Expanding an Integrated Treatment Program for Multi-Diagnosis and High-Risk Populations

A brief overview of the integrated treatment programs that are currently being reviewed as part of the project which is “Expansion of a Multi-Diagnosis and High-Risk Populations Integrated Treatment Program for Ex-offenders with Mental Illnesses, Addictive Disorders, and HIV Seropositivity or High-Risk Status”

A Brief Introduction

It stands to reason that the prevalence of comorbid disorders necessitates the treatment of both conditions at the same time, a concept known as an integrated treatment for the co-occurring disorder. An integrated treatment program translates to the use of various therapies, such as a combination of psychotherapy and pharmacotherapy, to treat two or more illnesses. When opposed to treating individual conditions with different treatment plans, integrated treatment for co-occurring disorders has consistently been shown to be superior. A multidisciplinary team, comprising social workers in various positions such as student counsellors, psychotherapists, and case managers, is often used in the integrated treatment of co-occurring disorders. Any mode of care that focuses on the services vital to the reduction of drug dependence and mental illness often includes social workers.

Despite a growing body of evidence linking co-occurring drug abuse and mental conditions with the criminal justice system and STDs/HIV, people with this complex profile of symptom are all too often left out of recovery services, resulting in rising criminal justice costs and health-care, and no improved chances of accessing comprehensive care. System reimbursement and fragmentation mechanisms are significant obstacles in Memphis, Tennessee: Ex-offenders face numerous challenges in order to be able to access services, and services that once included model case management systems are now overburdened to the point that crisis management is the norm.

Tennessee’s regulated Medicaid program has practically decimated local efforts by refusing reimbursement for addictions treatment; ex-offenders face multiple barriers in reinstituting benefits to obtain services, and services that once included model case management systems are now overburdened to the point that crisis management is now the standard. The expansion component’s goal is to create a model response that unwinds these complications by implementing a logical sequence of organized and interconnected services and defining a practice strategy that can be repeated in other settings for both the seropositive and the top risk seronegative consumers.

The integrated treatment project combines ASAM PPC-IIR Intensive Outpatient Level II.1 with Robert Drake’s (2001) principles of coordinated treatment that are based on research, as well as the CDC’s (1997; 1999), NIDA’s, and SAMHSA’s clinical prevention concepts.  

The Background

The beautiful city of Memphis is located in Shelby County, which is bordered on the west by the Mississippi River and on the south by the state of Mississippi. Shelby County has a total population of just under 900,000 people, with African Americans accounting for 49% of the people, Caucasians for 47%, and Hispanics for 3%. Around 55 percent of the population in Memphis are African American, and more than 40 percent of African-American families in Memphis generate median incomes beneath the poverty line. Upper-, middle-, and lower-income communities are interlaced throughout Memphis, and the public housing developments are scattered throughout the area. Although renovation efforts have improved some areas of the city in the last ten to fifteen years, many regions continue to struggle with gangs, crime, and prostitution. TennCare, Tennessee’s Medicaid network, protects 175,000 Shelby County residents, and another 65,100 Memphis residents are not insured (Clay and Tomlinson, 2000).

Individuals with co-occurring conditions are more likely to develop sexually transmitted infections, have more complicated medical conditions, and and have a disproportionate amount of representation reflected by those that are regularly recycled into the criminal justice system. Services for this increasing, highly underserved population are fragmented and scarce in Memphis, Tennessee being a significant problem as an MSA with annual AIDS Case Rates of 57.8% in 2001.

(Fantz, 2000) In Memphis and Shelby County, there were nearly 6,500 HIV/AIDS cases recorded in 2000. Since 1992, the antibodies of HIV have been found in the blood of over 500 Memphis residents every year. The Tennessee Department of Health reports an average of 277 confirmed cases of full-blown AIDS per year, and Memphis has double as many STD cases as St. Louis and much more HIV-positive cases per capita than cities like Atlanta (Tennessee Department of Health, 2000). Memphis, in particular, has the unenviable distinction of being the 6th most STD-affected city in the world (CDC, 1997).

The total number of prisoners held by the Shelby County Division of Corrections has increased from a mean score of 571 inmates per day in the year 1985 to an average of 2,900 inmates per day today in addition to the growing prevalence of STDs among Shelby County residents (Shelby County Division of Corrections, 2002). Every 7 minutes, an inmate is processed in Memphis prisons, which hold more than three thousand inmates on average (Fantz, 2000). According to national reports, incarcerated people have higher rates of many diseases than the general population. For example, compared to the general population, the rates of HIV are five to eight times higher, the rates of Hepatitis C are nine to ten times higher, and the rates of tuberculosis are four to seventeen times higher(Hammett and Maruschak, 1999).

