Integration of Substance Use Disorder Treatment Into a Traditional Community Mental Health Treatment System

The population seen in the Catholic Charities of Baltimore community mental health clinics is generally of low socioeconomic status, is primarily insured by Medicaid or Medicare, and has a high rate of co-occurring mental and substance use disorders. In response to the opioid epidemic, the board of directors prioritized an initiative to provide integrated substance use disorder treatment to patients within the agency’s community mental health clinics.

Catholic Charities of Baltimore used a practice improvement strategy that relied on their preexisting model of training, supervision, and care coordination to successfully integrate substance use treatment into the mental health continuum of care.

Every patient referred to one of the eight outpatient Catholic Charities of Baltimore community mental health clinics is initially assigned to a therapist. The therapist performs an intake interview, develops a treatment plan, and begins treating the patient with various treatment modalities. For children and adolescents, therapy may be clinic or school based. The therapist may refer the patient for psychiatric services when necessary, and patients are required to engage and remain in therapy to see a psychiatric provider.

Supervision is foundational to improving and sustaining practice. Each therapist meets biweekly with their supervisor to review caseloads and patient treatment plans. Similarly, psychiatric providers have monthly supervision meetings to discuss challenging cases, formulation, and medication regimens. Collaboration between therapists and psychiatric providers occurs informally but also via formal treatment team meetings in which high-intensity cases are often the focus. Finally, all supervisors conduct regular chart reviews to monitor the care being provided.

The process of integrating mental and substance use disorder treatments began in 2013, when Catholic Charities of Baltimore hired a consultant to survey clinician opinions on treating substance use disorders. The COMPASS-EZ survey (6), a self-assessment tool that looks at a program’s policies, procedures, and practices to identify the program’s baseline and opportunities for improvement, was used. It became apparent that Catholic Charities of Baltimore did not have policy guidance for how to work with people with substance use disorders. As we began to discuss how to implement policies to support integrated treatment, many psychiatrists and therapists voiced concern about their lack of competency in addressing co-occurring substance use in the populations they served. In particular, school-based therapists struggled to fully understand the effects of substance use disorders on child attachment styles, family systems, and family functioning. Because Catholic Charities of Baltimore needed internal guidance for the integration of substance use disorder services, the position of assistant medical director of substance use services was created in 2016 (E.O.), and an administrator with significant knowledge of the provision of substance use disorder services was hired for the position in 2018 (K.L.-H.). Under their guidance, integrated treatment became, by policy, the new standard of care to be achieved through a deliberate practice improvement approach. To support the success of the training efforts described next, supervisors were formally tasked with incorporating integrated substance use disorder treatment planning and intervention during supervision.

First, the agency offered didactics and literature to train all clinicians, including psychiatric providers and therapists, on performing thorough substance use assessments to screen for commonly used substances, family substance use history, and past substance use disorder treatment. Training also provided instruction on how to diagnose substance use disorders on the basis of DSM-5 criteria. Additional training sessions included education and guidance on how to use nonjudgmental language in addiction care, the stages of change, how to access different levels of care used in substance use disorder treatment, treatment planning, and the harm-reduction approach to treatment (7).

All therapists were required to take 10 hours of substance use disorder training initially. Those with further interest were offered enhanced training (a minimum of 40 hours). For therapists working with children, training focused on the effects of substance use on family functioning, including adverse childhood experiences.

Therapists and supervisors received the same training, but as part of the preexisting supervisory structure, supervisors monitored therapists to ensure that substance use disorders were diagnosed when appropriate and evidence-based therapy modalities were used. Supervisors also reviewed documentation to make sure that substance use disorders were appropriately addressed. High-level supervision was performed by the lead administrator (K.L.-H.), who met regularly with supervisors to review expectations for supervision, screening, documentation, and treatment. As a result, the consistency of diagnoses, treatment planning, and stage-matched interventions improved.

Guidelines and policies on medication treatment options for substance use disorders (e.g., buprenorphine, extended-release naltrexone, disulfiram, acamprosate, nicotine replacement products, varenicline, and bupropion), urine toxicology monitoring and interpretation, and naloxone prescription for patients with opioid use disorders were developed for psychiatric providers. All psychiatric providers were asked to obtain buprenorphine waivers. Two- to 3-hour training sessions, consisting of didactics and case-based learning, were integrated into quarterly provider meetings. Policies were reinforced in group meetings, individual training, supervision, and real-time consultations.

Training of administrative staff was also critical. A script was created to answer patients’ frequently asked questions, including those regarding concerns about group attendance, frequency of urine toxicology testing, and participation in therapy. Administrative staff also learned how to communicate what was not available, such as methadone treatment.

Prior to starting services, each clinic conducted a needs assessment. The clinic’s director identified patients with a substance use disorder. Therapists reviewed caseloads to identify patients with possible substance use needs who had been screened with the CAGE-AID (a four-item tool to screen for alcohol and drug use that asks questions about cutting down, feeling annoyed, feeling guilty, and needing an eye opener) and CRAFFT (an assessment tool that screens for substance-related risks and problems among adolescents) tools. Matching treatment to the patient’s current stage of change was emphasized; patients in precontemplation or contemplation were provided with psychoeducation related to the substance they were using, informed about the relationship between that substance and their psychiatric symptoms, and offered assistance with making good decisions about substance use. Patients continued to receive treatment (including medication) for their psychiatric disorder while receiving encouragement and psychoeducation about appropriate treatment for substance use disorders.

