With the changes brought about by the growth of managed care, evidence-based practice and the advent of the Affordable Care Act, we increasingly recognize that substance use disorder and mental illness are behavioral health issues often found together in the same patient.
The field of behavioral health offers a way for substance abuse and mental health practitioners to work in concert with a coordinated approach to prevention, treatment and recovery for patients struggling with substance use disorders and mental illness.
Prevention
At OASAS, we believe that substance abuse disorders are preventable, and prevention programs need to address not just the individual but the larger community as well. The broad category of mental, emotional and behavioral disorders, including depression, conduct disorder and substance use disorders among youth, often occur together and share some common and early developmental risk factors, including, a family history of addiction or mental illness, living in a family in conflict, and community availability of alcohol, drugs and other substances.
I am pleased to report that OASAS supports more than 180 prevention service providers operating in schools and community-based organizations delivering evidence-based education programs, environmental efforts to reduce underage drinking, and early interventions for adolescents. The evidence-based programs and strategies (EBPS) delivered by our programs improve community, school, family and youth risk factors that will also address the development of other mental, emotional and behavioral disorders.
Our EBPS programs, such as “Life Skills Training” and the “Too Good for Drugs” curricula, are delivered to K-12 students. These programs teach personal and social skills to better manage emotions, reduce the effects of peer pressure to use drugs and lower other risk factors. According to the Washington State Institute for Public Policy, these programs have been shown to be cost effective.
OASAS supports the implementation of liquor store and tavern compliance checks, alcohol server training, local social host regulations and other strategies through our providers and a network of more than 145 anti-drug coalitions supported by our regional Prevention Resources Centers (PRCs). These strategies are designed to change the community, social, and economic contexts in which people access alcohol, tobacco, or prescription drugs.
OASAS supports two early intervention services for teen and adult substance users: “Teen Intervene” and “Screening, Brief Intervention, and Referral to Treatment” (SBIRT).
“Teen Intervene” is a school-based program that helps youth identify the reasons they have chosen to use alcohol or other drugs, examine the effects of substance abuse in their lives, and learn to make healthier choices. “Teen Intervene” has been shown to result in greater abstinence, less binge drinking, and less marijuana use among young people in the program.
SBIRT is used primarily in healthcare settings and is more adult-focused, but it has the potential to be a good early intervention strategy for young people, as well. In 2012, OASAS launched a preliminary SBIRT project in two school-based health clinics in the Bronx and Nassau County. This year we began working with three additional school-based health clinics in upstate New York. If successful, we will work to integrate SBIRT into additional school settings statewide.
Initial research also shows that SBIRT can be used effectively to reduce depressive symptoms. For example, Wisconsin’s “Initiative to Promote Healthy Lifestyles” showed depressive symptom scores dropped by 55 percent over six to eight weeks with a simple intervention that promotes engagement in behaviors shown to ameliorate depressive symptoms.
Treatment
It is clear that the field of substance use disorder treatment has been evolving for many years as our understanding of addiction has changed. For centuries, alcoholism and addiction were seen as a moral failure on the part of the individual. Society’s treatment consisted of commitments to prison or inebriate asylums. We’ve seen that medical and psychiatric approaches to treatment were largely unsuccessful through the 1930’s.
With the beginning of 12-step programs, such as Alcoholics Anonymous and Narcotics Anonymous, self-help became a major component of treating alcoholism and addiction. These approaches were effective in treating many people, but for those who did not succeed in this model, a lack of readiness or not yet having hit bottom, were often thought to be the reason. While some people may not have been ready, for many there were other reasons for a lack of success.
Over the years, the addiction treatment community has relied heavily on individuals in recovery to help those wishing to attain it and their contribution has been invaluable. But the system did not have an adequate understanding of the issues of mental health. Debilitating mental health issues could have a major impact on a person’s ability to connect with a sponsor, talk in group counseling and be successful in treatment. Depression, bipolar illness, anxiety disorders, personality disorders, as well as psychoses could greatly impair someone’s compliance with treatment.
We now know that addiction treatment programs often lacked psychiatrists or other professional staff with mental health experience, making them poorly equipped to assess, understand and be effective with the mental health population. Similarly, the mental health community often lacked staff with experience treating addictions and addiction certified physicians. Patients who suffered simultaneously from addiction and mental illness often got caught between each system.
By the mid 1980’s addiction and mental health professionals began to recognize the need to more effectively treat this population. This problem went through several different names: dual diagnosis, mentally ill chemical affected (MICA), chemical abuse and mental illness (CAMI), before coming to be known today as co-occurring disorders.
Our programs then tried simultaneous but uncoordinated treatment of the issues. Our lack of coordination led to programs working against each other instead of working together. As we strengthened coordination between substance use disorder and mental health treatment programs, uncoordinated treatment lessened. Fully integrated treatment has started to become the standard. In this newer model, one physician or other healthcare professional works with the patient to provide a unified treatment plan and approach. We have a much better understanding today of the neurochemical components of substance use disorder and of certain mental illnesses. The same brain chemistry vulnerability that can lead to substance use disorder may also be implicated in depression and anxiety.
As our understanding of co-occurring disorders has improved, we have also recognized the impact of post-traumatic stress disorders and traumatic brain injury, while incorporating trauma-informed care into our approaches. Similarly, we have become better at recognizing the impact of personality disorders on treatment approaches.
One of the major developments in healthcare in recent years has been the Health Home. OASAS is playing a critical role in the selection, development and implementation of Health Homes for Medicaid recipients.
The Health Home seeks to fully coordinate all aspects of an individual’s care, e.g., physical health, substance use disorder, and mental health. The Health Homes build networks of providers and support services, e.g., housing, education and vocational training, to meet the person’s needs in a truly coordinated fashion.
Clinical approaches incorporating evidence-based practices have improved the treatment community’s ability to provide “person-centered” care. Person-centered and person-directed practices have allowed us to find a common language and understanding of the treatment of patients that has moved the fields of substance use disorder (SUD) and mental health (MH) treatment together in the same direction. Evidence-based or promising practices have become the standard of care in both SUD and MH treatment, and together with the movement towards recovery-oriented care, we have laid the foundation for our continued movement toward more effective care.
We at OASAS have worked to improve the addiction field’s understanding of mental health issues. We now know that 60 to 80% of patients have co-occurring mental health issues. We have encouraged our programs to use mental health screening tools like the Modified Mini to identify potential co-occurring issues. At OASAS, training on the treatment of mental health and substance use disorder is a priority. We recognize that improving the outcomes for our population with multiple issues is an important responsibility.
Recovery
Along with prevention and treatment, recovery is the third and equally important part of OASAS’ approach to providing behavioral health services for people suffering with substance abuse disorders.
Recently, the treatment community has focused on developing a recovery-oriented system of care (ROSC). This hopeful new treatment technique involves changing from the current recovery approach, which treats addiction and mental illnesses as acute crises, to understanding that recovery is a journey which often requires long-term supports and services, particularly for those with co-occurring issues.
OASAS also supports the training of peer-based recovery coaches and participates in public awareness efforts such as celebrating Recovery Month each September.
The field of behavioral health is changing rapidly as the Affordable Care Act and Governor Cuomo’s Medicaid Redesign Team’s policies are implemented. OASAS is responding to this climate and will continue to deliver prevention, treatment and recovery services to provide a better quality of life for the people of New York.
