Mental Health Policy - Substance Abuse and Co-Occurring Conditions

Mental Health Policy IISubstance Abuse and Co-occurring Disorders

10/26/15 Mental Health Policy II 1

Mental Health Policy IIDrug Policy

Questions for Discussion/Debate:

• Why do people who are not mentally ill use drugs (and some become addicted)?

• Why do people with mental illnesses, especially serious mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder use drugs at such high rates?

http://www.mojvideo.com/video-trainspotting-1996-1-3-full-movie-eng-subs/8e2dfbfdf66718be7e8310/26/15 Mental Health Policy II 2

http://www.mojvideo.com/video-trainspotting-1996-1-3-full-movie-eng-subs/8e2dfbfdf66718be7e83




Drug use, begun in an effort to enhance pleasure, increase social connectedness, satisfy curiosity, or reduce pain frequently turns into a persisting, insistent compulsion that instead induces misery and suffering leading to the spread of disease and to a countless number of premature deaths. Still, even with that oft-repeated trajectory alcohol and other drugs continue to be widely used and misused.

- Swartz (2012)




• What is the nature of addiction? That is, why does someone who uses and tries a drug become addicted and why does another person using the same drug not become addicted? Is it genetic, psychosocial, a choice?

• Does having a mental illness predispose one towards drug addiction or does using drugs predispose one towards developing a mental illness (the marijuana argument)?




• Is drug addiction (including alcohol addiction) a disease?


























































The chance of having a co-occurring substance use disorder, given a mental illness probably varies by the specific mental illness (there is an unequal distribution).



Any Substance Abuse or DependenceGroup % Odds RatioGeneral Population 16.7 -

Schizophrenia 47.0 4.6

Any Mood Disorder 32.0 2.6 Any Bipolar Disorder 56.1 6.6 Major Depression 27.2 1.9 Dysthymia 31.4 2.4

Any Anxiety Disorder 23.7 1.7

Obsessive-compulsive Disorder 32.8 2.5 Phobia 22.9 1.6 Panic Disorder 35.8 2.9



Mental illnesses tend to precede substance use disorders (but not use):

• The age of onset for most mental illnesses (anxiety disorders, impulse control disorders) is about 11 years old while the age of onset for substance use disorders is about 20 years old. Mood disorders (depression) tend to occur later (30 years).

• This is important because people with mental illnesses tend to use alcohol and other drugs more often than people who do not have a mental illness and to become dependent on alcohol and other drugs given any use.

• Why is a person with a mental illness more inclined to have an SUD:• Higher rates of use/same rates of developing a disorder?• Same rates of use/higher rate of developing a disorder?• Higher rates of use/higher rate of developing a disorder?





Historically, individuals with co-occurring disorders received sequential or parallel treatment from the separate mental health services and substance abuse treatment systems.

Neither system had developed the capacity to provide both mental health and substance abuse treatment within a single program.

Fragmented and uncoordinated services created a service gap for persons with co-occurring disorders.

80%+ of persons with co-occurring disorders do not perceive a need for treatment

Individuals may have been sorted by which disorder was more prominent…



Those who have a severe psychiatric disorder such as schizophrenia or bipolar disorder tend to present to facilities that have historically treated psychiatric disorders…

Individuals with character disorders such as ASPD, and NPD where the drug abuse problems are more clinically salient tend to present at facilities that have historically treated substance use disorders (and in the criminal justice system).

Thus, the two general kinds of programs probably see different kinds of co-occurring disordered clients (in general).

But in many programs the mental illness of the SUD simply goes unrecognized and untreated.



For the past 10 years, the thinking on best practices has been to provide integrated services for treatment clients with co-occurring disorders at multiple levels:

Integrated Treatment - interaction between the mental health and/or substance abuse clinician(s) and the individual, which addresses the substance abuse and mental health needs of the individual. (Assertive Community Treatment?)

Integrated Program(s) - the organizational structure for providing integrated treatment, the mental health and/or substance abuse program is responsible for ensuring an array of staff or linkages with other programs to address all of the needs of its clients. The program is responsible for ensuring that services are provided in an appropriate and easily accessible setting, services are culturally competent, etc.



Integrated System - the organizational structure for supporting an array of programs for people with different needs, including individuals with co-occurring substance abuse disorders and mental disorders. The system is responsible for ensuring appropriate funding mechanisms to support the continuum of services needs, addressing credentialing/licensing issues, establishing data collection/reporting systems, needs assessment, planning and other related functions.



