Case Management in Substance Use Disorders

 

Ruwan M Jayatunge M.D. 

Abstract: This article discusses 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 an 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 for 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 recognized 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 polysubstance 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 a more severe illness course.

There is a 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 outcomes (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). The 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 a 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 services 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 that 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 defined as a process that 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 of 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 et al, 2004). The main 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 patient's 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 the effectiveness of case management as it helped keep public inebriates engaged in treatment, stabilize their situation, 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 on improving linkage with treatment. Vanderplasschen et al (2007) are 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 healthcare 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).

 

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 a wide variety of needs across the range of symptom severity. They need effective and uninterrupted support to combat their addictions. To provide optimal support and care case management services have been recommended. Case management is a pragmatic intervention that helps in treatment, stabilizes the situation, improves access to service providers, reduces clinical deterioration, and provides continuity of care.  Case management promotes recovery and enables the substance abuse client to fully integrate into society as a healthy, substance-free individual. 

 

 

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