Substance Use in Patients with Severe Mental Illness: Challenges in Outpatient Treatment

Sad African woman sit on sofa thinking of life troubles

As the opioid crisis moves into its fourth decade, experts indicate that the latest wave – called the fourth wave – is complicated by three factors. The first factor is the presence of illicit fentanyl in illicit drugs of misuse, the second is the increasing practice of polysubstance misuse, and the third is the presence of co-occurring mental health disorders among people with substance use disorders, and vice-versa.

Fentanyl increases the risk of overdose and overdose fatality because of its potency – it’s 50 times more powerful than heroin and 100 times more powerful than morphine – and the fact that drug traffickers use it to increase the volume and perceived effect of the drugs they sell.

Polysubstance misuse creates problems because of the negative interactions between certain drugs, the complications of withdrawal from more than one substance at a time, and the problem of creating individualized treatment plans for patients with a complex substance misuse history.

To learn more about the waves of the opioid crisis, fentanyl, and polysubstance misuse, please read these articles on the blog section of our website:

The Opioid Crisis: California Takes Action

Opioid Crisis Report: Need for Fentanyl Detox Increases

Opioid Overdose in Ohio: Local Efforts Offer Communities Hope

In this article, we’ll discuss the third factor in the current wave of the overdose crisis: the phenomenon of co-occurring disorders. However, we’ll approach the topic from a different angle than usual. We operate substance use disorder (SUD) treatment centers around the country, and offer mental health treatment – i.e. treatment for co-occurring disorders – in the context of integrated, whole-person SUD treatment. The data we address here is about SUD treatment in the context of mental health treatment. While treatment for SUD in a mental health setting is considered treatment for co-occurring disorders, few studies exist on SUD treatment from the perspective of clinicians whose primary role is treating mental health disorders such as depression, anxiety, or personality disorders

That’s why the study we discuss in this article is relevant: it does exactly that, which fills a void in the research which needs filling. It’s also relevant to us because researchers collected data in three states: California, Ohio, and New York.

We offer addiction treatment in two of those states: California and Ohio.

This research will help us help our patients in those states, and increase our overall understanding of the complex dynamics related to the assessment and treatment of co-occurring disorders.

We’ll discuss the study in a moment.

First, we’ll look at the latest data available on co-occurring mental health and substance use disorders.

Co-Occurring Disorders in the U.S.: Facts and Figures

The COVID-19 pandemic had a significant impact on mental health disorders and substance use disorders among people in the U.S. Now that the COVID-19 pandemic is moving toward endemic status, like the seasonal flu, rather than the pandemic status associated with a novel respiratory virus, we have the benefit of time, perspective, and most importantly, data, to gauge the effect of the pandemic on national rates of mental illness and substance use disorder.

Here’s data from the 2019 National Survey on Drug Use and Health (2019 NSDUH) published by the Substance Abuse and Mental Health Service Administration (SAMHSA).

Mental Illness and Substance Use Disorder: 2019 NSDUH

  • Adults 18+ diagnosed with serious mental illness (SMI): 13.1 million
  • Adults 18+ diagnosed with co-occurring substance use disorder (SUD): 3.6 million
  • Among Adults 18+ diagnosed with SMI: 12.7% received specialized SUD treatment
  • Among Adults 18+ diagnosed had SMI: 33.4% did not receive SMI or SUD treatment

The 2020 NSDUH contains valuable data, but the emergence of the pandemic three months into the year attenuated the collection and thorough analysis of the data. Therefore, the 2021 NSDUH offers the most reliable data to date on the impact of the pandemic on mental health, substance use disorder, and co-occurring mental illness and substance use disorder.

Here’s the same set of data from 2019 – with more detail – updated for 2021, published in late 2022.

Mental Illness and Substance Use Disorder: 2021 NSDUH

  • Adults 18+ diagnosed with serious mental illness (SMI): 14.1 million
  • Adults 18+ diagnosed with co-occurring substance use disorder (SUD): 6.4 million
  • Among Adults 18+ diagnosed with SMI:
    • Received SMI and SUD treatment: 16.1%
    • SUD treatment but no SMI treatment: 2.2%
  • Among Adults 18+ diagnosed had SMI: 33.1% did not receive SMI or SUD treatment

These two data sets tell us two important things:

  1. Rates of SUD among adults with SMI increased by 78% between 2019 and 2021.
  2. The percentage of individuals who received specialty treatment for SUD increased, and the number of people who received SMI or SUD treatment increased, but those increases did not keep pace with the overall increases in co-occurring SMI and SUD

That’s why the study we’ll discuss now has meaning: as these rates increase, we need to understand the gaps in our treatment capacity, in order to close them and offer appropriate support to everyone needs it.

Treating SUD Among People with Serious Mental Illness: The Clinician Perspective

The study “Managing Substance Use For Clients With Serious Mental Illnesses: Knowledge, Attitude, And Training Challenges Among Outpatient Behavioral Health Providers In California, Ohio, And New York” surveyed 717 community-based outpatient mental health treatment providers about their experiences supporting patients with a primary mental health diagnosis and a secondary SUD diagnosis.

Since evidence from the 2019 and 2020 NSDUH (links above) shows that alcohol and cannabis are the most common substances of disordered use among individuals diagnosed with severe mental illness (SMI), the study authors defined the following fundamental research objective:

The first goal of the current study is to assess community mental health providers’ relative preparedness to address alcohol, cannabis, and substance use generally with their clients who have serious mental illnesses.

