Question

1. Many European governments have implemented innovative approaches to address the employment, health, and legal costs associated with heroin injection. List these countries and thoroughly describe the type of programs these counties have created to address the concerns.

Needs to be a page long response

Answer 1

The systematic coordination of general and behavioral health care. Integrating services for primary care, mental health, and substance use-related problems together produces the best outcomes and provides the most effective approach for supporting whole-person health and wellness.

This chapter describes the key components of health care systems; historical reasons substance use and its consequences have been addressed separately from other health problems; the key role that health care systems can play in providing prevention, treatment, and recovery support services (RSS) for substance use disorders; and the recent developments that are leading to improved integration of substance use-related care with the rest of medicine. This chapter also describes the challenges to effective integration, as well as promising trends, such as in health information technology (health IT) that will facilitate it. Because these changes are still underway, much of the relevant research is still formative and descriptive; information presented in this chapter often derives from reports and descriptive papers.

KEY FINDINGS*
Well-supported scientific evidence shows that the traditional separation of substance use disorder treatment and mental health services from mainstream health care has created obstacles to successful care coordination. Efforts are needed to support integrating screening, assessments, interventions, use of medications, and care coordination between general health systems and specialty substance use disorder treatment programs or services.
Supported scientific evidence indicates that closer integration of substance use-related services in mainstream health care systems will have value to both systems. Substance use disorders are medical conditions and their treatment has impacts on and is impacted by other mental and physical health conditions. Integration can help address health disparities, reduce health care costs for both patients and family members, and improve general health outcomes.
Supported scientific evidence indicates that individuals with substance use disorders often access the health care system for reasons other than their substance use disorder. Many do not seek specialty treatment but they are over-represented in many general health care settings.
Promising scientific evidence suggests that integrating care for substance use disorders into mainstream health care can increase the quality, effectiveness, and efficiency of health care. Many of the health home and chronic care model practices now used by mainstream health care to manage other diseases could be extended to include the management of substance use disorders.
Insurance coverage for substance use disorder services is becoming more robust as a result of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act. The Affordable Care Act also requires non-grandfathered individual and small group market plans to cover services to prevent and treat substance use disorders.
Health care delivery organizations, such as health homes and accountable care organizations (ACOs), are being developed to better integrate care. The roles of existing care delivery organizations, such as community health centers, are also being expanded to meet the demands of integrated care for substance use disorder prevention, treatment, and recovery.
Use of Health IT is expanding to support greater communication and collaboration among providers, fostering better integrated and collaborative care, while at the same time protecting patient privacy. It also has the potential for expanding access to care, extending the workforce, improving care coordination, reaching individuals who are resistant to engaging in traditional treatment settings, and providing outcomes and recovery monitoring.
Supported evidence indicates that one fundamental way to address racial and ethnic disparities in health care is to increase the number of people who have health insurance coverage.
Well-supported evidence shows that the current substance use disorder workforce does not have the capacity to meet the existing need for integrated health care, and the current general health care workforce is undertrained to deal with substance use-related problems. Health care now requires a new, larger, more diverse workforce with the skills to prevent, identify, and treat substance use disorders, providing “personalized care” through integrated care delivery.
*
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a practical or clinical sense and is widely practiced.5
In 2015, 20.8 million Americans had a substance use disorder. As discussed in Chapter 1 - Introduction and Overview, these disorders vary in intensity and may respond to different intensities of intervention. Diverse health care systems have many roles to play in addressing our nation's substance misuse and substance use disorder problems, including:

Screening for substance misuse and substance use disorders;
Delivering prevention interventions to prevent substance misuse and related health consequences;
Early intervention to prevent escalation of misuse to a substance use disorder;
Engaging patients with substance use disorders into treatment;
Treating substance use disorders of all levels of severity;
Coordinating care across both health care systems and social services systems including criminal justice, housing and employment support, and child welfare;
Linking patients to RSS; and
Long-term monitoring and follow-up.
There is a great diversity of health care systems across the United States, with varying levels of integration across health care settings and wide-ranging workforces that incorporate diverse structural and financing models and leverage different levels of technology.

Health Care Settings
Health care systems are made up of diverse health care organizations ranging from 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.

It is known that most people with substance use disorders do not seek treatment on their own, many because they do not believe they need it or they are not ready for it, and others because they are not aware that treatment exists or how to access it. But individuals with substance use disorders often do access the health care system for other reasons, including acute health problems like illness, injury, or overdose, as well as chronic health conditions such as HIV/AIDS, heart disease, or depression. Thus, screening for substance misuse and substance use disorders in diverse health care settings is the first step to identifying substance use problems and engaging patients in the appropriate level of care.