When patients indicated their readiness to address their substance use, individualized treatment goals were created by the treatment team in collaboration with the patient. Means to achieve these goals could include psychotherapy, medication, or referrals to self-help groups or more intensive services. Abstinence was encouraged but not always the goal. Therapists provided evidence-based, individual therapy, including motivational interviewing, mindfulness practice, and cognitive-behavioral therapy. Additionally, 50 therapists received dialectical behavior therapy training, which supported strategies to help patients with substance use disorders. Monthly peer supervision among the therapists, which included supervisors but was informal, was offered to discuss best practices in the treatment of substance use disorders. Topics of discussion included barriers to treatment, transference and countertransference, working with adolescents, and contingency management. Patients who needed medication to treat substance use disorder were stratified according to risk, in that patients actively using heroin or illicit opioids were seen first, followed by patients with alcohol, sedative or hypnotic, stimulant, and tobacco use disorders.

All therapists at each clinic were expected to start screening for, diagnosing, and treating substance use disorders. In contrast, for psychiatric providers, medication treatment for substance use disorders began in one clinic. A psychiatric provider trained in addiction treatment prescribed medication to patients who consented to treatment with medication. Once a patient on medication demonstrated abstinence or a significant, sustained reduction in substance use, they were transferred to the care of a general psychiatric provider (but continued to work with their therapist). As each individual patient stepped down to less-intensive treatment, the addiction psychiatrist provided supervision to discuss the patient’s course and answer any of the receiving clinician’s questions. Gradually, the caseloads of the general psychiatric practitioners grew, with providers treating up to 25 patients per month for substance use disorders. On a biannual basis, the charts of patients with substance use disorders were reviewed by the assistant medical director of substance use services, and the psychiatric providers treating the patients received feedback on their documentation, prescription of medications for substance use disorders, medication dosing, and treatment planning. Once a clinic had successfully integrated care, the addiction psychiatrist transitioned to the next clinic, and the process was repeated.

Simultaneously, psychiatric providers at the other clinics were encouraged to begin prescribing medications to patients with substance use disorders if they felt comfortable doing so, and the addiction psychiatrist was available for real-time consultation as necessary. Occasionally, high-risk patients (e.g., those in need of acute opioid withdrawal management) from other clinics were triaged via videoconference with the addiction psychiatrist. Eventually, an additional addiction psychiatrist was hired to meet the growing need.

Our services were advertised mostly by word of mouth through partner agencies. Over time, new partnerships were formed with agencies offering higher levels of substance use disorder care, such as intensive outpatient, partial hospitalization, inpatient detoxification, and residential services. In addition, many patients receiving treatment for substance use disorders from other providers decided that receiving concurrent treatment for mental and substance use disorders in one location would be more convenient.

Two grants assisted with the process of integrating treatment: a $150,000 grant from CareFirst to implement integration and a $505,000 grant from the Maryland Community Health Resources Commission to expand services in the eight clinics of Catholic Charities of Baltimore. Although the ongoing provision of services will be sustained via billing, the initial work of providing the training, support, and infrastructure needed to prepare our clinics and clinicians to care for those with substance use disorders was facilitated by grant support.

Fifteen outcomes were measured, including the number of patients receiving concurrent treatment, retained in treatment, and completing treatment. Most noteworthy was the number of patients (N=5,846) screened for substance use disorders. Identification of patients with substance use disorders (ages ≥14 years) increased more than fourfold within the first 2 years of clinicians’ treating co-occurring disorders, with 2,046 (35%) receiving a substance use disorder diagnosis. Every patient screening positive received a comprehensive assessment and an individualized, integrated stage-matched treatment plan, which included harm reduction, motivational interviewing, and medication when warranted. Our clinics improved the integration of treatment planning for co-occurring disorders to reflect case complexity by assessing patients’ readiness to change and promoting motivational interviewing. Of the patients with a substance use disorder diagnosis, 1,116 (1,014 adults and 102 youths; 55%) engaged in active treatment. Although our preliminary data analyses focused on the increase in services offered, we are now examining the outcomes of those treated.

One main barrier to implementing substance use disorder treatment is the need to connect with local substance use disorder resources, which may require painstaking outreach and partnership development. Knowing how and where to make referrals for higher levels of care is imperative.

Incorporating urine toxicology testing into our treatment protocols, particularly for medication treatment of opioid use disorder, was a challenge. We extensively deliberated on this topic given the staffing, workflow, and cost considerations of using point-of-care urine toxicology tests. Ultimately, we decided to outsource toxicology testing to local laboratories.

Last, although our initial target was integrated care for those with co-occurring disorders, we soon discovered that patients having only a diagnosis of substance use disorder also desired services at our clinics. As a result, it was necessary to apply for licensing for outpatient level 1 substance use disorder treatment, which would allow this patient population to be treated as well.

Integration of substance use disorder treatment into an established mental health center is challenging but also possible and effective. The process begins with clinic leaders evaluating the current culture regarding substance use disorder treatment and working toward changing the philosophy to include integrated care. The second step is to determine baseline knowledge and provide the necessary practice improvement infrastructure to bolster clinicians’ competency in treating substance use disorders through ongoing training, supervision, and consultation, which allow providers to expand their expertise and feel comfortable with increasingly complex cases. It is important to anchor these processes through policies, protocols, and data collection. Future studies will examine patient outcomes, including abstinence rates, adherence to treatment regimens, time to remission, and patient satisfaction.

The authors thank the clinicians who were open to growing their work for the well-being of the people they serve.