As greater numbers of persons diagnosed with co-occurring or dual diagnoses will have access to care under the Affordable Health Care Act (ACA), the treatment community needs to organize to meet those needs. As this process unfolds, complications regarding treatment become clear, and action is urgently needed. The purpose of this editorial is to identify some anticipated problems.

The provision of integrated physical and behavioral care services is an important aspect of the ACA. In this integrated model, mental illness and substance use problems are referred to as behavioral health issues. Expected outcomes are increased access to care, better outcomes, and lower costs.

Requirements from ACA include federal parity protections of mental health and substance abuse treatment. Incentives are in place to encourage the development of health care homes that offer both physical and behavioral health services. Receiving behavioral and medical care in one setting is an advantage for patients that would theoretically support greater awareness of and attendance to patient needs on each side of the physical and behavioral equation.

However, what is unclear is the place of chemical dependency services under the umbrella of behavioral health. For example, in Washington State, mental health and substance use treatment departments are merging into one department of behavioral health services. The marriage of these two entities has historically not been a happy one. Perhaps, requirements of the ACA can serve as the counselor who saves the marriage this time, because the numbers of patients that now qualify for chemical dependency services are likely to grow exponentially. The U.S. Department of Health and Human Services (2013) estimates that 62.5 million Americans will now have access to mental health and/or substance use disorder (SUD) services that were limited or not available at all. One concern with integration and increased numbers of eligible patients is the numbers of addiction professionals prepared to treat this population.

The mental health needs of consumers are often so profound that chemical dependency counseling and recovery may be delayed or unavailable. If, for example, a patient is suicidal or psychotic because of sustained drug use, the acute problem must be treated first, and safety must be the primary concern. Coordination of care into recovery from SUDs after an acute episode has resolved may or may not be available. Some addiction treatment centers are changing their treatment focus and licensing to accommodate or specialize in behavioral health. Consequently, they may now accept patients for treatment with dual diagnoses or mental health issues alone.

Unfortunately, the concept of integration is worthy but often does not produce the desired result, because services provided by specialists must be in place. Among the barriers to adequate care for the patient with dual diagnoses or SUDs are conflicting requirements among states about qualifications of who may assess and treat this population. Licensing and certification in the specialty are ideal. A brief list of some professionals involved in this area are licensed clinical social workers, master's level social workers, chemical dependency counselors, nurses, psychotherapists, and physicians, among others, who may or may not have formal training in chemical dependency. In Washington State, for example, a master's level nurse would need to earn an additional 2-year degree in chemical dependency counseling to qualify for a state license. Although no one wants to dilute the expertise provided by a chemical dependency license, this kind of complication does not make entering the chemical dependency area attractive. It is beyond the scope of this editorial to explore the regulations for each state, but a brief perusal of regulations leads only to more questions.

Various state requirements are confusing, and several organizations have information to guide a hopeful addictions professional. The National Association for Alcoholism and Drug Abuse Counselors is another group that has affiliates in each state, but each state has differing requirements for deemed status. The Addiction Technology Transfer Centers feature contact information for various state regulatory commissions. This confusing array of requirements is addressed by the International Certification and Reciprocity Consortium that works to standardize credentialing and education for professionals. Their focus is prevention, addiction treatment, and recovery. At this writing, all but six states participate in reciprocity efforts through this organization, although states can require additional certification or training.

The International Nurses Society on Addictions (IntNSA) is well positioned to join with International Certification and Reciprocity Consortium to forward their efforts and possibly expand recognition of the Certified Addictions Registered Nurse (CARN) and CARN Advanced Practice as nationally recognized credentials. At the time of this writing, and through the efforts of IntNSA, only North Carolina lists the IntNSA credential as a deemed SUD treatment professional.

The American Nurses Association published core competencies for nurses working in addictions, but the CARN is not recognized by American Nurses Association credentialing bodies. The American Psychiatric Nurses Association was active in advocating for mental health parity and offers links to substance abuse education activities. Whereas various federal agencies offer links to educational activities, individual states regulate certification and licensure.

How can IntNSA assume a leadership role in meeting the needs of the millions of people newly eligible for dual diagnosis or substance abuse services? Currently, IntNSA is in the process of applying to the Accrediting Board of Nursing Specialties to endorse IntNSA's certifications. Certifications endorsed by this organization are recognized by the National Council of State Boards of Nursing. This is a step in the right direction toward recognizing the specialty within nursing. The key problem of differing state requirements with regard to chemical dependency certification will still need to be addressed because there is no national standard for chemical dependency certification across disciplines. The Board of Directors may want to consider further initiatives to explore this effort and perhaps to partner with other national and international organizations to assure that those needing SUD treatment have qualified professionals, including nurses, to manage their care.

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