, diagnosing, and treating substance use disorders. (Action Item 2.1C)
Additionally, in 2011 ONDCP will work in partnership with CDC to disseminate materials and conduct training for first responders. The goal is to help them recognize and effectively manage overdoses to reduce deaths and disabilities. (Action Item 3.2D)
HHS will develop public health strategies that include issuing guidelines and providing technical assistance related to the use of Federal funds to support syringe exchange programs as part of a comprehensive strategy to get people into treatment and into the mainstream public health system. (Action Item 3.1E)
American Indian and Alaskan Native communities are particularly in need of expanded addiction treatment services. Drug use rates are significantly higher among these communities (18.3%) than among other ethnicities (e.g., 9.6% for African Americans and 8.8% for Caucasians). To address this need, the Indian Health Service (IHS) implemented a specially tailored version of SBIRT in emergency rooms in these communities. To further improve access and quality for American Indians and Alaskan Natives who have served in the Armed Forces, IHS and the Veterans Health Administration (VHA) in 2010 entered into a formal collaborative agreement under which American Indian and Alaska Native Veterans and active duty military have access to substance use disorder treatment services that can be integrated with posttraumatic stress disorder and traumatic brain injury protocols as needed. (Action Item 3.1B)
Community Health Centers (CHCs), which provide care for more than 19 million low-income Americans, have not traditionally offered extensive specialized services for substance use disorders, despite the fact they are prevalent in the populations served by CHCs. The Health Resources Services Administration (HRSA) is working to improve CHC substance use disorder services. In 2010, HRSA added SBIRT to the list of fundable services for CHCs and established a Training and Technical Assistance Center in collaboration with SAMHSA. The center will help integrate behavioral health services in primary care settings and provide information and consultation to CHCs interested in offering behavioral health services. (Action Item 3.1A)
As mentioned in Chapter 2, work will continue over the next 4 years with Federal partners (HRSA, SAMHSA, the Indian Health Service, the Centers for Medicare and Medicaid Services, the Office of the National Coordinator for Health Information Technology, and HHS’ Office of the Assistant Secretary for Planning and Evaluation) to ensure services for substance use disorders meet the National Quality Forum Standards to treat substance use conditions and are integrated in essential benefits packages by 2014. National Quality Forum Standards are a set of agreed-upon and endorsed national voluntary consensus standards on evidence-based practices to treat substance use disorders. (Action Item 3.2C)
The effectiveness of addiction treatment has been hampered by the limited range of available FDAapproved medications relative to other chronic medical disorders. Fortunately, advances in neuroscience research are identifying promising directions for medication development, including medications that help in the management of acute withdrawal symptoms and others that reduce cravings and counter relapse triggers. The Administration has actively supported research to develop new medications. For example, NIDA research is supporting the development of vaccines for cocaine, opiates, and nicotine.
These vaccines act by preventing the drug from reaching the brain. The cocaine and nicotine vaccines have had promising results in human trials, effectively reducing drug use in those who achieve high antibody levels. (Action Item 3.2A)
Additionally, NIDA has continued its work to combat HIV infection, which is more prevalent among drug users than in the general population and is especially common among injecting drug users. In September 2010, NIDA funded 12 “Seek, Test, and Treat” research applications in the criminal justice system. These studies will develop and test strategies to expand access to HIV testing for individuals in the criminal justice system, increase availability of antiretroviral therapy for criminal justice-involved HIV-positive individuals, and ensure continued access to services following community reentry. (Action Item 3.2E)
In September 2010, ONDCP co-sponsored a Family Treatment Forum. Experts from HHS, Education, and DOJ participated in panel discussions and answered questions from family treatment providers. The forum resulted in a new partnership between the HRSA’s Federally Qualified Health Centers (FQHCs) and family treatment providers. Through FQHCs, which offer basic medical services to underserved populations, family treatment providers will now be able to create partnerships and refer their clients to medical services. Often people who are being treated for substance use disorders require additional medical treatment. In 2011, ONDCP continues to facilitate this new connection to ensure access to medical care for women and children taking part in family treatment programs.
