Redesign of Addictions Services and Concurrent Disorders
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 52
Background and Current Challenges
People suffering concurrent disorders (also called dual diagnosis) have both a diagnosable addiction and a psychiatric disorder. It is widely accepted that there is a strong relationship between addiction and psychiatric disorders, and that either condition can lead to, or affect the other.1 Dr. Kenneth Minkoff goes so far as to state that “dual diagnosis is an expectation, not an exception.
Providing services to people with concurrent disorders has historically been challenging. In British Columbia, addictions, mental health and primary care services were for many years delivered as separate systems under different ministries, with little opportunity for coordination. With the recent regionalization of health services, addictions, mental health and primary care services are now co-located under the health authorities (since 2002). This opens the door to the possibility of better integration and planning.
The need for a seamless system of services is important for concurrent disorder consumers. These individuals are among the most challenged in any health care system. Unless proper screening and assessments can be done by both mental health and addictions providers, many people will be treated for only one disorder. Even when both disorders have been identified, treatment is difficult since traditionally, the two systems have differed in philosophy and approach.2 The consumer might receive different treatment for the same symptoms from each provider. This can lead to confusion, reductions in medication compliance and a loss of overall health. The complex symptoms of these clients can also cause them to refuse treatment, even when offered and available.
There are many inherent barriers to accessing services for people with co-occurring disorders as they are often unable to make significant contact with others. They tend to be among the most marginalized and isolated members of society. In addition, consumers with mental health issues may be reluctant to reveal addictions concerns to mental health service providers and social assistance workers because of the stigma attached. There is an urgent need for education, common language and common clinical standards among the various agencies involved in services for concurrent disorder consumers. A lack of such coordination can be disastrous. For example, there is currently a perception among consumers and service providers that disability assistance in British Columbia may be terminated if a person admits to substance misuse. The belief is that, if the mental health symptoms are attributed to substance misuse, the person may lose their classification for social assistance purposes, resulting in a significant or total loss of income.
Another issue that decreases access and reduces effectiveness of services is the debate over the root cause of concurrent disorders. Some models are based on the belief that the addiction is caused by an effort to self-medicate for mental health symptoms; others state that the psychiatric disorders are caused by substance misuse. Still other models identify common factors such as genetic loading or personality disorders as risks, while a bi-directional model proposes that either disorder can make people vulnerable to the other.4 This debate can result in a complete lack of service. For example, consumers state that they will often be refused treatment at emergency wards when they present with psychosis because the psychosis will be attributed to drug use and, therefore, be considered not worth treating.
In an integrated system, how and where a person enters care would not matter, as treatment follows regardless. In the above example, the consumer in emergency would be treated episodically but would then be referred to appropriate concurrent disorder specialists. The model of treatment would allow enough time and assessment for the symptoms to lead to a treatment plan, without the need to determine too quickly the origin of the symptoms. Health Canada describes program and system integration in its Best Practices document:
Program integration means: mental health treatments and substance abuse treatments are brought together by the same clinicians/ support workers or team of clinicians/support workers, in the same program, to ensure that the individual receives a consistent explanation of illness/problems and a coherent prescription for treatment rather than a contradictory set of messages from different providers.
System integration means: the development of enduring linkages between service providers or treatment units within a system, or across multiple systems, to facilitate the provision of service to individuals at the local level. Mental health treatment and substance abuse treatment are, therefore, brought together by two or more clinicians/support workers working for different treatment units or service providers. Various coordination and collaborative arrangements are used to develop and implement an integrated treatment plan.
Addictions Redesign in Vancouver
Currently in the community of Vancouver, the Vancouver Coastal Health Authority is in the process of redesigning addiction and mental health to integrate into primary care services. Over a five-year time period, community health centres are being redesigned with the goal of increasing access and services to high-risk and hardto-reach clients. One of the overarching principles of the collective redesigns is that client care must be integrated and seamless, with many points of entry into a unified system. With respect to addictions, services are being redesigned over a three-year timeframe. Addictions teams and services are being implemented in all of the community health centres across Vancouver (to be completed by June 2004) and will provide:
methadone maintenance therapy
The new model of care for addictions is based on best practice research and includes the following eight principles:
Sees addiction as a public health issue
Recognizes the relationship between addiction and mental healt
Supports both abstinence and substance use reduction as goal
Integrates with primary care
Has multiple entry points
Uses evidence-based research
Provides treatment on demand
Involves the client in all aspects of treatment planning
Standardized education and clinical practice guidelines are being implemented for all addiction services. When a client comes into the system, regardless of their presenting symptoms, they will be assessed and will access whatever services they are seeking at the time. The assessment tools include mental health assessment, so that over time, the client may be directed to mental health services (either on-site or with external mental health teams) if that is part of their symptomology. Education is extended to all of the staff at the community health centres, including reception staff. This ensures that all staff interacting with the client have knowledge related to addictions.
Individual mental health workers are being added to the teams at the sites, and greater links with existing mental health teams are being formed. This opens the door to coordinated education and clinical standards development between disciplines.
Existing Resources for Dual Diagnosis
An excellent existing dual diagnosis program (that covers Vancouver) is part of the network of services that will be supplemented by having better-educated and coordinated service providers at community health centres. The dual diagnosis team provides a model of care for people with concurrent disorders and has specialized staff including a physician who is an ‘addictionologist.’ This team is available to do education with staff at other sites and currently attends at Vancouver Detox on a weekly basis to assist with dual diagnosis clients who are detoxing and considering a treatment plan. The dual diagnosis program provides group therapies including rational emotive therapy, relapse prevention, anger management and family support, among others. This programming will be more accessible to clients as primary care teams learn how to assess and connect people with what they need.
A community engagement and education process is being undertaken to promote collaboration, increase understanding of addictions and concurrent disorders and to receive input from consumers of services and their families. While the effort to integrate services is in an early stage of development, there are increasing opportunities and an understanding of where and how health care delivery systems need to improve to better serve hard-toreach clients such as those with concurrent disorders.
About the Author
Susann is with Vancouver Coastal Health Authority's Addictions Services, Community Engagement. For information, contact firstname.lastname@example.org
Drake, R. (2003).Dual diagnosis and integrate treatment of mental illness and substance abuse. See: www.nami.org/Content/ContentGroups/HelplineI/Dual_Diagnosis_and_Integrated_Treatment_of_Mental_Illness_and_Substance_Abuse_Disorder.htm
Minkoff K. (2001). Dual diagnosis: An integrated model for the treatment of people with co-occurring psychiatric and substance disorders in managed care systems. Presentation.
Based on discussion with service providers and consumers in the Vancouver community
Hodgins, D. (2000). Meeting the challenge of concurrent disorders.Developments, 20(2) See: corp.aadac.com/programsservices/developments/vol20_issue2.asp
Centre for Addiction and Mental Health. (2002). Best practices: Concurrent mental health and substance use disorders. Ottawa: Health Canada. See www.cds-sca.com