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Recommendation 3a: Health and social care systems should make an enduring commitment to provide services for people with substance use disorders. These services should be fully integrated with mainstream healthcare systems, be equally accessible to all people in need, and should target a range of outcomes, including but not limited to eliminating illicit drug consumption.

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     In one sense, nothing new is needed in the design of substance use disorder care systems, as comprehensive models of population health management are already in use for other serious chronic health problems. Chronic care systems include population and clinically-based early detection approaches, offer less extensive treatments for early stage disorder, and provide more involved treatments for serious cases. In such systems, primary care physicians and other generalists work individually or in interdisciplinary teams to manage cases to the limits of their expertise. When those limits are reached, generalists call on specialist support for collaborative care. Interventions that improve function and reduce morbidity and mortality are considered valuable even if they do not restore the individual to perfect health. The patient’s family is educated about the nature of the disorder and its management, and their own needs are cared for as well. Further services are provided for other problems patients may have (e.g., homelessness, joblessness, parenting challenges), whether they are causally related to the core health problem or not. Long-term recovery support services are provided to ensure that early gains are routinized and spread to broader areas of the individual’s life. This basic lesson can be applied in the design of accessible and effective, care systems for substance use disorders.

     The “hub and spoke” model, which integrates regional specialty addiction treatment centers (hubs) and geographically dispersed healthcare settings (spokes) that can provide ongoing, community-based care, is a promising method for providing such care. Certified Opioid Treatment Programs staffed by addiction specialists form the hubs, providing methadone maintenance, buprenorphine induction, and naltrexone as indicated. Spokes – which include primary care, mental health care settings, outpatient addiction treatment, and clinics specializing in chronic pain management – provide maintenance medications for OUD and links to other social services. Vermont and California are among the states that have greatly increased buprenorphine access with this model, which is also being rolled out in at least a dozen other states.

     The specific elements that substance use disorders care systems should comprise have been elaborated elsewhere and need not be reiterated in detail here. Broad categories of care include emergency interventions for managing acute crises (e.g., naloxone and emergency care for overdose, detoxification and stabilization units), case-finding in the community and in medical settings (e.g., addiction consult-liaison services in the emergency department and medical wards), outpatient and residential settings providing behavioral and pharmacological addiction treatments, mutual help groups and long-term recovery support services (e.g., peer coaching, recovery housing), and efforts to prevent and/or treat common medical comorbidities (e.g., syringe exchange, hepatitis B vaccination). Care also includes mental health services responsive to the psychiatric disorders (e.g., depression, post-traumatic stress disorder) and adverse experiences (e.g., child abuse, sexual assault, violence exposure) that are prevalent in the population. The system should assist affected people at all stages of the “Cascade of Care”, an organizing concept pioneered in the HIV field.  Building a cascade of care requires increasing the proportion of affected individuals being identified and diagnosed, the proportion of those diagnosed individuals who are linked to care, the proportion linked to care who receive effective services, the proportion who receive services who are retained for at least six months, and the proportion of those retained who transition to long-term recovery. Among the useful guides for the elements of such systems and the evidence behind them are the American Society of Addiction Medicine Levels of Care, and the U.S. Surgeon General’s Report on Alcohol, Drugs and Health.

     Because in many areas of health care, removal of illness is (often appropriately) considered the highest success of treatment, it bears mentioning that people who experience addiction often aspire to more, namely, recovery.  Although each individual defines recovery from addiction in their own way, common themes are the building or rebuilding of relationships with other people; contributing to the well-being of one’s family, friends, and community; being esteemed and valued by others; adopting productive roles, and having a sense of purpose in life. High-quality care systems help individuals achieve these goals, very commonly by linking individuals to recovery-supporting organizations (e.g., mutual help groups) and support services.   

     To enhance the coordination of and the culture within which services are provided, the Commission also recommends that health workers in the field unify under the well-established and deservedly respected label of public health. This would require abandoning factional, internecine debates over whether one form of recovery is better than another, or whether use reduction or harm reduction is a better goal. Politics are inherently and justifiably a part of how health policy is made, but the costs and benefits of individual service options can still be evaluated based on scientific evidence rather than ideology. And in any event, the needs, problems, strengths and goals of people with substance use disorders vary, and responsive care systems will make space for many paths to better health. Moreover, the alleged contradictions between different philosophies are more apparent than real. For example, interventions that are putatively about reducing harm and not drug use (e.g., needle exchange) often lead to reduced drug use, and interventions putatively focused on abstinence rather than harm reduction often lead people to continue using drugs with less functional impairment. Further, individuals in their own lives often integrate components of allegedly opposing approaches into a healthier life. For example, individuals on opioid agonist therapy who attend abstinence-focused 12-step mutual help organizations have better outcomes than those who do not. If those who access services can integrate diverse helping models peaceably, those who provide such services can do so too.