Care Coordination Enhances the Medical Model for Individuals with Substance Abuse Disorder

WellLife Network recently launched the Substance Abuse Care Coordination Team, a specialized program within their Long Island Care Management Division, designed to address the needs of the Medicaid Substance Use Disorder (SUD) population. Care Management is a comprehensive person-centered intervention designed to bridge the gap in services and ensure continuity of care with the objective of promoting overall health and wellness. However, despite overwhelming evidence supporting the great need, the SUD population often lacks access to this service.

With the growing national awareness of the opioid epidemic, it has become apparent that the law and order approach initiated in 1930 with the Treasury Department’s Federal Bureau of Narcotics to the current state of the War on Drugs cannot successfully subside and eliminate the vast concern that we face. According to the CDC, from the years 2000 to 2015, more than half a million people died from drug overdoses in America (Rudd, Seth, David, & Scholl, 2016). On September 21, 2016, FBI Director James Comey acknowledged this position in front of a Georgetown University audience by stating “you can’t arrest your way out of any kind of problem (Documentary Screening, 2016).”

The Dislocation Theory of Addiction

The disease model of addiction remains the predominant perspective in understanding substance use disorders. Overall, as illustrated in this model, substance use is a medical ailment, changing the functioning of the brain with the repercussions of behavioral destruction. While it identifies that substance use disorders are progressive and chronic illnesses that affects the brain functioning the same way that diabetes affects the function of the pancreas, the disease model does not account for the environmental impact that Bruce Alexander claims is at the core of addiction. Bruce Alexander, an American journalist and psychologist, describes the dislocation theory as addiction being a direct result of the social stressors and acceptance that each individual is required to experience in the society in which they are currently living. Eventually, the prolonged dislocation that is often experienced can ultimately result in emotional distress, hopelessness, indignity, and eventually, addiction. This theory touches upon the important influence that society and the environment has on all individuals living in all communities in United States (Alexander, 2014).

Our society perceives individual’s with substance use disorders through the impact of the War on Drugs. Since its’ inception, the War on Drugs has served to perpetuate a stigma that marginalizes these individuals with a moral turpitude labeling them “addicts” pushing them to the fringes of society, isolating those labeled “addict” without holding the community accountable for the social stressors within its’ environment (Alexander, 2014). This is where the Dislocation Theory of Addiction is so vital and the view seen through the narrow lens of the Disease Model fails. Often society understands the Disease Model of Addiction as a disruption of willpower or loss of control, therefore creating a perception of a being without autonomy (Buchman, Illes, Reiner, 2010). Once that perception is established it is easy to neglect their humanity and assign a label.

Filling the Gaps Through Care Coordination

Care coordination attempts to fill the gaps that are unresolved due to different vulnerabilities that many individuals, especially those on Medicaid, experience. Standard examples of a care coordinator’s practice include assistance navigating, advocating and collaborating with health care providers, social service agencies and when necessary the criminal justice system, as well as providing linkages to community resources. Care coordinators will often undertake and explore these deeper issues that disenfranchise impoverished individuals such as lack of affordable housing and access to public transportation. In crisis situations, care coordinators are able to assist individuals to the Department of Social Services and wait with them while they receive an emergency housing placement. Additionally, through networking, care management is able to develop relationships with sober housing and other transitional housing entities. This vital relationship assists individuals by providing a more stable environment for those with substance use diagnoses to ensure focus on their recovery while their basic need of safety is being met. While these concrete areas of care management are vital in providing a stable environment, it is in the development of a safe relationship which carries the most gains.

When dissecting the dislocation theory, trauma can be correlated with the causation of addiction in an individual, as well as the effect. With this knowledge, it is important that as care managers we are aware of the effects of trauma and how we can best service our clients through this lens. Trauma-informed practices and interventions are critical to providing service due to the inter-relation of substance use, mental health, and trauma. Research regarding the high level of trauma that is experienced for those seeking substance abuse treatment illustrates the importance of multifaceted care. Additionally, the research emphasizes the importance of compassion, trust building, and high-quality relationships in service coordination for trauma informed care (Kirst, Aert, Matheson & Stergiopoulos, 2016).