Elements of Best Practices therapy include:

Case Management (often in the context of ACT)Multi-disciplinary teams Stages of Treatment Models (Related to stages of change)

EngagementPersuasionActive TreatmentRelapse Prevention

Multi-modal therapy:Motivational InterviewingCBTMedication managementIndividual and Group SessionsSupported Employment



• Until the ACA, co-occurring medical conditions was recognized as a large but unaddressed problem.

• The majority of excess deaths among those with an SMI are due to physical illnesses, in particular cardiovascular disease, respiratory illness and cancer. (Lawrence and Kisely).

• Although substance use, unhealthy lifestyles, and the side effects of medications increase the risk of physical illness in people with SMI, there is a growing body of evidence that unequal healthcare provision also plays a role in this disparity.

• Infectious diseases also play an important role, particularly HIV and STDs, the prevalence of which are elevated among those with an SMI.


Epidemiology: Infectious Conditions

Jane Addams College of Social Work

Chronic Medical Conditions Men(N=282)

Women(N=149)

Tuberculosis 5.7% 5.8%

HIV or AIDS 3.0 5.2

Other STDs 14.7 30.7

Based on WHO-CIDI chronic conditions section. Red text indicates significant gender differences.



Barriers to effective healthcare provision for the mentally ill can be split into system-level issues, provider issues, and patient-related factors:

• Systemic issues include the geographic, managerial and resource separation of physical and mental healthcare facilities, lack of clarity as to who takes responsibility for the physical health of patients with SMI, fragmentation of care across providers, lack of integration between medicine and psychiatry, lack of continuity of care, and under-resourcing of mental healthcare that provides little opportunity for specialists to focus on issues outside their core specialty.

• At the provider level there are the effects of stigma, time and resource constraints, and the possibility of regarding physical complaints as psychosomatic symptoms.



• Patient-related factors include health risk factors and lifestyle factors such as substance use, diet, lack of exercise and obesity, side effects of medications and the effects of mental illness including cognitive impairment, social isolation and lack of family support, higher pain threshold or reduced sensitivity to pain, suspiciousness or fear, self-neglect, lack of motivation, socio-economic factors and difficulties in communicating health needs.

• Both primary care settings and psychiatric settings regularly fail to diagnose physical illnesses in patients with mental illness.



• To address the systemic separation of mental healthcare and physical healthcare, a range of integrated care models have been proposed.

• These include co-location of services, having staff from one service visit another on a regular basis, or appointing case managers to liase between services and co-ordinate the overall care for the patient.


A reminder about provisions in the Affordable Care Act and Health Homes:

The Affordable Care Act (ACA) includes several opportunities to support Medicaid in transforming the health care delivery system. One of these is detailed in Section 2703 of ACA – health homes.

Health homes comprise six services that Medicaid programscan provide to eligible beneficiaries:• Comprehensive care management;• Care coordination and health promotion;• Comprehensive transitional care/follow-up;• Patient and family support;• Referral to community and social support services;• Use of health information technology (HIT) to link services, if

applicable.



Medicaid beneficiaries eligible for health home services include those who have: (1) two or more chronic conditions; (2) one chronic condition and are at risk for a second; (3) a serious and persistent mental health condition.

Chronic conditions include mental health, substance abuse, asthma, diabetes, heart disease, and being overweight.

Dual eligible (Medicaid and Medicare) beneficiaries cannot be excluded from health home services.

The movement from fee-for-service to managed care is also supposed to provide better integrated care.




Drug policy is largely driven by how one views drug use (including alcohol use) and/or which viewpoint one tends to emphasize. Is drug use (addiction) mainly a:

• Choice or moral Issue and therefore mainly a criminal justice problem?

• A social issue driven by economic and other inequities and therefore a more general problem of social justice?

• Brain disease and therefore a public health problem?



ADVICE TO MOTHERS! — Are you broken in your rest by a sick child suffering with the pain of cutting teeth? Go at once to a chemist and get a bottle of MRS. WINSLOW’S SOOTHING SYRUP. It will relieve the poor sufferer immediately. It is perfectly harmless and pleasant to taste, it produces natural quiet sleep, by relieving the child from pain, and the little cherub awakes “as bright as a button.” 10/26/15 Mental Health Policy II 52




• For much of the 19th century through the first decade of the 20th century, so-called “patent medicines” were marketed and sold over-the-counter without prescription to the American public.

• Patent medicines originated in England in the 1600s and traveled with British emigrants to the new colony, where they eventually reached their peak in the second half of the 1800s.

