When a patient with an opioid use disorder (OUD) fails to respond to treatment—despite the best efforts of counselors in the substance use disorder (SUD) treatment program—the problem may be a co-occurring mental health disorder, perhaps one that hasn’t yet been diagnosed. Under federal law, opioid treatment programs (OTPs) using methadone or buprenorphine are required to provide counseling, medical, vocational, educational, and other assessment and treatment services.
This puts OTPs way above the outpatient offices, which prescribe buprenorphine (not methadone) and do not even assess for mental illness, much less treat it.
Two recent publications have documented the shortfallings of treatment in general, and of the need to expand mental health treatment for people with OUD and co-occurring mental illness.
A recent study in the Journal of Substance Abuse Treatment looks at the link between OUDs and various degrees of mental illness severity, types of treatment, and other parameters. The study is based on the 2008-2014 National Survey on Drug Use and Health, and concludes that of all people with OUD—many not in any treatment (the survey is based on self-report), estimates are that between half and three-quarters of people with an OUD may have a co-occurring mental health disorder.
No Treatment—or Inappropriate Treatment
Interestingly, the Novak study found that most people with an OUD who received any treatment were likely to receive only mental health treatment. In other words, their OUD was left untreated by anything—including the gold standards methadone or buprenorphine.
The most common treatment was a prescription medication for a mental health problem—but, the authors noted, “this was true regardless of whether or not the individual had any mental illness.”
“A high proportion of individuals with OUD and co-occurring mental illness are not receiving needed care,” the authors emphasize. “However, nearly one in five of those with OUD but no diagnosed mental illness is receiving prescription medication for mental illness.” The authors underscore the need for facilitating access to behavioral health care and coordinating access across settings.
Type of Treatment Selected
By Severity of Mental Illness
In People with OUD
(N = 3398)
| Behavioral Health Treatment | No mental illness (%) |
Mild/moderate mental illness (%) |
Serious mental illness (%) |
|---|---|---|---|
| OUD only | 14 | 11 | 10 |
| Mental health only | 14 | 26 | 38 |
| Both | 7 | 16 | 32 |
| Neither | 66 | 47 | 21 |
OTPs Not Involved in Either Study
The authors suggest that patients afflicted with OUDs and mental illness have complex treatment needs, as is well-known. Patients (not necessarily in OTPs) with co-occurring disorders are
- Less likely to finish treatment
- Likely to have worse treatment outcomes
(Emphasis added.)
Citing other studies, the authors noted that people with OUD but no mental illness are more likely to get mental health treatment than treatment for their OUD. Not surprisingly, their treatment outcomes are worse.
Treating OUD in Mental Health Settings?
But instead of giving credit to OTPs for providing—as it requires—mental health services, SAMHSA seems to be suggesting in a recent communication that OUD could be treated in mental health settings. A communication recently written by SAMHSA authors and published in Drug and Alcohol Dependence used the same National Survey source as the first study, but selected data from different years—2015-2017—and focused on SUDs. The authors, including Elinore McCance-Katz, MD, PhD, director of SAMHSA and assistant secretary of the Department of Health and Human Services, noted: “Of particular concern was the high prevalence of mental illness among people with OUD, including 1 in 4 adults with OUD having co-occurring SMI [serious mental illness] in the past year.”
The SAMHSA authors point to the “often missed opportunity” to provide SUD treatment at the same time as mental health treatment. For some time, SAMHSA has been in favor of blending SUD and mental health services, aiming to merge the block grants. The Substance Abuse Prevention and Treatment block grant is much bigger than the Community Mental Health Services block grant, and states that merge the two among their provider bases are interested in this as well. Regarding current efforts to make medication-assisted treatment for OUD more available, they stress the importance of including “a continuum of treatment and recovery support services to address the co-occurring mental and substance use disorders.”
They also cite innovative service delivery models as promising approaches to providing comprehensive services to people with OUD. Examples include the Hub-and-Spoke model, which features OTPs as central to diagnosis and assessment and treating difficult patients, and Certified Community Behavioral Health Clinics (which are not allowed to dispense methadone).
The authors conclude by emphasizing that “efforts to expand access to comprehensive service delivery models that can address the substance use, mental health, and physical health co-morbidities of this population are urgently needed.”
References
Novak P, Feder KA, Ali MM, Chen J. Behavioral health treatment utilization among individuals with co-occurring opioid use disorder and mental illness: Evidence from a national survey. J Subst Abuse Treat. 2019 Mar;98:47-52. doi: 0.1016/j.jsat.2018.12.006.
Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019 Apr 1;197:78-82. Epub 2019 Feb 14. doi: 10.1016/j.drugalcdep.2018.12.030.
