Next steps on the depression-opioid problem

Likely, the connection between depression and opioid use is so obvious that no one acts upon it or even talks about it. Yet, the consequences frequently are quite deadly. The issue: The failure to link depression treatment with opioid treatment.

Major case in point: Of the 306 bills to address our national opioid crisis currently being crafted by members of Congress on the Hill, not a single one recognizes that treatment for depression is a critical preventive measure for opioid dependence and suicide, and a necessary concurrent treatment.

Why is this true? Nationally, for more than a half century, mental health care and substance use care have been separated. These fields have separate institutes—NIMH, NIDA and NIAAA—in the National Institutes of Health, and they have separate centers—CMHS, CSAP, and CSAT—in the Substance Abuse and Mental Health Services Administration. Although some states have begun to combine oversight of these functions into a single agency, separate national state advocacy groups—NASMHPD and NASADAD—persist. Hence, it should come as no surprise that efforts to combine the care from these fields have flagged and progress will be difficult at best.

Overwhelming evidence has been amassed to document the connection between depression and opioid use: If one is depressed, the probability almost triples that one also will use and become dependent upon opioids. Conversely, if one uses opioids, the probability also doubles that one will develop depression in as short a period as 30 days. Further, it is well known that both depression and opioid use can lead to sudden death, including through suicide, regardless of whether the latter is recognized. At a more global level, it must be noted that of 115 million opioid prescriptions in 2016, more than 51% were to people who suffer from a mental illness, according to research published in the July-August 2017 issue of the Journal of the American Board of Family Medicine. More than half! This is a shocking number.

Fortunately, at the practice level, major efforts now are underway to integrate primary care and mental health care and primary care and substance use care. Appreciable federal resources have been made available through SAMHSA, HRSA and CMS for this purpose under the Affordable Care Act (ACA). We need to insist that these efforts also simultaneously integrate mental health care and substance use care.

Under the ACA, primary care physicians already are required to screen for depression. CMS regulatory guidance also has added Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening for substance use, including opioids. Similar screening should be required by specialty providers: mental health practitioners should screen for substance use conditions; and substance use providers should screen for mental health conditions, especially depression.

All persons screening positive should receive needed cross-treatment. The growth of integrated funding and integrated treatment teams can and will facilitate these efforts.

National advocacy will be necessary to bring this fundamental connection between depression and opioid use to the legislative attention of Congress. The headline for this effort: Treatment of depression is a major part of the solution for our crisis of opioid and suicide deaths.

With hundreds dying every day from opioids, we can't afford to tarry in this advocacy work.