Supporting People with Opioid Use Disorder and Co-Occurring Mental Health and Chronic Pain Conditions

Write-up by IRIS team member: Yali Deng

There is great comorbidity between substance use disorders (SUDs; including opioid use disorder, i.e., OUD) and mental health disorders, which are often referred to as co-occurring disorders. It is hard to determine the causal mechanism between SUDs and mental health disorders, however they usually share the same genetic and environmental risk factors, such as brain functioning, stress, trauma, and adverse childhood experiences (National Institute on Drug Abuse, 2021). A national representative study showed that among adults with OUD, about 64% reported any mental illness in the past year, and 27% reported severe mental illness (Jones & McCance-Katz, 2019). Mental illness can contribute to substance use and complicate the treatment of SUDs. Individuals with co-occurring disorders often report unmet treatment needs. Only 25% of adults with OUD and a co-occurring mental illness received both mental health and substance use treatment in the past year (Jones & McCance-Katz, 2019).

Co-occurring disorders with OUD is an important topic that IRIS funded projects and Fellows have examined through their research. One mixed methods pilot project led by Dr. Melanie Bennett examined how co-occurring disorders (depression and chronic pain) are related to OUD treatment outcomes. Results indicated that higher depression scores significantly predicted a positive opioid urinalysis at 90-day follow-up, while chronic pain did not significantly predict treatment outcomes. Participants had an interest in addressing their mental and physical health in addiction treatment and felt a sense of relief when treatment providers took their pain seriously. IRIS Research Fellow Meg Kaiser also conducted a qualitative study which highlighted the importance of mental health and co-occurring disorder training for peer recovery specialists.

In this research corner, we introduce two articles focusing on individuals receiving medication for OUDs (MOUD) who have a comorbid mental health disorder. The first provides evidence on how psychiatric diagnosis was related to MOUD discontinuation. The second offers insights on barriers and facilitators of integrated care for rural MOUD patients with co-occurring disorders.

Article 1

"The Impact of Psychiatric Comorbidity on Treatment Discontinuation Among Individuals Receiving Medications for Opioid Use Disorder"

Friesen, E. L., & Kurdyak, P. (2020). The impact of psychiatric comorbidity on treatment discontinuation among individuals receiving medications for opioid use disorder. Drug and alcohol dependence, 216, 108244. https://doi.org/10.1016/j.drugalcdep.2020.108244 

This study by Friesen and Kurdyak (2020) used Treatment Episode Dataset-Discharge 2015-2017 (TEDS-D) to examine the association between psychiatric comorbidity and treatment discontinuation among people receiving MOUD. The TEDS-D is an administrative dataset that includes discharge records from addiction treatment centers across the country. The MOUD discontinuation outcome variable was divided into client dropout (i.e., whether clients left treatment) and facility termination (i.e., whether addiction facility terminated the treatment). 

This study found that psychiatric comorbidity was associated with 12% lower odds of dropout from treatment but was associated with 59% higher odds of facility termination after controlling for demographic and clinical covariates (e.g., substance use patterns, treatment history). However, when considering effect size, only the association between psychiatric comorbidity and facility termination was assessed to be clinically meaningful. This study further controlled for state differences and found that the association between psychiatric disorders and treatment discontinuation varies across states. The variation may derive from differences in treatment policies and practices, especially states’ capacity to treat individuals with co-occurring disorders.

This study indicates individuals with psychiatric disorders are more likely to experience facility-initiated treatment discontinuation. It may indicate systematic-level barriers (such as lack of equipment and workforce shortages) for individuals with co-occurring disorders to access opioid use treatment. The authors discussed a previous study indicating only 18% of addiction treatment centers sampled in 11 states had the ability to treat individuals with comorbid substance use and psychiatry disorders (McGovern et al., 2014). These results have implications for practitioners and activists to advocate for more federal and state level resources to support treatment facilities to better handle the needs for people with co-occurring disorders.

Article 2

"Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction"

Snell-Rood, C., Pollini, R. A., & Willging, C. (2021). Barriers to integrated medication-assisted treatment for rural patients with co-occurring disorders: The gap in managing addiction. Psychiatric Services, 72(8), 935-942. https://doi.org/10.1176/appi.ps.202000312

This study explored the process, barriers, and facilitators of integrated care for rural MOUD patients with co-occurring OUD and mental health conditions, with a focus on organizational and systematic contexts. This qualitative study analyzed interviews with 26 healthcare providers and 16 stakeholders (i.e., administrators, public health officials, harm reduction advocates) who have expertise related to integrated care for MOUD in rural California.

Findings indicated that a shortage of primary care providers with mental health care training and a lack of therapists with expertise working with patients who receive MOUD limits the system’s ability to provide integrated care. Due to the shortage of in-house mental health resources, many organizations have to rely on offering outside referrals. However, referring patients elsewhere can cause discomfort and frustration, considering the huge barriers to accessing mental health care, including high costs and limited options for therapists who accept their insurance. Many patients were denied treatment by mental health care providers because of their limited ability to deal with co-occurring disorders. Others were put on long waiting lists. These huge barriers can cause frustration and feelings of powerlessness which may hinder patient’ future help-seeking and increase the risk of substance use due to lack of resources.

This study indicates the importance of addressing systematic factors related to implementing integrated care. For example, more resources should be invested to support mental health services in rural areas, especially to expand the workforce with expertise in dealing with co-occurring disorders. Importantly, this study indicates that MOUD patients with mild to moderate mental health conditions are often left out of mental health treatment because these needs are considered less urgent in the context of therapist shortages. Additional training is needed for primary care providers and other recovery support staff to equip them with integrated expertise on co-occurring disorders so that they can better support people with mental health needs.

References

Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and alcohol dependence, 197, 78-82. https://doi.org/10.1016/j.drugalcdep.2018.12.030

McGovern, M. P., Lambert-Harris, C., Gotham, H. J., Claus, R. E., & Xie, H. (2014). Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems. Administration and Policy in Mental Health and Mental Health Services Research, 41, 205-214. https://doi.org/10.1007/s10488-012-0449-1

National Institute on Drug Abuse. (2021, April 13). Why is there comorbidity between substance use disorders and mental illnesses? https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/why-there-comorbidity-between-substance-use-disorders-mental-illnesses