Address the emerging SMI and opioid crisis

Evidence from the field suggests that a new, more complex health problem is emerging for persons who have serious mental illness (SMI). Today, a large and growing proportion of these individuals also use or are dependent upon opioids. Anecdotal reports from the field suggest that up to half of adults with SMI in our urban areas, particularly those with schizophrenia or bipolar disorder, have this comorbidity.

The devastating effects of opioids are well known. With today’s much stronger formulation of prescription opioids that include fentanyl or k-fentanyl (a particularly strong version of fentanyl produced in China), one can become addicted with the use of as few as three or four pills. Street opioids, such as heroin laced with impure k-fentanyl, can lead to death with a single use. Overdose and death are very common; naloxone can save lives, but is not yet broadly available to persons with SMI, especially those who are homeless and live on the streets.

And other equally tragic effects can occur as well. Within as short as 30 days of starting to use opioids, the likelihood doubles that one also will develop depression. And the reverse also is true: a person with depression has twice the likelihood of using or becoming dependent upon opioids. Thus, this relationship is a downward-spiraling vicious cycle likely to lead directly to death from overdose or indirectly from suicide.

These linkages should not be surprising to anyone. Opioid use or other drug use is principally a “disease of despair.” The disease is an addiction. The despair is a psychological comorbidity reflected in the depression. Both must be addressed.

We have documented for more than three decades the relationship between SMI and long-term physical conditions, such as heart disease, diabetes, cancer, COPD, and arthritis, among others. Many of these conditions can and do lead to early death when not treated appropriately. Opioids frequently are prescribed to address pain associated with these conditions. Thus, it is easy to discern how an adult with SMI also could become addicted to opioids. It also is easy to understand how this addiction could morph from prescription opioids to street heroin, overdose, and death.

The action question is how we can respond to this growing epidemic in an effective way. Clearly, we must develop the capacity to offer integrated mental health and substance use care to this population. We also must make integrated primary care available at the same time and in the same encounters, with appropriate social supports linked to all of these services.

We have tools that can help us build the needed integrated delivery systems. Section 2703 of the Affordable Care Act (ACA) provides two years of funding to set up health homes, with accelerated federal Medicaid reimbursement for care during this period. Are you leveraging this provision?

Another part of the solution will involve more effective delivery of medication assisted treatment (MAT) to promote recovery from opioids. To do this will require a defined training plan so that providers are prepared to deliver MAT effectively, as well a plan for appropriate monitoring of the number of clients served, etc. What will be very new is adapting these treatments to persons who also have SMI. Have you been doing planning to accomplish this new design?

Similarly, from the mental health side, it will be important to adapt our care coordination practices to these new realities. We need to change care coordination so that the care coordinator monitors progress on recovery from addiction, in addition to progress in addressing mental illness, in addition to progress in treating long-term physical conditions, in addition to personal despair. How are you planning to make these adaptations?

Perhaps most important, we must call upon peers to help us develop and implement these key dimensions of care so that they will work well together. At the same time, we must incorporate peer support as a key ingredient in helping consumers successfully negotiate a more complex care system and regain personal self-worth and inclusion, both of which are bulwarks against despair.

The stakes are very high.  We must be successful in this endeavor.