Fact Sheet Series > Substance Abuse Treatment

Substance Abuse Treatment and Public Health: Working Together to Benefit Injection Drug Users
February 2002

Changing Epidemics Increase the Need for Collaboration

Populations in need are changing.

In the last decade, the demographics of the HIV/AIDS and hepatitis B and C epidemics have changed. Increasingly, IDUs, the disadvantaged, minorities, and people with multiple physical and mental health problems are the ones most heavily affected. As a result, infected individuals frequently need substance abuse treatment, mental health services, and primary health care services, in addition to state-of-the-art HIV and hepatitis treatment.

Similarly, addicted patients may enter substance abuse treatment with multiple problems that necessitate a coordinated mix of treatment strategies or they may need additional services such as HIV, sexually transmitted disease (STD), or viral hepatitis prevention.

In 1999, the National Institute on Drug Abuse (NIDA) published Principles of Drug Addiction Treatment: A Research-based Guide. Using the results of 30 years of scientific research and insights from clinical practice, the guide articulated a set of 13 overarching principles of effective substance abuse treatment. Several of these principles speak to the diverse and evolving needs of individuals in treatment:

• Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems.

• An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture.

Providers often see patients with needs outside their area of expertise.

Only a fraction of the people who could benefit from substance abuse treatment actually are able to obtain it. However, providers in many settings, such as primary medical care, hospital emergency rooms, STD clinics, HIV counseling and testing sites, and public health clinics, see patients with substance abuse problems. Providers in substance abuse treatment settings work with patients who have HIV, hepatitis B or C, STDs, tuberculosis, or mental health problems. Staff of criminal justice facilities work with inmates who have multiple substance abuse, physical, and mental health problems. Staff from many institutions, settings, and disciplines need to be able to screen for behaviors and conditions that often occur together. For example, substance abuse treatment staff may need to improve their skills in identifying and working with patients' high-risk sexual behaviors; STD/HIV staff could benefit from training in drug behaviors and interventions.

Formidable Barriers Limit Collaboration

Significant barriers can prevent staff of different types of institutions from providing more comprehensive screening, treatment, and risk reduction services:

• Staff from public health or substance abuse treatment may not know what questions to ask a patient, or know how to assess a problem in another area. Or they may feel uncomfortable about going outside of their own area of expertise.

• Federal confidentiality protections prohibit substance abuse treatment staff from revealing anything about patients, even to state and local public health staff. STD and other state and local regulations create similar limitations for public health staff. Though essential to protect patients, these restrictions reduce the ability of substance abuse treatment and public health staff to work together to help a patient seen at both types of facilities.

• Separate mandates and funding, distinct patient profiles, and different organizational cultures, philosophies, and training paradigms divide disciplines and institutions from each other. These divisions can create tensions and mistrust and limited or prevented communication across agency lines.

Cross-Training is a Powerful Way to Break Down Barriers, Bridge the Divisions, and Improve Services for Patients

Cross-training is an approach first used in the late 1980s and early 1990s to help public health and substance abuse treatment staff collaborate better in care related to HIV and STDs. In 1993, the federal Center for Substance Abuse Treatment (CSAT), and the CDC developed an interagency initiative, called "Substance Abuse and Infectious Disease: Cross-Training for Collaborative Systems of Prevention, Treatment, and Care," to provide cross-training workshops across the country. In 1998, the Health Resources and Services Administration (HRSA) joined the initiative. The workshops focus on helping staff:

• learn about the structure, funding, philosophy, and policies of other agencies and organizations;

• enhance their knowledge about substance abuse and HIV/AIDS, STD, tuberculosis, and viral hepatitis issues affecting patients;

• improve and become more comfortable with screening, risk assessment, and harm reduction skills that may come from other disciplines;

• improve their ability to respond to the interwoven health and behavior problems of patients seeking services; and

• make personal connections across agency disciplines, cultures, and bureaucracies; these connections help to bridge the divisions by promoting mutual respect and a common vocabulary, fostering willingness to hear other points of view, and motivating staff to develop regular communications and collaborative working relationships with other agencies and organizations.