Trauma-informed practice requires the care coordinator to be knowledgeable of the impacts and influences that previous and prior experiences can have on a person. Since those who have a history of distressing experiences, such as trauma, are linked with a significantly higher level of anxiety, it is vital for a care coordinator to encompass empathy, compassion, and trust. When discussing the medical need for a dentist for someone with a substance abuse diagnoses (Humphris & King, 2011), one of the more meaningful interactions with a client would be to attend their dentist appointment with them as a safe support through what could potentially be a re-traumatizing experience. Not only does this give the client an added security to complete a necessary medical appointment, but it also allows for a sense of peace in a stressful situation, which may not be something that they have ever experienced. This same sense of peace and connection can be illustrated through care coordination work navigating the legal system.

As a result of the War on Drugs many of our clients have been faced with criminal charges. These incidents may be indicative of where the criminal justice system is counterintuitive to the goal of health and wellness promotion or eradicating the epidemic. By attending scheduled court appearances or probation appointments to be an added support system in a stressful situation, care coordination not only serves the role of attempting to fill in the gaps in the system, but poses as the workings of the dislocation theory in real time. The technique that is at play in providing care coordination with substance use disorders is to largely understand the bio-psychosocial stressors outside of the scope of their awareness. It is not the scheduling of the doctors’ appointment or calling the probation officer to give an update that makes care coordination with substance use work, but actually going to the appointment with them.

In the field of substance abuse treatment as well as mental health, many understand the conventional perspective of therapeutic intervention. For instance, the scenario of an individual entering a clinician’s office participating in session and actively engaging in treatment works for many individuals who have reached a higher level of functioning to obtain their goals.

A Bridge to Wellness

Care coordination is often the bridge that leads individuals to stable therapeutic intervention. One expectation of a care coordinator is that they are versed in evidenced based practices such as motivational interviewing, behavioral therapies, and crisis intervention. These practices allow for the care coordinator to actively assess a situation in the field to ensure the safety and well-being of the individual.

Primarily, the mobility, flexibility and consistency of the care coordinators allows for a significant and valid therapeutic relationship to be established in motion. By taking a nonjudgmental, unbiased, and supportive approach to interacting with individuals, care coordinators are able to effectively engage and provide psycho-education in the hope that their client might trust the process in conventional treatment in the future. A study published by the American Journal of Public Health discovered that of individuals enrolled in outpatient treatment, those linked to care coordination, in addition to treatment, had longer sobriety time and were less likely to relapse (Shwartz, Baker, Mulvey, & Plough,1997). Alexander referred to the opposite of addiction being connection, in a recent study, thus confirming the validity of community support and correction positively affecting individual’s long-term sobriety and psychological function.

One instance of Client B is a testament to this approach. A care coordinator received a call from Client B who stated that he was in distress in a public location and was without medication. The care coordinator was able to meet client in the field and assess safely all mental health symptoms. Once danger was ruled out, the client was sent to an emergency room for psychiatric assessment and client continues to engage with the care coordinator in addition to fulfilling his treatment and legal requirements as a result of the consistency of the relationship. Through this expression of the care coordinator’s engagement skills, a relationship was established. It could be argued that in a field where the environment is unstable and there can be no power differential between a care coordinator and a client, the relationship will always be the cornerstone of clients’ chances for success in their goals. Client B had no prior consistency with providers in the past due to the nature of his mental illness and substance use.

Knowledge and assessment skills are essential to effective practice in this capacity. Assessing an individual’s safety is a necessity and the care coordinators use of clinical assessment as an orientation allows for the relationship to be fostered. In addition, this allows care managers to have a gauge of an individual’s behavioral pattern which can be beneficial with a high-risk population. Care coordinators have been able to advocate for clients in emergency situations due to the care coordinator knowing the client’s baseline of functioning. This knowledge can only be obtained through the extensive work of establishing a safe space with the client upon initial contact in the field.

The pairing of the medical model and the dislocation theory of addiction, highlights, for care coordinators, the importance of addressing the biological as well as the societal and environmental factors effecting individuals with addiction disorders.

Florence Maroney, LMHC, and Kacie Mitterando, BA, are Care Coordinators, and Patrick Lovaglio, LMSW, is Program Coordinator of the Substance Abuse Team, at WellLife Network.

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