The 717 community-based outpatient mental health providers who responded to the surveys answered questions on what they perceived as barriers to SUD treatment, their knowledge of SUD and SUD treatment in general, their level of comfort discussing SUD treatment with patients, their general willingness to refer patients to SUD treatment, and their perception of the effectiveness of SUD treatment outside of their outpatient setting.

Let’s take a look at what they found.

Barriers To Effective SUD Treatment For People Diagnosed With SMI

Numbers represent the percentage of providers in each state who identified each factor as a barrier to SUD care.

  • Patient does not recognize or accept SUD as an issue:
    • California: 74%
    • Ohio: 78%
    • New York: 68%
  • Availability of SUD treatment:
    • California: 67%
    • Ohio: 65%
    • New York: 58%
  • Cost of SUD treatment:
    • California: 62%
    • Ohio: 58%
    • New York: 29%
  • Delays in admission to SUD treatment programs:
    • California: 52%
    • Ohio: 69%
    • New York: 59%
  • Inefficient communication with other providers:
    • California: 45%
    • Ohio: 45%
    • New York: 43%

When we read this data, we know what we need to do: increase our advocacy and awareness efforts. We can increase our outreach efforts to people who need SUD treatment and mental health providers, which can help patients recognize they may need support, and inform providers we offer treatment options in California and New York. We can also streamline our admissions processes and improve our communication with mental health providers. The data indicates general deficiencies in those areas, which means we need to do our part to address those deficiencies.

Those are the clinician identified barriers to care. We know we can help remove some of those barriers. Let’s look at the rest of the data.

How Do Community-Based Mental Health Providers Rate their Readiness to Treat SUD?

We can help remove the barriers to care mentioned above. While we may not have a direct influence on what mental health providers do in their own practice, we’re interested in their view on SUD treatment, and how they think about and approach questions of addiction and recovery in the primary mental health context.

Let’s look at what the researchers found.

Mental Health Providers: Self-Rated SUD Treatment Knowledge and Application

Clinicians self-reported information on these areas on a scale of 1-5, with 1 being the lowest level of knowledge/confidence and 5 being the highest level of knowledge/confidence.

Knowledge of cannabis use disorder (CUD) and alcohol use disorder (AUD):

  • California:
    • CUD: 2.7
    • AUD: 3.0
  • Ohio:
    • CUD: 2.9
    • AUD: 3.5
  • New York:
    • CUD: 3.3
    • AUD: 3.7

Confidence in ability to assess CUD or AUD:

  • California:
    • CUD: 3.0
    • AUD: 3.3
  • Ohio:
    • CUD: 3.2
    • AUD: 3.5
  • New York:
    • CUD: 3.3
    • AUD: 3.6

Comfort level discussing CUD or AUD with patients:

  • California:
    • CUD: 3.7
    • AUD: 3.8
  • Ohio:
    • CUD: 4.0
    • AUD: 4.1
  • New York:
    • CUD: 4.2
    • AUD: 4.3

Willingness to refer patients to SUD or AUD treatment:

  • California:
    • SUD: 2.7
    • AUD: 2.8
  • Ohio:
    • SUD: 3.3
    • AUD: 3.5
  • New York:
    • SUD: 2.9
    • AUD: 3.2

Confidence in CUD, AUD, or general SUD treatment effectiveness:

  • California:
    • CUD: 3.0
    • AUD: 3.1
    • SUD: 3.1
  • Ohio:
    • CUD: 2.9
    • AUD: 3.3
    • SUD: 3.4
  • New York:
    • CUD: 2.8
    • AUD: 3.0
    • SUD: 3.0

We see two critical pieces of information in this data.

First, mental health providers, across the board, report being more comfortable identifying, talking about, and referring patients to treatment for alcohol use disorder than cannabis use disorder. That’s understandable. Data on the negative impact of cannabis use is available – and the connection between cannabis and cannabis-induced psychosis is clearly established in peer-reviewed literature – but many cannabis users downplay the negative impact of their cannabis use. In addition, effective treatments for alcohol use disorder are well-established by evidence, while research on treatment on cannabis misuse is often a secondary topic in studies on SUD in general. Therefore, less is known about how to treat cannabis misuse – and providers are reluctant to refer patients to any type of treatment that does not have a robust evidence base.

Second, we observe the level of confidence in the effectiveness of SUD treatment is lower than we expected: in all three states, confidence is right in the middle, around a three on a scale of one to five. That’s on us, as treatment providers: we need to do a better job of sharing our methods with our peers in mental health treatment, sharing our successes, and informing them that treatment for substance use disorder is safe, effective, and lifechanging.

Future Directions: More Training Needed

In the conclusion of the publication, study authors offer this observation:

Serious gaps persist in the implementation of training, programs, and interventions addressing substance use among individuals with serious mental illnesses in community mental health settings. Substance use training to address the service needs of individuals with co-occurring disorders is insufficient and a significant need exists for systemic changes to workforce training of community mental health providers.

That conclusion carries serious implications.

In light of the contours of Wave Four of the opioid crisis – which is partially driven by the increase in co-occurring SUD and mental health disorders, exacerbated by the COVID-19 pandemic – this is a warning for local, state, and federal officials and all treatment providers. We need to take advantage of the funding now available for mental health and SUD treatment and support, but also take advantage of the funding directed toward the comprehensive, multidisciplinary training for mental health providers that’s included in the latest nationwide effort to address the harm cause by this dangerous ongoing public health crisis.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.