Felony drug charges are the most common reason for arrests in Shelby County (Shelby County Division of Corrections, 2002). This is in line with national patterns (for example, drug crimes accounted for 58 percent of total prison population in 1991 and 63 percent in 1997).  Substance use has also grown from 60 percent to 73 percent of Federal inmates disclosing illegal substance use at some point between 1991 and 1997 (US Department of Justice, 1999).

Furthermore, drug offenders seem to have a higher tendency to be imprisoned for longer periods of time: between 1980 and 1994, the average sentence rose from forty seven up to eighty months (Office of National Drug Control Policy, 1996).In the United States, there are often times more IDUs in prisons than in hospitals, opioid rehab clinics, or social welfare organizations. Just 13 percent of all State prisoners and 15 percent of all Federal prisoners that used drugs on a daily basis received treatment in 1997. (Hammett and Maruschak, 1999).

Description of The Project

The expansion component’s aim of the integrated treatment program is to build a model that disentangles these complexities by introducing a logical sequence of organized and interconnected services and establishing a practice strategy that can be repeated in other settings for both high-risk seronegative and seropositive consumers. The integrated treatment project blends ASAM PPC-IIR Intensive Outpatient Level II.1 with Robert Drake’s (2001) principles of coordinated treatment based on research, as well as the CDC’s (1997; 1999), NIDA’s, and SAMHSA’s primary clinical prevention concepts, Which Includes the Main Components Mentioned Below:

• Thorough Assessment: The integrated treatment program is structured to evaluate risk and create a care plan that includes medical reactive or preventive therapies, links to Ryan White HIV Consortia organizations, social services, accommodation, and other resources as required. Each participant is assigned a primary counsellor who assists them in gaining access to needed and accessible services.
• Support Group: The ASAM PPC-IIR Intensive Outpatient (IOP) Level II.1 program is a five-day-per-week, field-tested, three-hour-per-day intense, integrated treatment program for co-occurring disorders of three regular groups, each lasting one hour, designed to include addictions treatment, psycho-education, therapy, relapse prevention, and coping strategies with a risk reduction factor layered on top. All attendees will be provided with transportation. TIP 8 from SAMHSA encourages the use of IOP as a model method for the said population.
• Individual Counseling and Risk Management: This is an essential aspect of the risk management system because it provides anonymity, flexibility and allows for more detailed intervention tailoring (Rounsaville & Carroll). Furthermore, during the integrated treatment program, each client can meet with a trained nurse with experience in dual diagnosis and IDU/STDs care and a Risk Reduction specialist, on an ongoing basis to address health status problems and risk management issues.
• Pharmacologic Care: This involves an initial assessment to determine the need for medication monitoring, psychotropic medication, medication education, and regular evaluation by a physician who specializes in both psychopharmacologic and addictions treatment.

The principles of the integrated treatment spelt out by Robert Drake (2001) based on research, widely regarded as the premier national professional on co-occurrence treatment, are combined with the CDC’s main concepts of clinical prevention (1997; 1999), SAMHSA #37 Series of Treatment Improvement Protocol, Substance or Drug Abuse Treatment for People with HIV/AIDS, and NIDA.

What are the foundations? Integrated treatments would be more comprehensive in treating a disease that is an interaction of conditions. This explains the rationale behind using the integrated treatment. Furthermore, having several doctors treat clients in the same facility allows for better coordination and more precise recommendations. The dual care strategy of the integrated treatment program incorporates medical and mental health education/monitoring, which has been shown to minimize high-risk behaviors and recidivism among HIV-seropositive prisoners in the trial prison release programs (JAMA, 1998).

According to cost-effectiveness research, outreach programs that are community based like the integrated treatment program help avoid potential medical costs connected with HIV/AIDS treatment and care by avoiding HIV infections (NIDA, 1999). Substance users who join the integrated treatment program and stay in care have a higher tendency than those who do not cut down on risky habits like using the same injections and needle devices or engaging in unsafe sexual intercourse (NIDA, 2002).

The NIDA Outreach Model’s risk mitigation techniques, engaging the individuals at risk in customized evaluations of their own risk behaviors, use of indigenous workers, outreach, designing safety strategies, assisting in recognizing obstacles and tools to risk behaviors, increasing incentive to improve behavior patterns. to learn more please contact our staff at 615-490-9376. Additionally, we teach strategies for social skills development and concrete risk-reducing techniques and this forms a key part of our integrated treatment program.