Mild substance use disorders may respond to brief counseling sessions in primary care, while severe substance use disorders are often chronic conditions requiring substance use disorder treatment like specialty residential or intensive outpatient treatment as well as long-term management through primary care. A wide range of health care settings is needed to effectively meet the diverse needs of patients.

Workforce
Just as a diversity of health care settings is needed to meet the needs of patients, a diversity of health care professionals is also critical. Health care services can be delivered by a wide-range of providers including doctors, nurses, nurse practitioners, psychologists, licensed counselors, care managers, social workers, health educators, peer workers, and others. With limited resources for prevention and treatment, matching patients to the appropriate level of care, delivered by the appropriate level of provider, is crucial for extending those resources to reach the most patients possible.

Structural and Financing Models
A range of promising health care structures and financing models are currently being explored for integrating general health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system. As part of ongoing health reform efforts, both federal and state governments are investing in models and innovations ranging from health homes and ACOs, to managed care and Coordinated Care Organizations (CCOs), to pay-for-performance and shared-savings models. These new models are developing and testing strategies for effectively and sustainably financing high-quality care that integrates behavioral health and general health care.

Technology Integration
Technology can play a key role in supporting these integrated care models. Electronic health records (EHRs), telehealth, health information exchanges (HIE), patient registries, mobile applications, Web-based tools, and other innovative technologies have the potential to extend the reach of the workforce; support quality measurement and improvement initiatives to drive a learning health care system; electronically deliver prevention, treatment, and recovery interventions; efficiently monitor patients; identify population health trends and threats; and engage patients who are hesitant to participate in formal care.

KEY TERMS
Learning Health Care System. As described by the Institute of Medicine (IOM), a learning health care system is “designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.”4

The Promise of Integration
When health care is not well integrated and coordinated across systems, too many patients fall through the cracks, leading to missed opportunities for prevention or early intervention, ineffective referrals, incomplete treatment, high rates of hospital and emergency department readmissions, and individual tragedies that could have been prevented. For example, a recent study found that doctors continue to prescribe opioids for 91 percent of patients who suffered a non-fatal overdose, with 63 percent of those patients continuing to receive high doses; 17 percent of these patients overdosed again within 2 years.6 Effective coordination between emergency departments and primary care providers can help to prevent these tragedies.

Other tragedies occur when patients complete treatment and the health care system fails to provide adequate follow-up and coordination of the wrap-around services or recovery supports necessary to help them maintain their recovery, leading to relapse. The risk for overdose is particularly high after a period of abstinence, due to reduced tolerance—patients no longer know what a safe dose is for them—and this all too often results in overdose deaths. This is a common story when patients are released from prison without a coordinated plan for continuing treatment in the community. One study from the Washington State Department of Corrections found that during the first 2 weeks after release, the risk of death among former inmates was 12.7 times higher than among state residents of the same age, sex, and race. Health care systems play a key role in providing the coordination necessary to avert these tragic outcomes.7

KEY TERMS
Wrap-Around Services. Wrap-around services are non-clinical services that facilitate patient engagement and retention in treatment as well as their ongoing recovery. This can include services to address patient needs related to transportation, employment, childcare, housing, and legal and financial problems, among others.
Substance Use Disorder Services Have Traditionally Been Separate From Mental Health and General Health Care
The separation of the treatment systems for substance use disorders, mental illness, and general health care has historical roots.8-10 For example, Alcoholics Anonymous (AA) was founded in 1935 in part because mainstream psychiatric and general medical providers did not attend to substance use disorders. If treated at all, alcoholism was most often treated in asylums, separate from the rest of health care. The separation of substance use disorder treatment and general health care was further influenced by social and political trends of the 1970s. At that time, substance misuse and addiction were generally viewed as social problems best dealt with through civil and criminal justice interventions such as involuntary commitment to psychiatric hospitals, prison-run “narcotic farms,” or other forms of confinement.11 However, when many college students and returning Vietnam veterans were misusing alcohol, using drugs, and/or becoming addicted to illicit substances, high numbers of arrests and other forms of punishment became politically and economically infeasible. At this time, there was a major push to significantly expand substance misuse prevention and treatment services.

Despite the compelling national need for treatment, the existing health care system was neither trained to care for, nor especially eager to accept, patients with substance use disorders. For these reasons, new substance use disorder treatment programs were created, ultimately expanding to programs in more than 14,000 locations across the United States. This meant that with the exception of withdrawal management in hospitals (detoxification), virtually all substance use disorder treatment was delivered by programs that were geographically, financially, culturally, and organizationally separate from mainstream health care.