• Many patent medicines were nothing more than alcohol-based beverages in which cocaine or opium had been dissolved with additives to enhance the taste and to disguise the bitterness of the cocaine or opium.

• Unchecked by any statutory requirement to demonstrate their effectiveness, patent medicines were aggressively marketed as bringing relief or outright cures for a wide variety of medical ills and symptoms that ranged from cancer to tuberculosis to paralysis to “female complaints”.



• By the late 1800s, the growing popularity of the patent medicines brought increased scrutiny as their addicting properties, ineffectiveness, and the falseness of their claims to being cures became apparent to the medical community and a growing number of the general public.

• The Journal of the American Medical Association published an entire volume of articles that detailed the fraudulence of the marketing claims underlying patent medicines and other forms of quackery in 1911 with two subsequent volumes published in 1921 and 1936.

• The push for greater control of the patent medicine market led to the passage of the Pure Food and Drug Act in 1906. This Act did not restrict sales of patent medicines but it did require the ingredients be included on the label.



Negro Cocaine “Fiends” New Southern Menace

By

Edward Huntington Williams, MD

NY Times – February 8, 1914

A recent experience of Chief of Police Byerly of Asheville, N.C., illustrates this particular phase of cocainism. The Chief was informed that a hitherto inoffensive negro, with whom he was well acquainted, was "running amuck" in a cocaine frenzy, had attempted to stab a storekeeper, and was at the moment engaged in "beating up" various members of his own household. Being fully aware of the respect that the negro has for brass buttons, (and, incidentally, having a record for courage,) the officer went single-handed to the negro's house for the purpose of arresting him.



• Those who sought to prohibit narcotics use on a national level played upon existing racial stereotypes and fears to gain political support among the southern states, which were strongly opposed to ceding any power to the Federal government.

• Black Americans were not the only group portrayed as demonic, white-women-and-children-plundering, drug-fueled criminals.

• Chinese immigrant laborers, known as “coolies” first brought to America to work in the gold mines and transcontinental railroads in the mid 1800s were associated with smoking opiates. Portrayals of Chinese smoking parlors or “opium dens” as they were called, included lurid descriptions of how white women were enticed into licentious behavior through the lure of smoking opium with Chinese men.



Image from the movie, The Dividend (1916)10/26/15 Mental Health Policy II 58


• Concerned over the corrupting influence of opium smoking Chinamen, but driven more by an even greater desire to insure continued trade with China and be in compliance with following an international conference on opium held in Shanghai, the U.S. government passed the Opiate Exclusion Act of 1909, which banned the importation of opium for smoking (but not for other purposes such as inclusion in pharmaceutical preparations).

• Mexican laborers working in agriculture were associated with marihuana use and demonized as becoming criminal and violent when using the drug in much the same way as the blacks and Chinese were portrayed in their use of cocaine and opium.



William Randolph Hearst10/26/15 Mental Health Policy II 60


Rupert Murdoch



• William Randolph Hearst, owner of a newspaper empire and model for the main protagonist in the movie Citizen Kane, had a significant financial stake in the timber industry to supply paper for his newspapers. At the time, paper made from hemp was a competing product.

• Hearst had also lost 800,000 acres of timberland he owned in Mexico to Pancho Villa during the Mexican revolution, fueling Hearst’s already considerable xenophobia and targeting it towards Mexicans.

• To preserve his investment in timber, vent his anger at Mexicans, promulgate widespread fear and anger, and sell more papers, Hearst directed his papers to run stories about the “lazy”, “degenerate”, “violent”, and “marihuana smoking” Mexicans. Lurid titles such as “Marijuana makes fiends of boys in 30 days” and “Mexican narcotic, marihuana inciting with lust to slay, blamed for death cruise” began appearing in Hearst-controlled newspapers such as the San Francisco Examiner (and other Hearst publications) in the 1920s.



The Harrison Narcotics Act of 1914

Made the importation, manufacturing, sale, and distribution of narcotics, defined as cocaine, opiates, and opiate derivatives such as heroin, illegal without first registering with the Bureau of Internal Revenue, recording each transaction, and paying an annual tax and licensing fee.

The law circumvented the limited policing powers of the Federal government and instead used the Federal powers to tax and control inter-state commerce as the levers for enacting narcotics control.

The Harrison Act sharply curtailed the legal availability of narcotic drugs and would remain in effect for over half a century (until the Controlled Substances Act of 1970).