Because treatment is not the only path to recovery, development of integrated treatment and recovery support services (RSS) networks and Recovery Oriented Systems of Care (ROSC) is critical. RSS are nonclinical services that are often provided by community organizations, faith groups, and other grassroots entities. They include coaching, peer mentoring, housing, employment readiness, spiritual support, and transportation. ROSCs are networks of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders.
In 2010, ONDCP established a Recovery Branch within its Office of Demand Reduction. The new branch has engaged Federal partners, state and local governments, membership and advocacy organizations, service providers, and other stakeholders in the design and development of policies, systems, services, communication campaigns, and other activities that support long-term recovery.
During its initial year of operation, the Recovery Branch convened and co-sponsored a series of events to inform policy development. These events included an expert roundtable that explored strategies for integrating peer recovery support services and peer-led organizations into substance use disorder treatment and general health systems under healthcare reform; two national summits focusing on developing policies, systems, and services to support recovery, one focusing on adults and the other on adolescents and young adults in both secondary and postsecondary education settings; the first-ever Young Peoples Networking Dialogue on Recovery, through which youth were able to inform policymakers about their needs, goals, and aspirations; and the 2010 Joint Meeting on Adolescent Treatment Effectiveness (JMATE), which brought together researchers, program developers, public officials, and youth in recovery.
In 2011, ONDCP will focus its recovery efforts on developing a national plan for promoting and supporting the adoption of ROSC approaches by states, tribes, and local governments; identifying and eliminating regulatory, policy, and practice barriers to recovery; and celebrating and supporting recovery through messaging, outreach, and information strategies as well as through participation in and/or sponsorship of recovery-focused events. Additionally, ONDCP in collaboration with Education will continue its ongoing efforts to foster the development of recovery high schools, campus recovery programs, and treatment recovery support services within mainstream high school and higher education settings. This work will build on Federal investments in the Texas Tech Center for the Study of Addiction and Recovery to develop and disseminate information on a model collegiate recovery community curriculum. (Action Item 3.3C)
As part of its eight Strategic Initiatives, SAMHSA has developed a Recovery Support Initiative. Through this effort, SAMSHA is supporting the new technical assistance program, Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS). The purpose of BRSS TACS is to provide policy and practice analyses, as well as training and technical assistance to states, providers, and systems to increase the adoption and implementation of integrated, peer-driven recovery supports for people with mental and substance use disorders. Through BRSS TACS, SAMHSA will work with a broad array of stakeholders including, but not limited to, people in recovery.
Several SAMHSA grants will provide funds to propagate promising practices for building and expanding ROSCs at the state and community levels and to support the development of peer recovery support services. ROSC frameworks support the delivery and coordination of services across systems and organizations through information technology and the use of individualized service/recovery plans that are designed and implemented in partnership with clients with the goal of long-term recovery in the community.
SAMHSA’s recovery-focused grant programs have seeded the infrastructure necessary for ROSC in communities across the Nation. Lessons learned from these programs will help policymakers understand the challenges and opportunities encountered by states and tribes as they seek to develop recovery-focused systems, policies, and programs.
In 2010, SAMHSA issued 30 new Access to Recovery (ATR) grants to 23 states, 6 tribes, and the District of Columbia. Funded at $98.9 million annually over 4 years, this program expands treatment and recovery support services that are critical to sustaining recovery by establishing voucher programs. (Action Item 3.3A)
The Targeted Capacity Expansion (TCE) Local ROSC grant program has increased the Administration’s understanding of how to implement ROSC in local communities, which can be especially challenging if infrastructure to accommodate them is not established through statewide systems, such as publicly funded treatment services and the child welfare and criminal justice systems. (Action Item 3.3C)
Through these programs, more people will succeed in their long-term recovery, thus reducing the number of chronic drug users in the United States and expanding the number of resilient and healthy families and communities.
Approximately 30 percent of the chronically homeless population has a serious mental illness and around two-thirds have a primary substance use disorder or other chronic health condition that create major difficulties in accessing and maintaining stable, affordable, and appropriate housing.
