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Addiction is an incredibly misunderstood aspect of behavioral health. Mischaracterized as an immoral personal choice or failing of character and will power instead of a disease of the brain, misinformation about the nature of addiction leads to ineffective and even harmful interventions. We define addiction as increasing use, more stereotyped use, and more time and energy spent on the use of a substance despite mounting consequences and disruption of function in multiple areas of life. In this chapter, we will critically examine addiction in order to define it and attempt to use an integrated clinical perspective to understand the current opiate epidemic in the United States. We will then discuss the challenges of diagnosis and treatment of addiction.

A diagnosis is a term used to identify a condition that the patient is suffering from. A simple unifying clinical diagnosis is responsible for most illnesses. Diagnosis is made more efficient and reliable by using operational definitions of diseases and a deductive approach to diagnosis. Different approaches to diagnosis vary in how reliable they are and also vary in how valid they are. Complicated or unusual conditions often require inductive logic for diagnosis, a method that can be used to generate a differential diagnosis. Complicated conditions also often have interacting mechanisms that exacerbate other conditions in comorbid ways. The formulation is a way of describing all of the interacting elements that contribute to the disorder that the patient is suffering from.

Integrative medicine is an intensive service that facilitates patients dramatically improving their quality of life. It is directed at rehabilitation of the person and at function, quality of life, and longevity due to improved health. Once a diagnostic formulation of the patient is completed by the team, we deliver coordinated care using the model we have described. This chapter illustrates how integration works in one of our clinics, which we provide as a case example.

Integrative medicine demands practitioners work together as a team and requires common goals, good communication, and, for many, ongoing education and challenging changes in practice. In this chapter we review the general organization and components of a treatment team and contemplate how these interdisciplinary roles may be organized in the treatment of a complex patient. We will describe the processes and characteristics of an effective team and discuss ways to implement a team. Finally, this chapter explores the qualifications for and challenges of leadership within a team-based decision-making model.

This chapter is an example of a patient guide for a patient in a medication-assisted treatment (MAT) program within an integrative medicine setting. We believe that part of our responsibility to our patients is to ensure that they fully understand what they are committing to when they join our program; we consider this informed consent to treatment. Because we consider them such a vital piece of the integrative medicine team, we are as transparent as possible about our expectations and our responsibilities to our patients as their treatment provider.

Integrated care begins with a careful and thoughtful conceptualization of the patient’s current and past conditions and underlying elements. The diagnostic formulation attempts to explain all the elements of dysfunction that the patient suffers from in a coherent way. Clinicians gather the information needed to create a complete conceptualization of a person, a task vital to creating accurate and nuanced diagnostic pictures of a patient’s whole situation. They then synthesize the gathered information into a formulation that considers psychiatric disorders in four core categories: deviations of life story/environment, vulnerabilities of temperament, misdirection of behavior, and damage from disease. Looking at these four aspects of a person’s dysfunction creates a complex picture of a person, allowing us to consider how these different features interplay and influence the current circumstances and choices that are influencing patients’ lives.

Integrated care is provided by teams of experts from different fields including medicine, psychology, and nursing. There is a continuum between coordinated care, co-located care, and integrated care. Better integration improves outcome for more complicated patients, and the most complex patients require the highest levels of integration. There are several models of integrated care with demonstrated effectiveness in a variety of settings and studies. Integrated care models are poorly matched to the current system of reimbursement, and the short-term financial goals of decreasing expenses or maximizing profits have resulted in greater expenses later as these patients get more complex and have increased morbidity. The lack of integrated care has made these patients extremely costly, and the health system is responding to them by suggesting that they, rather than the conditions they are afflicted with, are the problem. While there is good evidence that these patients can be treated in a cost-effective manner, the current financial organization of medical care makes it difficult to initiate and sustain cost-effective care and is a major barrier to the provision of integrated medical care.

The practice of integrative medicine is not the model used for the majority of current clinical practices in US healthcare, thus rendering it counterintuitive and often in contrast with training that clinicians of all disciplines receive. Thus, an important member of the integrative medicine team that promotes sustainability and early buy-in to this approach to practice is that of the trainee. Whether it is a medical resident or a psychology student, incorporating them into integrated settings early in their training and careers allows for maximum exposure to this system of care, creating a new generation of clinicians who are competent in coordination and integrative medicine from the onset of their careers.

This case synopsis of Sara covers a 10-year span of treatment for a single patient. It looks at her diagnostic formulation in detail and discusses the differential diagnosis of her psychiatric conditions. It also discusses the therapeutic approach to the patient in detail including the phases of her therapy and the issues of her clinical course. The focus throughout is on how the psychological treatment of complex patients is time-consuming and complicated, but how the recovery of a severely ill person can be achieved through integrated care.

A few key elements underlie effective integrative medicine. First is the doctor-patient contract in which there is a mutual understanding of what it means to be a patient, namely, trusting and engaging with providers as an informed participant in one’s own treatment. For providers, there are three practices that must occur for integrative medicine to be effective. The most important element of integrative medicine is professionals communicating and collaborating about mutual patients. The second most important activity is gathering and sharing all available care records. The third key integrative medicine activity is advocacy for the resources to help the patient succeed in treatment. Finally, it is important to understand that patient-centered care is not the same as patient-directed care; patient satisfaction is not a measure of effective healthcare.

Individual long-term integrated primary and psychological care are the cornerstones of our integrative medicine approach, especially in the context of treating addiction. While medications are an important tool in the process of recovery, therapy is necessary in order to help the patient to address their addiction as well as the myriad of psychological, relational, and personal issues that threaten their recovery. This chapter introduces the framework from which integrative medicine can intervene in addressing addiction in patients.

The goals of medical care are improved function, improved quality of life, and improved longevity. Integrative healthcare is able to achieve these goals better in vulnerable populations than the current healthcare model. Patients with complex comorbidity including mental illness issues and addiction, as well as those who are disenfranchised from care, are more costly to care for and account for a larger part of healthcare expenditure with limited benefit. An inadequate understanding of the interactions between the mind, the brain, and the body leads to a great deal of misdirected treatment. Integrative healthcare seeks to provide less fractured and more coherent care that is more cost sufficient and has better outcomes.

Psychopharmacological interventions are incredibly successful in conjunction with rehabilitative treatment for opiate addiction. However, a comprehensive approach to addictions is necessary, and while pharmacotherapy plays an important role, it is insufficient on its own. A multidisciplinary team is an important part of treatment in order to address the behavioral and psychological elements we have described in this book. The team can implement treatment effectively and hold patients accountable in their recovery. Furthermore, our patients often have psychiatric and medical comorbidity that contributes to their addiction that must be addressed for success, including health concerns such as chronic diseases like hepatitis C, HIV, and chronic pain.