• The Harrison Act in many respects reflected compromises with powerful special interests such as pharmaceutical manufacturers, druggists, and the American Medical Association who were concerned that the legislation would curtail income and impose onerous record-keeping requirements.

• The Act did not prohibit the sale or distribution of narcotics but “merely” required those who did so to register with the Treasury Department, keep records of their transactions, and pay taxes and fees.

• Transactions between physicians, pharmacists and patients were not taxed, but did have to be recorded.

• The Act did not prohibit narcotics use or sale as prohibition did with alcohol; manufacturers could still make narcotics, physicians could still prescribe them, pharmacists could still dispense them, and patients could still take them.













• Research on the nature of addiction eventually gave way to serving as a testing ground for new drugs to determine their relative analgesic versus addicting properties.

• Such compounds were of interest to the pharmaceutical industry that wanted to find drugs useful for reducing pain but which were not habit-forming. They wanted to avoid making the same mistake as when heroin was synthesized.

• Addicts who had been clean for some time were reintroduced to drug use again for the purposes of such studies, the justification being there was time enough before their release date for them to go through withdrawal (again) and get clean.

• ARC researchers also involved unwitting subjects in CIA-sponsored studies as part of a project named MK-ULTRA to gauge the usefulness of experimental drugs such as LSD in interrogations.



• By the 1950s, the initial hopes that accompanied the construction of the Narcotic Farms had given way to cynicism and disenchantment over the poor treatment results and research that was increasingly deflected from the original goal of understanding addiction to less noble, ethically questionable pursuits.

• ARC was moved out of Lexington to the medical campus of Johns Hopkins University in Baltimore and eventually became the intramural research program of the National Institute on Drug Abuse.

• The narcotics farm in Lexington closed its doors to drug treatment in 1975 and became a Federal prison, time having simply passed it by with local, less expensive, and more advanced treatment programs becoming more common across the country. It is presently used as a facility to provide medical care to inmates in the federal prison system.





• Harry Anslinger was America’s first drug czar as the first Bureau of Narcotics Commissioner (1930).

• In his new role Anslinger was savvy, energetic, passionate for the cause and above all, a political survivor.

• He remained Commissioner for 32 years, working under five presidential administrations until he finally (was forced to?) retired in 1962.

• As cocaine and opiate distribution had largely been addressed and relatively well controlled by the provisions of the Pure Food and Drug Act in 1906 and in 1914 by the Harrison Act and subsequent Supreme Court interpretations, Anslinger targeted marijuana.



• Anslinger penned fantastical articles such as the Assassin of Youth that were published in popular media outlets such as American Magazine and Reader’s Digest.

• The articles were based on the thinnest of anecdotal evidence and grossly exaggerated the effects of drug use.

• By exaggerating the drug menace faced by the country, Anslinger made the case not only for tougher legislative action, he also underscored the need for the continued existence of and budgetary support for the Narcotics Bureau.

• His articles and testimony were shrewdly tailored to stoke existing fears in the general public about the dangers of drug use and the selected stories often played on racial prejudices and stereotypes to achieve that end.





Screen shot from the 1937 movie – Reefer Madness







Woodstock Music Festival - 1969









• Stimulants such as Benzedrine, tranquilizers such as Miltown, and barbiturates such as Nembutal were used regularly and legally by millions of Americans at the peak of their popularity in the 1960s.

• In 1963,15 percent of the adult U.S. population (30 million) was taking prescription drugs for psychiatric problems. These figures do not take into account the many additional millions of Americans who used the same or equivalent drugs after acquiring them illegally without a prescription.

• A culture that encouraged drug use to improve mood, lose weight, increase stamina and productivity, and get some rest when needed, helped set the stage for younger Americans to congregate in the city of San Francisco in January of 1967 for a “Be-In”.







Elvis meets Nixon – 1970



Soldiers exchange vials of heroin Quang Tri Province, South Vietnam July 1971







The Man in the Moon with Cocaine Spoon at Studio 54



Griselda Blanca – “La Madrina”











President George H. W. Bush displaying a confiscated bag of crack cocaine during a Presidential address to the nation in 1989





The Platzspitz “Needle Park” in Zurich Switzerland, circa 1992





Rush Limbaugh, Oxycodone Addict10/26/15 Mental Health Policy II 100


One of many pain clinics in Broward County, Florida10/26/15 Mental Health Policy II 101


At an Aug. 15 2011 news conference, Florida officials displayed prescription drugs that were surrendered to the state by pain clinics.



Methamphetamine Lab






Mental Health Policy - Substance Abuse and Co-Occurring Conditions

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