By Ellen Grimm, Granite State News Collaborative

About half of those who experience a substance use disorder during their lives will also experience a mental health disorder, according to the National Institute of Mental Health. And studies show the reverse is also true: About half of those with mental illness will also experience substance use disorder. Some experts put that number even higher.

Yet despite that close relationship, the two conditions are too often treated separately, according to experts in both fields.

“How do we come together?” asked Phoebe Axtman, Director of Education for the N.H. Harm Reduction Coalition. Axtman, who also has her own private practice, is an MLADC (Master Licensed Drug and Alcohol Counselor), which means she is trained to treat both substance use and mental health disorders. LADCs (Licensed Drug and Alcohol Counselors) are more narrowly focused on substance use disorders (SUD). Axtman says there's a need for more training in co-occurring disorders.

“In places like New Hampshire, where we are experiencing a high level of drug use among people that have mental illness. As drug and alcohol counselors, treatment providers, we need more education on mental health, just like someone who works in mental health needs more training in addiction and substance use,” she said

This division is not unique to New Hampshire and has deep roots, despite inclusion of substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s authoritative volume on mental health disorders, said Michael Bradley, clinical supervisor at the Mental Health Center of Greater Manchester.

“There has been some progress over the years in my 30-some years in the field. But there remains much more progress to be attained,” he said. “(Substance use disorder) is a category of emotional illness or mental illness. And yet, the separation of treatment for that mental illness remains.” In fact, he said, some studies find the overlap between conditions is between 50% and 80%. “The overlap is huge. And we as fields need to be able to accommodate that.” Both fields, meanwhile, are dealing with longstanding workforce shortages in New Hampshire.

Bradley, who said his comments reflect his own views and not those of the Mental Health Center of Greater Manchester, is semi-retired and said he continues to work in part because the agency is shorthanded in nearly every department. Among his duties: supervising staff's licensing pursuits, following up with clients after emergency visits, and overseeing motivational groups.

Bradley suggested a multifaceted approach is needed to better integrate care. “We see adjustments that need to be made on the legislative level, on the educational level, as well as agency-wide levels,” he said. In addition, stigma remains a barrier for some mental health providers, who may not have originally entered the field with substance use disorder in mind and are reluctant to treat this population, he said. Some experts have suggested this stigma in part stems from a long-held practice of separating SUD education from programs that prepare many in the behavioral health field, and that better integrating the disciplines could help alleviate the problem and better serve patients’ needs. 

Phoebe Axtman acknowledged that additional training, though essential, can be a lot to ask of mental health providers who already have huge caseloads. “I don't think anyone asked for that or saw it coming, but I think in our culture because these things are increasingly happening, there's a call for us to do things differently,” she said. This includes the need for more widespread use of harm-reduction approaches, she said, including syringe exchanges and test strips that can detect fentanyl..

Meanwhile, the addiction problem has worsened both nationally and statewide. The federal government estimates more than 100,000 people died from drug overdoses in 2021, according to provisional data released in May. That’s the highest number of annual overdose deaths ever recorded. The vast majority of those deaths involved opioids.

In New Hampshire, opioid-related emergency department visits increased by 20% from April to May of this year, according to the New Hampshire Drug Monitoring Initiative.

In the state's two largest cities, Manchester and Nashua, there were 84 suspected opioid overdoses during August, according to the American Medical Response Ambulance Service. Preliminary data shows Nashua experienced 32 suspected opioid-related deaths through August, compared with 30 suspected opioid-related deaths during all of 2021. Nashua was on pace to have the highest number of suspected deaths from opioids in a one-year period since the epidemic began in 2015, according to AMR, and Manchester was on pace to have the highest number of suspected opioid-related deaths in a one-year period since 2017.

As concerning as these numbers may be, Bradley said, they are the tip of the iceberg.

“There are people that have overdosed three, four or more times and have been revived by NARCAN, (Naloxone), and they've experienced brain damage because of that,” he said “Their functioning is compromised.”

More programs, more need

Phoebe Axtman's practice receives referrals through the Doorway program, the federally funded statewide system established to address the opioid crisis. At nine Doorway sites around the state, people receive initial services, such as stabilization care, and then are referred to various treatment programs.

The number of these programs has increased in the state, but that has not alleviated the longstanding workforce shortage, according to Annette Escalante, Senior Vice President of Substance Use Treatment Services at Farnum Center in Manchester. In fact, it means the same insufficient pool of workers is spread that much more thinly.

Another challenge for facilities needing on-site staff, she said: During the pandemic, telehealth greatly expanded, attracting providers who prefer to work from home.

The Farnum Center provides a range of services, including medical detoxification, inpatient care, and outpatient counseling. In addition, the facility has a contract with Catholic Medical Center to conduct assessments for people who arrive at the Doorway of Greater Manchester seeking care.

