Ruwan M Jayatunge M.D.

Abstract: This article discusses the case management in substance use disorders. Substance use disorders have devastating physical, mental, spiritual and socio-economic consequences for users and their families.  It causes enormous burden to the health care system. Individuals with Substance use disorders have multiple social, physical, and mental health treatment needs. To provide more effective treatment in substance use disorders, case management has been introduced. Numerous studies have shown that case management is effective in treating substance use disorders.

Key Words: Substance Use Disorders, Addictions, Case Management

Alcoholism, drug dependence and addiction are known as substance use disorders (USDHHS, 2004). Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress (APA, 1994). Substance use disorders affect millions of individuals and the problems associated with these disorders are pervasive and destructive (Caravella, 2008). Substance use disorders are major contributors to morbidity and premature mortality.

Substance abuse is increasingly recognised as a chronic and relapsing disorder (McLellan, 2002) Compton and colleagues (2005) found poor social adjustment and psychosocial burdens connected with substance use disorders. Hesse and colleagues (2007) highlight that Substance use disorders are associated with a wide range of serious health, social and economic complications.

Substance use disorders are often presented with co-occurring disorders—the use of more than one substance and/or one or more psychiatric disorders simultaneously. A co-occurring disorder may also be a medical condition. Clients with SUDs may also display poly-substance patterns, in which they experience physical or psychological effects from more than one substance. (NASW, 2013).

Individuals with substance use disorders have complex, multiple problems, and disabilities. Surveys indicate that substance abuse and other mental illnesses are often comorbid. Depression, Bipolar Affective Disorder, PTSD, Schizophrenia Personality Disorders etc are comorbid with substance use disorders.  Comorbidity is often associated with more severe illness course.

There is high level of comorbidity of PTSD and substance use disorders (Saladin et al. 1995). The comorbidity of PTSD with substance use disorders is complex because while a substance use disorder may often develop as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states exaggerate these symptoms (Brady et al. 2000).

Comorbidity of substance use disorders with mood and anxiety disorders has been found in many studies. Mirin, Weiss & Michael (1988) hypothesized that up to 70 percent of individuals treated for substance abuse have a lifetime history of depression.

Substance use could trigger psychotic symptoms in vulnerable individuals (Green, 2006). Co-occurring substance use disorders including alcohol are common in schizophrenia and are associated with poor outcome (Mesholam-Gately et al. 2014).

People with substance use disorders are heterogeneous, with wide variations across groups in terms of substances used, comorbid disorders, and their strengths and resources (McGovern  & Carroll, 2003). Multiplicity of social, familial and economic problems associated with substance use disorders make the treatment process challenging and sometimes prolongs the recovery. In substance use disorders multiple needs of the individual should be considered and multimodal approach is recommended. The goals of treatment include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning (APA, 2006).

 

Providing Case Management   Services in Substance Use Disorders

Addiction is a chronic disease for which multiple episodes of treatment, remission, relapse, and retreatment frequently occur before achieving stable recovery (Tai &Volkow, 2013).  People with substance use disorders have a wide variety of needs across the range of symptom severity (Reif et al. 2014). Substance abuse can have a devastating effect on the social support networks of individuals (Sarrazin & Hall, 2004). They need effective and uninterrupted support to combat their addictions. In Substance Use Disorders multiple aspects of a patient’s care ought to be addressed. To coordinate the treatment and support servicers case management has been recommended in numerous therapeutic modalities.

Since the 1970s, case management has been introduced in various countries to improve the accessibility, accountability, coordination and continuity of services provided to diverse at-risk populations with multi-faceted problems, such as persons with mental illness, the elderly, homeless persons and multi-problem families (Hall et al., 2002; Holloway & Carson, 2001; Moxley, 1989; Sargent et al., 2007; Kolind et al., 2009). Case management has a long and  relatively successful history for the treatment and support of several mental health  populations in the United States, Australia, Canada and several European countries  (Burns, Fioritti, Holloway, Malm, & Rössler, 2001; Hesse et al, 2007).

Case management is regarded as one of the most important innovations in mental health and community care of the past decades (Holloway et al., 2001; Vanderplasschen et al., 2004). Case management has been widely used as an intervention in the treatment of substance abuse problems (Rapp et al., 2014).

In general terms Case Management is defined as a multi-step process which ensures coordination of medical and specialty care and access to a range of appropriate medical, psychosocial and social services for the client and family and which promotes and supports the independent functioning of the client and family. A case manager is the person who takes responsibility for coordinating various forms of support to achieve the objectives of the case plan. They have a strong relationship with the client and are the key liaison between all services involved.

According to the Ontario Addiction Services Advisory Council (2000) Case Management services are a defined as a process which includes the designation of a primary worker whose responsibilities include the ongoing assessment of the client and his/her problems, ongoing adjustment of the treatment plan, linking to and coordination of required services, monitoring and support, developing and implementing the discharge plan, and advocating for the client. Case management services are offered regardless where the individual is in the system.

The National Case Management Standards Network of Canada (2009) defines case management as a collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. Case management supports the clients’ achievement of safe, realistic and reasonable goals within a complex health, social, and fiscal environment.

Case management is flexible and consists of a broad range of activities.  Case management is a client-centered strategy to improve coordination and continuity of care, especially for persons who have multiple needs (Moxley, 1989).  Hall et al (2002) describe case management as a coordinated and integrated approach to service delivery, intended to provide ongoing supportive care and to help people access the resources they need for living and functioning in the community. The core functions of case management—assessment, linking, monitoring, and advocacy—remain constant across almost all applications of case management (Rapp et al. 2008). Case management is also viewed as a tool or service to help clients maintain their autonomy while achieving positive health outcomes (MacNeil Vroomen et al., 2012).

