Meeting Patients Where They Are: Integrating Substance Use Disorder Care Across Healthcare Settings

BIO:

Anne C. Fernandez, PhD, is an Associate Professor in the Department of Psychiatry at the University of Michigan, a licensed clinical psychologist, and Director of Clinical Research for MI-ACRE (Michigan Addiction Center for Research and Education). She is an expert in addiction, motivational interviewing, and behavioral medicine, with research supported by the National Institutes of Health focusing on integrating screening, intervention, and treatment for substance use disorders in broad healthcare settings. Dr. Fernandez works in outpatient addiction care at the University of Michigan Addiction Treatment Service and co-founded a multidisciplinary clinic for patients with alcohol-associated liver disease at the University of Michigan. She leads several clinical trials examining preoperative alcohol interventions for surgical patients and contingency management for co-occurring alcohol and opioid use disorder. Her innovative research also leverages machine learning and natural language processing to identify patients in need of addiction prevention and intervention at critical timepoints in clinical care. Dr. Fernandez received her doctoral degree in clinical psychology from the University of Rhode Island, completed her pre-doctoral internship in Behavioral Medicine at Yale New Haven Hospital, and her post-doctoral fellowship at the Center for Alcohol and Addiction Studies at Brown University. She resides in Ann Arbor, Michigan and paints watercolors in her (limited) free time.

As a clinician who has practiced across mental health, physical health, and substance use disorder (SUD) treatment settings, I have witnessed firsthand the consequences of fragmented care for people with SUDs. I have seen patients turned away from mental health therapy because of their substance use, and heard trainees express frustration that their programs provided no opportunity to work with this patient population. These experiences have shaped my conviction that we must fundamentally rethink how addiction psychologists work in the field, and how we train the broader healthcare workforce to address SUDs.

The Treatment Gap

SUDs are among the most prevalent mental health conditions in America, yet they remain dramatically undertreated compared to conditions like depression and anxiety. While the majority of people with common mental health disorders receive some form of treatment, the opposite is true for SUDs, most people struggling with addiction never access care.

The problem isn't just about specialty SUD treatment availability, it's about where and how we reach people. Most individuals with SUDs don't seek specialty addiction treatment, but they do seek care in mental health clinics, primary care offices, and emergency departments for depression, anxiety, chronic pain, or medical complications. If we want to address SUDs effectively, we as clinicians must meet patients with SUDs where they are seeking help.

Embedding Addiction Psychology in Medical Settings

One innovative approach is embedding addiction psychologists directly within general medical settings where patients with SUDs are already receiving care. My work in this space includes co-founding a multidisciplinary clinic for patients with alcohol-associated liver disease at the University of Michigan, bringing together hepatology, psychiatry, psychology, nursing, and social work in a single integrated setting. This model emerged from recognizing that traditional specialty SUD treatment engagement rates were extremely low in this population, yet they regularly attended their hepatology appointments. By embedding addiction psychological services within hepatology care, we've been able to reach more patients with high mortality risk who otherwise might never receive SUD treatment.

My clinical research program also addresses substance use at critical medical junctures when both patients and healthcare systems have unique incentives to change. For example, surgical optimization for patients with unhealthy alcohol use can decrease the likelihood of surgical complications, thus improving patient health and reducing healthcare costs. Research from my team found that unhealthy substance use is common among patients presenting for elective surgery, yet systematic screening and intervention remain rare in surgical settings.

Through the ASPIRE (Alcohol Screening and Preoperative Intervention Research) studies, we've developed interventions to help surgical patients reduce alcohol use before their procedures. Initial results were promising, with participants rating interventions as satisfactory and personally relevant, maintaining high retention in follow-up, and showing substantial reductions in weekly alcohol use. The ongoing ASPIRE-2 study is now working to identify the most effective adaptive interventions for reducing alcohol use before and after surgery over an extended follow-up period. This line of research also leverages natural language processing of electronic health records to identify overlooked patient cohorts in need of addiction prevention and intervention at key timepoints in clinical care. These examples demonstrate how addiction psychologists can expand access to evidence-based SUD treatment by strategically positioning services and research within healthcare settings where patients commonly seek care.

Training All Providers, Not Just Specialists

The solution isn't simply training more addiction specialists; it's ensuring every healthcare professional can address SUDs at an appropriate level within their scope of practice. Addiction psychologists have an important role in advocating for these changes in our organizations. We need a workforce where clinicians can recognize SUDs, offer evidence-based brief interventions, provide harm reduction education, make appropriate referrals, and continue treating other conditions even when substance use is present.

Broader training creates ripple effects throughout the healthcare system. The therapeutic approaches effective for SUDs—motivational interviewing, cognitive-behavioral strategies, medication management—are the same tools that work across many mental health conditions. When clinicians develop competency in addressing substance use, they become more effective at managing the complex, real-world presentations that most patients bring to treatment.

Additionally, mounting research challenges old assumptions that mental health treatment can't proceed while someone is actively using substances. Teaching the workforce about this evidence can eliminate unnecessary delays that keep people suffering longer than needed.

Making It Happen: A Multilevel Approach

For meaningful change, we need action at multiple levels including training programs. Accrediting organizations and educators must prioritize SUD competencies in curricula. When training programs systematically exclude one of the most common mental health conditions, they fail to prepare graduates for clinical reality. After graduation, licensed practitioners need accessible pathways to develop SUD competencies through continuing education and consultation models. In addition policy and payers should support SUD prevention and care integration, incentivize SUD training and workforce development, and reimburse adequately for SUD services in all healthcare settings.

Changing Culture, Not Just Curriculum

Beyond skills training, we need cultural transformation in how healthcare systems view SUDs. Policies and practices that categorically exclude patients with active substance use from mental health clinics or psychology training programs are based on outdated assumptions rather than clinical evidence. These exclusions communicate to patients that their problems don't matter and their attempts to get help are unwelcome.

The path forward requires both practical and philosophical shifts in how we approach SUD care. When we exclude patients with SUDs from general mental health settings, require abstinence before treatment, or fail to train our workforce in basic SUD competencies, we perpetuate a separate and unequal system of care. The evidence is clear: integrated care models work, and mental health treatment remains effective even when substance use is present. By breaking down silos in our training programs, our practice settings, and our institutional cultures we can build a healthcare system that truly meets patients where they are. SUDs touch millions of lives, and our fragmented system leaves most without help. Ensuring that every healthcare professional can recognize and address SUDs within their scope of practice isn't just better medicine, it's an ethical imperative and the kind of care our patients deserve. We, as addiction psychologists and trainees, are well-positioned to advocate for these types of changes in our clinics, academic institutions, healthcare systems, and within APA.