The Cross-Training Initiative still pursues these objectives, but it has evolved considerably since its early days. Participants from substance abuse treatment and public health are now joined by those from other disciplines, including primary care, mental health, and corrections. The curriculum has evolved as well. Rather than trying to present a definitive course on all aspects of infectious disease care or substance abuse treatment, workshops now help participants focus on components of integrated, comprehensive care. Increasingly, the planning, delivery, and evaluation of the cross-training also emphasize systemic change, such as:

• developing collaborations across agencies and disciplines;

• building the capacity of agencies and organizations to deliver services; and

• building the capacity of communities to plan and conduct the training themselves.

Keys to Success in Cross-Training

Reflect the diversity of the epidemics. This means covering prevention, treatment, and care issues for the various substance abuse and infectious disease topics. It also means including participants from a range of disciplines that work with affected individuals. Greater diversity helps the participants appreciate and understand the points of view and approaches of other agencies and disciplines.

Obtain high-level participation and endorsement. Success is more likely if high-level administrators are involved in the planning and execution of the workshops. Their participation and endorsement can help break down the barriers across disciplines and reinforce the importance of the training.

Tailor to the community. Before holding a workshop, successful cross-training planners should analyze the community to ensure that topics and skills-building exercises reflect and are tailored to the needs, cultures, and languages of the community. Participants and workshop trainers should also reflect the cultures, languages, and other characteristics of the community.

Recognize the value of the cultures and perspectives of each discipline involved in the training. Success is more likely if participants are sensitive to the other agencies and organizations involved. Differences in priorities, missions, and perspectives pose the greatest challenge for collaboration. In some cases, participants must overcome longstanding negative attitudes or bias toward patients and staff of other agencies.

Work to develop QSOAs before beginning a cross-training. Qualified Service Organization Agreements (QSOAs) are interagency agreements that allow substance abuse treatment and public health provider agencies to share some information about patients within the legal constraints of federal confidentiality protections. Having QSOAs in place before a cross-training occurs will allow training participants to immediately build on relationships forged during the training.

Persevere. Change does not come overnight. Cross-training participants need to demonstrate their commitment to improving communication, developing collaborations, and creating systems change over the long term.

Follow-up and reinforce. Following up to track changes and provide assistance to participants can help to nurture the seeds of collaboration that may emerge during a cross-training. Additional cross-trainings over time are also necessary to reinforce the training and to train new staff.

To Learn More About This Topic

Read the overview fact sheet in this series on drug users and substance abuse treatment - "Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits." It provides basic information, links to the other fact sheets in this series, and links to other useful information (both print and web).

Visit websites of the Centers for Disease Control and Prevention and the Academy for Educational Development for these and related materials:

• Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach, which provides extensive information on HIV and viral hepatitis infection in IDUs and the legal, social, and policy environment, and describes strategies and principles of a comprehensive approach to addressing these issues.

• Interventions to Increase IDUs' Access to Sterile Syringes, a series of six fact sheets.

• Drug Use, HIV, and the Criminal Justice System, a series of eight fact sheets.

Visit the CSAT website that describes the Substance Abuse and Infection Disease: Cross-Training for Collaborative Systems of Prevention, Treatment and Care initiative. This website has links to information and training on Qualified Service Organization Agreements (QSOAs). Also visit the Cross-Training Connections website for additional information and resources: www.hsrnet.com/crosstraining

Check out these sources of information:

Hser YI, Polinsky ML, Maglione M, Anglin MD. Matching clients' needs with drug treatment services. Journal of Substance Abuse Treatment 1999;16(4):299-305.

National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide. Rockville (MD): NIDA; 1999. NIH Publication No. 99-4180.

Office of Minority Health (OMH). HIV/AIDS and substance abuse: making connections with cross-training. Washington (DC): OMH, U.S. Department of Health and Human Services; Fall 2000.

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