Through the Grants for the Benefit of Homeless Individuals program (GBHI), SAMHSA is helping to provide supportive permanent housing and reduce the barriers that homeless persons experience during recovery from substance use and/or mental disorders. GBHI supports the expansion of treatment and services for homeless individuals with substance use and/or mental health disorders, and supports the integration of these services into primary care. SAMHSA will fund programs that demonstrate effectiveness in treating persons who are homeless, including runaways, street youth, and Veterans, and transitioning them into permanent housing with supportive services as needed. Services include outreach, screening and assessment, referral, direct treatment, and wrap-around supportive services, all directed to permanent and stable housing.
Through grants awarded by SAMHSA, the El Paso Alliance, National Alliance of Methadone Advocates (NAMA), and numerous other peer-led organizations have created successful peer recovery support programs. NAMA, in collaboration with the Albert Einstein College of Medicine, established Medication Assisted Recovery Services (MARS), the first medication-assisted recovery community organization in the
10-year history of the program.
In 2006, the El Paso Alliance developed The Recovery Alliance, a peer-led recovery community organization that provides peer-designed and peer-delivered recovery support services for persons in recovery from addiction. These include recovery coaching, education, vocational skill development, and informational support. The Recovery Alliance acts as a bridge between treatment providers, drug courts or probation officers, and other service providers in the local community, providing long-term peer recovery support services. Outcomes for the 449 persons served to date by The Recovery Alliance include substantial increases in employment rates and substantial decreases in homelessness.
In 2008, The El Paso Alliance developed Project Sendero al Bienestar (Pathway to Wellbeing). This project uses a peer recovery model and motivational enhancement strategies to serve indigent populations who are seeking recovery from substance use disorders and co-occurring mental health problems. It was funded by a grant under SAMHSA’s Treatment Capacity in Targeted Areas of Need, Local Recovery-Oriented Systems of Care Grant (TCE-ROSC) Program. The project provides detoxification, peer-operated residential services, and peer recovery services to a culturally diverse and largely Hispanic population. Outcomes for the 290 individuals served to date include marked improvements in rates of employment, abstinence, and homelessness.
New Action Item: Deliver Quality Recovery Support Services to Veterans and Military Families
[ONDCP, VA, DOD, SAMHSA]
Consistent with the Presidential Study Directive—Strengthening Our Military Families, ONDCP will lead an interagency effort to identify recovery support services for alcohol and drug addiction that are appropriate for active duty military, Veterans, and their families and to ensure that those services are made available to our military families to the greatest extent possible.
Several agencies are partnering to help persons in recovery from substance use disorders become successful and productive members of American society. Often, there are legal barriers that impede one’s ability to fully integrate back into the workforce and society due to barriers triggered by a person’s past use of illegal drugs or those triggered by a former drug user’s interaction with the criminal justice system.
The societal implications of these barriers to persons working to recover from substance use disorders are significant. In the last 30 years there has been substantial growth in the number of prisoners released from prison each year in the United States: 150,000 in 1972 to 630,000 in 2002.
Offenders returning to the community face numerous obstacles to resuming a normal life. Research shows that state prison inmates with substance abuse problems are more likely to have a past criminal record, have a history of homelessness and exposure to physical or mental abuse, and have family who have been incarcerated or abuse alcohol or drugs. Many individuals leaving the criminal justice system are unable to obtain access to housing and as many as 45 percent return to homelessness.
In 2011, ONDCP will partner with the Department of Housing and Urban Development (HUD) and DOJ to implement Project Reunite. Project Reunite, a recently launched pilot program, is a promising model for improving access to housing for ex-felons or homeless individuals whose families live in public housing. Local Housing Authorities, who have broad discretion in allotting housing to applicants, often deny public housing to individuals with a criminal record. Project Reunite will encourage policy changes at the local level that allow participating Housing Authorities to establish leases with eligible former offenders, allowing them to reside with their families and also link them to a variety of support services. For example, these individuals will not only have access to housing, but also access to case management, employment training, mental health and substance abuse treatment, as well as parenting classes.
This model has the potential to substantially reduce recidivism rates and greatly improve relationships between former offenders, their families, and their surrounding communities. An effort will be made to encourage other local housing authorities across the country to adopt this model. (Action Item 3.3B)