The need for integrated treatment of substance use disorders (SUDs) and psychiatric-mental health disorders (PMHDs) is at an all-time high. According to the Substance Abuse and Mental Health Services Administration (SAMHSA)2014 National Survey on Drug Use and Health, an estimated 43.6 million (18.1%) Americans aged 18 years and up experienced some form of mental illness, 20.2 million adults (8.4%) had an SUD, and 7.9 million people (3%) have both a mental disorder and an SUD (SAMHSA, 2014). Couple these facts with an extremely reduced psychiatric-mental health workforce and it is notable that the ability of this population to access specialized care requires a sea change in the current healthcare delivery system. As of January 2015, the Health Resources and Services Administration (2015) had designated 4,071 mental health professional shortage areas, including one or more in each state, the District of Columbia, and each of the territories. (SAMHSA, 2014). Most patients with PMHDs and SUDs are receiving care in prisons (Torrey et al., 2014). In 2012, the number of mentally ill persons in prisons and jails was 10 times the number remaining in state hospital with the estimation of 356,268 inmates with severe mental illness in prisons and jails and approximately 35,000 patients in state psychiatric hospitals, indicating a ratio of 10:1 (Torrey et al., 2014, p. 6). The bulk of care in the outpatient setting is now being delivered in heavily overburdened primary care and emergency room settings with 70% of primary care visits related to psychosocial disorders, and police and first responders are serving as the primary community-based workforce (Olsen, 2014).
Although the concept of integrated behavioral health and primary care has been written about since 1995 (Katon et al., 1995), it has been implemented only in a piecemeal manner across the country. States, however, are catching on, and legislatures are funding programs (Stanek & Gauthier, 2013). Some states are now legislating integration of PMHDs and SUDs (Washington State Healthcare Authority, 2015; WA State SB 6312, 2014), but these efforts are slowed by federal restraints on providers licensed to provide medication-assisted treatment, again pointing to access-to-care issues.
The concept of recovery in alcoholism began with the formation of Alcoholics Anonymous in the mid-1930s but was not extended to drug addiction until the mid-1980s with the formation of the Secular Organization for Sobriety and Rational Recovery (http://www.sossobriety.org/). The concept of recovery in mental illness was not described in the literature until 1993 (Anthony, 1993). Bringing all three components together, the first National Summit on recovery was convened by the SAMHSA Center for Substance Abuse Treatment in 2005 for the purpose of developing criteria for a common understanding of the guiding principles of recovery and the elements of recovery-oriented systems of care (ROSC; Center for Substance Abuse Treatment, 2007). Also in 2007, the first statewide recovery-oriented system of mental health care was described (Davidson et al., 2007). In 2009, ROSC (see Figure 1) was defined as "a coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve abstinence and improved health, wellness, and quality of life for those with or at risk of alcohol and drug problems" (SAMSHA, 2010; Sheedy & Whitter, 2009). Although the focus of ROSC is coordinated treatment of alcohol and drug problems, the treatment of co-occurring PMHDs and a need for primary care are inherent. However, the concept and components of ROSC have also been slow to catch on as states are dealing with severe budget cuts and hampered by the political process in general. A few states, such as Washington, are developing programs based on a paradigm of triple integration: mental health, substance abuse, and primary care treatment all under one roof. An example is the Northwest Integrated Health in Tacoma, WA (http://www.nwih.org).
This special issue of the Journal of Addictions Nursing begins with Gumbley's history and current overview of the state of the discipline of recovery-oriented care in the 21st century, DiClemente and colleagues then describe a comprehensive and creative approach to integrated, client-center recovery. Bitting and colleagues describe a unique example of a city-wide effort to integrate over 200 systems of care into one integrated ROSC in Houston, Texas. These two articles set the stage for an in-depth exploration of the effect of recovery interventions on readmission to an acute inpatient psychiatric unit by Koval and colleagues. Gadbois and colleagues narrate the effect of increasing nursing presence through implementation of comprehensive health assessment in an outpatient opioid treatment center. Two often-overlooked populations are also addressed in this issue. Nash and Collier explore the components of ROSC to adolescents in recovery, whereas Bush discusses the needs of breastfeeding mother-infant dyads in opioid recovery.
In Part 1 of a two-part series, Fornili explores the theoretical foundations for Screening, Brief Intervention, Referral to Treatment (SBIRT) services, using an evaluation framework for middle-range theory (Smith & Liehr, 2008) to compare Wagner's Chronic Care Model (Bodenheimer, Wagner, & Grumbach, 2002a; Coleman, Austin, Branch, & Wagner, 2009) and the recovery management model (White, 2008). The aim was to produce possible explanations for why traditional SBIRT works well for individuals with unhealthy alcohol use but not as well for those with more serious SUDs. This was partially in response to two articles published in the Journal of the American Medical Association in 2014 that discounted the importance and value of SBIRT and argued that its widespread adoption was not warranted. In Part 2, a continuing education feature, Fornili proposes a new, recovery-oriented model for improving primary care SBIRT outcomes. The SBIRT Plus Recovery Management (SBIRT+RM) model defines primary care roles and responsibilities for sustained recovery support and long-term recovery maintenance.
The significance of overarching disparities in healthcare, housing, and nutrition for patients enrolled in opioid treatment programs is emphasized in the original research of Gadbois and colleagues. After completing an agency-wide study sponsored by a university-based college of nursing and a large public opioid treatment program agency, providers had complete health screenings; all but one chart had complete assessments, but less than half documented follow-up to identified health problems, indicating a tremendous need for the incorporation of comprehensive healthcare in the outpatient opioid treatment center. The study outlines key elements of comprehensive health screening that are critical to integrating patient care for primary care and psychiatric disorders and SUDs. Positive outcomes that resulted included an increased emphasis on the role of comprehensive nursing care in OTCs. Koval and colleagues implemented recovery-oriented patient care practices, including a recovery toolkit, on an inpatient psychiatric unit that both reduced and readmission rates and sustained the decrease.
Over 200 agencies in the city of Houston, Texas, united into one large ROSC because of volunteer collaborative efforts that began in 2010. In this article, Bitting et al. describe the process that created this recovery safety net and include lessons learned, future plans, and the resources needed for other communities to replicate this incredible system.
Creating these systems described by Bitting et al. requires skillful navigation of the change process (DiClemente et al.). These authors describe the need for comprehensive, integrated community-based integrated care that focuses on wellness lifestyles and reduction of risky behaviors often engaged in by people with SUDs and co-occurring medical and psychiatric disorders.
The importance of prevention and early intervention is underscored in a theory-based article by Nash et al. about appropriate treatment for adolescents with SUDs. In their innovative approach to understanding the alternative peer group (APG) model, the authors describes the theoretical underpinnings that conceptualize APG and concludes with qualitative evidence by youths who have been involved in an APG.
A frequently neglected population is the mother-infant dyad in recovery from opioid addiction. Busch describes how implementing clinical practice guidelines (U.S. Preventive Services Task Force, 2008) that recommend 6 months of breast milk to promote optimum infant health can pose a challenge in opioid recovery. Suggestions for team-based care to promote recovery for both mother and infant as well as implementing infant best practices are described in this article.
We are hopeful that you, the reader, will find this collection of outstanding resources on the topic of ROSC a helpful resource to you and your healthcare team. We look forward to the day when all clients with SUDs and PMHDs have access to modern, recovery-oriented services and quality-of-life enhancements.
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