Let's start with a common scenario. I recently admitted a patient to our addiction treatment clinic who had an all too familiar story. Jesse these a 21-year-old man. He grew up in an affluent town. He started drinking alcohol at the age of 14. Shortly thereafter, he was exposed to marijuana and started smoking it daily. By the age of 16, he was at a party and some of his peers were snorting oxycodone. Jesse reports he fell in love. He quickly progressed to injection heroin use. Over the last year, he lost his older brother to an opioid overdose, he lost his job as an electrician apprentice, and he lost his apartment. His family has disowned him. Now he's living in his car, and doing what it takes to spend $80-$100 per day to avoid opioid withdrawal, and he came to see us seeking help. Within three hours of presentation, the licensed clinical social worker performed an intensive psychosocial interview. A licensed practicing nurse performed an oral swab, diagnosing him with hepatitis C. Our case manager met with him to start the process to investigate insurance coverage and housing options. I evaluated him and wrote his orders to start methadone. The pharmacist confirmed his dose, which the nurse then administered. Through inter-professional collaboration, I'm confident we saved Jesse's life. It has taken me years to appreciate the importance of inter-professionalism in practice, and I often wonder why more health professionals trainees aren't exposed to this type of collaboration early on in their training. Now, we realize that not all settings have the resources to function as a fully integrated inter-professional team, yet it should be noted that collaboration between professionals promotes improved patient care. So wherever possible, this inter-professionalism should be promoted. In this lesson, you'll learn the value of treating addiction like a chronic disease by leveraging the power of an inter-professional team through various stages of progression. We hope you appreciate that while there is an overlap in core skills among various disciplines, no single provider should have to manage treatment all on their own. Addiction treatment is increasingly being conceptualized using the chronic care management model, which is a long term proactive strategy that's delivered through a coordinated healthcare team rather than a single provider. If you think about it, this is what we have seen work to treat patients with many other chronic diseases, like diabetes, heart failure, lupus, and serious mental illness, including depression and schizophrenia. The goal of the chronic care management model is to engage patients and families throughout their experience with the health condition, and provide them with education, treatment options, self-care strategies, and support. This model contrasts the common practice to provide reactive acute care, which merely focuses on a complication of the condition, or managing a disease exacerbation. For substance use disorders then, the chronic care management model can be conceptualized with four stages; early identification and intervention, stabilization, clinical management and monitoring, and personal management. Within each of these four stages, there are unique opportunities for inter-professional treatment. In the early identification and prevention stage, team members utilize screening and motivational interviewing skills with the goal of identifying unhealthy substance use, enhancing motivation in accordance with risk, and educating accordingly. The goals of the stabilization phase are to safely guide the patient through withdrawal, manage their cravings, and promote abstinence, while acknowledging and respecting the patient's individual goals. Inter-professional team members utilize skills to initiate medicine and counseling strategies within this phase. In the clinical management phase, medications and counseling should be adjusted as needed through treatment monitoring. The intention here is to help the patient maintain the reduction of substance use and related harms in order to manage any medical and/or psychiatric consequences. In the personal management phase, individuals should be presented with a menu of options available for peer support groups and self-care activities, along with individual and family therapies to reinforce lifestyle changes. In addition to working on the goals in the previous stages, the focus here is to help the patient avoid emotional, physical, or social threats that can lead to a return to substance use. Throughout all the phases, the team needs to be flexible and patient-centered, while employing evidence-based strategies to address any issues that may arise in the course of treatment. This includes medication management, counseling, and prevention of return to use. The outline of this course follows these stages, and you will learn the basics of all these clinical methods. You may be wondering, where exactly do you fit in? The truth is there is a lot of overlap. If we look closer at the chronic care management approach, we see that many disciplines can be involved in most of these stages. In the early intervention phase, we see those on the front lines, those are the gatekeepers, such as medical assistants, nurses, advanced practice nurses, physicians assistants, doctors, and social workers, and all of these folks can utilize skills to identify risky substance use. If a substance use disorder is diagnosed, a wider range of professions, including generalized and specialized care, can collaborate to manage the disease. In these stages, stabilization, clinical management, and personal management, nurses, advanced practice nurses, physicians assistants, doctors, social workers, along with pharmacists, and counselors, and health coaches, and peer support specialists, can all play a key role. So what can this look like? Well, it can take on many forms. The team may be a community of providers throughout an entire city, or throughout a health care system. Alternatively, the team may be a small number of providers in a single clinic. For example, in a neighborhood health clinic, integrating behavioral health and addiction medicine, a medical assistant delivers universal screening to all patients. From there, a provider reviews the results of the screener, assesses further, and may diagnose a substance disorder. Then the pharmacist is brought in to discuss various medications that can reduce cravings, and review possible contraindications. In other settings, a primary care provider may be the one to screen, diagnose, asses, and prescribe medications. Beyond the medical management, a patient can also be referred to a counselor for psychotherapies, and may work with a social worker to find housing. Or even be assigned a peer support specialist who will call the patient on a regular basis, and be available for 24-7 guidance. Beyond individuals operating inter-professionally, entire systems can be built to integrate various healthcare services in one facility. So let's think about this. If a patient without transportation or other resources has to go to multiple different locations for different services, it makes it that much harder to make it to appointments and receive optimal care. Compare that to a patient who can receive medications, and monitoring, one-on-one counseling, and even pure support all in one location, and even in the same visit. Community health centers are proving to be successful models of integrated care, as many services are available under one roof. Having a one-stop-shop reduces the potential for loss to follow-up for the patient, and ultimately breaks down barriers to care, bolsters collaborative service delivery models, and expand substance use disorder treatment, often to communities in the greatest need. In addition to providing better care, more targeted medical care for patients, there's also the added benefit of seamless information sharing among providers, granted the proper consents are in place. So how do we know that inter-professionalism works? Perhaps the most widely studied model of inter-professional addiction treatment is the Massachusetts collaborative care model, where nurses working at the top of their licenses and physicians play a central role in identification, evaluation, and monitoring of individuals with opioid use disorder, treated with office-based buprenorphine. The program was rolled out across 14 community health centers across the state, and program expansion of this model had a profound impact on access to care, with a 375 percent increase in buprenorphine waivered physicians over a three-year time period. Federal legislation also pave the way for increased treatment delivery. In 2016, the Comprehensive Addiction and Recovery Act was passed, which allowed nurse practitioners and physician assistants to provide medications approved by the Food and Drug Administration for the treatment of opioid use disorder, including maintenance, detoxification, overdose reversal, and relapse prevention. This legislation allowed advanced practice nurses in some states to be able to independently prescribe buprenorphine. So while many practitioners can equip themselves with the proper knowledge, skills, and attitude to treat addiction, it's not always clear how to operationalize effective addiction treatment. Who should take ownership, and over what steps? If it isn't clear whose role it is to do what, then team members may repeat tasks and contribute to redundancy, and that's why it's vitally important to have clear role responsibilities outlined when working in teams. Substance use disorder treatment is a team sport. Individuals should not work in silos, and when feasible, there should be regular multi-disciplinary team meetings to discuss the care provided. With the proper resources and implementation, inter-professionalism can work really well, and improve efficiency. You may not work in an integrated health setting, or in a particularly cooperative environment, and depending on your role, you may not have the decision-making power to implement a collaborative care model, but inter-professionalism does not have to be circumstantial. You can familiarize yourself with what effective addiction treatment looks like, and you can be mindful of the resources in your area, and think creatively about how to effectively collaborate with your peers.