According to Annicka and colleagues (2012)   case management is a heterogeneous concept of care that consists of assessment, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the client’s health and service needs.  Case management was developed to address fragmentation in service delivery and is rooted in the social casework tradition (Weiss, 1998; Lillquist, 2008).  Case management is pragmatic as well as culturally sensitive. CM servicers help to recover from a substance abuse problem more effectively.

 

According to Vanderplasschen et al. (2004) four models of case management are usually distinguished for working with substance abusers: the brokerage / generalist model, assertive community treatment / intensive case management, the clinical / rehabilitation model, and strengths-based case management. Case management could reduce attrition from treatment and improve both psychosocial and drug and alcohol outcomes among persons with substance use disorders (Lightfoot et al. 1982; Vanderplasschen etal, 2004). The man objective of case management is to keep the individual with substance use disorder engaged in treatment, preventing relapses and helping the client to move towards recovery.

 

The Efficacy of Case Management Services

Case management in mental health services has been a positive initiative (Ziguras & Stuart, 2000). As indicated by Zwarenstein and colleagues (2005) in case management, an individual or a small team is responsible for navigating the patient through a complex process in the most efficient, effective and acceptable way. Case management has been suggested as an innovative strategy that facilitates the improvement of a patients’ quality of life, the reduction of hospital length of stay, the optimization of self-care and improvement in the satisfaction of the patient and the professionals involved (Lee et al., 1998).

Willenbring and colleagues (1991) demonstrated that the effectiveness of case management as it helped keep public inebriates engaged in treatment, stabilize their situation, and improve access to service providers, reduce clinical deterioration, and provide continuity of care.  Rapp and colleagues (2008) state that the effectiveness of case management is largely based with improving linkage with treatment. Vanderplasschen et al (2007) of the view that strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Intensive case management is associated with reduced health care costs and increased client satisfaction with services received (Vanderplasschen et al., 2007).  Fukui et al (2012) report positive outcomes with strengths based case management – especially for people with psychiatric disabilities and in the areas of hospitalization, housing, employment, symptoms, leisure time, social support and family burden.

Through Case management   clients with complex, multiple problems, and disabilities receive all the services they need in a timely, effective, and appropriate fashion (Rubin   1992;   Caravella, 2008). Evidence suggests that case management has been a powerful intervention to assist people with psychosocial problems (Cowger, 1994). Although case management may seem a radical intervention relative to clients’ situations, appreciation by clients is consistently high (Vanderplasschen, 2006).

 

Case Discussion

 

• MXVX: 51 year old male separated from his family and living alone. Mr. MXVX was diagnosed with Fibromyalgia, Depressive Disorder and Generalized Anxiety Disorder.  He had been abusing substances for over 18 years and predominantly used Oxycontin for pain symptoms. Ten years ago Mr. MXVX tried to end his life by overdosing himself. Several years ago he sustained a TBI (Traumatic Brain Injury) as a result of self harm.

Mr. MXVX was referred for Case Management and following treatment goals & plans have been identified.

1. MXVX needed psychological counselling and he was referred to a counsellor.
2. The client had no family doctor and he was connected with a GP (General Practitioner)
3. For his addiction issues referred him to an addiction specialist and as harm reduction procedure treated him with Methadone.
4. The client was referred to a Psychiatrist for a psychiatric assessment and to update his medications for depression and anxiety.
5. To provide him with financial assistance connected the client with Ontario Disability Support Program (ODSP).

After these procedures Mr. MXVX’s psychosocial health and functionality improved to a significant level. Now he is not abusing any street drugs and effectively connected with his support services.

 

• PXVX: 45 year old woman abused crack cocaine for five years and was impacted by homelessness. In case management Ms. PXVX was provided income and housing support. In addition she was referred for Methadone maintenance treatment (MMT).

 

Today Ms. PXVX is housed and she is on Methadone without abusing any other drugs. She is positive about her future and wishes to go to school to obtain additional skills and knowledge. She intends to be a journalist.

 

• AXVX: 36 year old male used heroin for nearly eight years and served three year jail term for a robbery. Following his drug habits the Children’s Aid Society had to remove his underage child and sent him for foster care. Mr. AXVX had no aim in his life. He was unemployed and homeless.

 

The case management servicers helped him to obtain income support and along with his other case workers found him housing. Also referred him for Methadone maintenance treatment (MMT). He is on 100 mg of Methadone daily and gets six take-home doses. He has moved away from his user friends and stopped using other street drugs. As a result of his positive changes Mr. AXVXc is now allowed to connect with his child for a longer period.  Mr. AXVX is now hoping to get his child for his care and to lead a productive life.

 

Conclusion

A significant burden of disease has been reported in Substance use disorders. Individuals with substance use disorders have complex, multiple problems, and disabilities and wide variety of needs across the range of symptom severity. They need effective and uninterrupted support to combat their addictions. To provide an optimal support and care case management services have been recommended. Case management is a pragmatic intervention that helps in treatment, stabilize their situation, and improve access to service providers, reduce clinical deterioration, and provide continuity of care.  Case management promotes recovery and enables the substance abuse client to fully integrate into society as a healthy, substance-free individual.

 

Acknowledgement

• Professor Adele Robinson MSW, RSW – Seneca College, King Campus, Toronto Canada

 

 

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