“There are more substance use disorder treatment programs available for clients to choose from and not enough workforce to manage the system,” Escalante said. As more for-profit programs have sprung up, Farnum, a nonprofit organization, has had to adjust its salaries to compete, Escalante said. 

“Nonprofits are competing with private entities that are able to pay in a way that puts us in a position of not being able to keep and retain staff because they're going to be drawn to where they can get even higher wages,” said Stephanie Savard, Chief External Relations Officer at Families in Transition in Manchester, a nonprofit organization that offers substance use disorder services, including outpatient and intensive outpatient programs, and conducts assessments for the Manchester Doorway.

“This is hard work,”  Savard said. “And (counselors) have credentials that they deserve to be reimbursed at an appropriate wage for,” Savard said. “However, it's causing financial strain for all of us providers in trying to keep ourselves in a place that we can hire the best quality people and keep the best quality people.”

According to Escalante, the system right now can be inflexible in ways that can lead to unnecessary risks, leading to repeat visits to emergency departments, for instance.

When a patient who comes in for medical detoxification exhibits psychosis, she said, it can be a challenge to distinguish between whether it is a drug-induced condition or a mental health issue. “Once you remove the substances from their system, you actually get to see if there's something else there that's going on that's cognitive,” she said.

“A lot of SUD programs are not equipped to be able to handle or deal with someone who has a co-occurring disorder. So what ends up happening is that person may be asked to leave their substance use disorder treatment or go through the whole process of treatment, only to get referred to a mental health provider,” she said. Yet that mental health provider may not have the necessary expertise in substance use disorder.

“We need more programs that address both issues at the same time and not a divided system,” Escalante said. In this regard, Farnum will soon undergo a training program in co-occurring disorders run by the Hazelden Betty Ford Foundation. “That means anyone who comes in contact with any client – via phone, kitchen staff, front desk staff – everyone will be trained,” she said. “That's truly a co-occurring disorder program.”

Changes need to happen also on the federal level, Escalante said. “The funding that comes to the state from the Substance Abuse and Mental Health Services Administration (SAMHSA) is divided,” Escalante said. “One portion goes to SUD, one portion goes to mental health,” she said. If the feds have divided it, it's pretty hard to try to get to a place where that person is being taken care of holistically,” she said.

Stephanie Savard said the situation has been improving, with more providers working to increase their skills to deal with co-occurring disorders, and although waiting lists are still long, it was worse five or ten years ago.

The Willows treatment center run by Families in Transition has dealt with co-occurring disorders since it opened in 2008, Savard said. “It's not just someone saying, 'I am just here for my substance use disorder,'” she said. “We all know it crosses the lines of other mental health disorders, of health issues, of homelessness, of poverty, of domestic violence.”

A major milestone in addressing co-occurring conditions was the expansion of MLADC certification in 2010 to include mental health training, according to Jacqui Abikoff, who was public policy chair for the New Hampshire Drug and Alcohol Counselors Association at the time.

Abikoff is now executive director of Lakes-Region-based Horizons Counseling Center, which provides various services, including outpatient counseling. The Center has been treating co-occurring conditions for decades, Abikoff said. Training in both substance use and mental health disorders – and what Abikoff describes as the “art of addressing both at the same time” – is part of the push for integrated care, eliminating silos in the health care system, she said.

Bridging gaps

In response to the workforce shortage, several Doorways in the state, including the Doorway of Greater Nashua, offer “bridge therapy” to those awaiting permanent counseling. “We do see some folks, whether it's weekly or biweekly, to offer that support in their early recovery while they're waiting for more of a long-term therapist,” said director Kristin Makara. The Nashua Doorway has been offering bridge therapy since 2020, she said, when Southern New Hampshire Health took over the Doorway program.

Makara, the only permanent clinician on a staff that includes several Certified Recovery Support Workers, is responsible for assessing patients for treatment needs. She said the Nashua Doorway has been looking for another clinician for nearly a year.

When it comes to addressing co-occurring disorders, Makara says there's another complicating factor: “If they didn't already have a preexisting mental health condition, (substance use) is potentially contributing to one,” she said. “Chemical changes in the brain, the life circumstances that are now changed because of the substance use, could potentially cause depression and anxiety. It's so bottled up into one bundle.” In order to better address this complexity, Makara said, Southern New Hampshire Health has been working on getting more staff trained in substance use disorder.

According to Cynthia Whitaker, president and CEO of Greater Nashua Mental Health, the divide between mental health and substance use disorder treatment is in part due to bureaucratic divisions, with two different bureaus and licensing boards representing each field. “That silo-ing of the two fields impacts the  workforce,” she said. Insurance, too, which requires a primary diagnosis, can contribute to the problem, she suggested. Medicaid expansion has helped, she said, by including coverage for substance use disorder.

A report focusing on the state’s Licensed Alcohol and Drug Counselors (LADC) released in 2021 by the Council on Licensure, Enforcement and Regulation (CLEAR), identified several areas for improvement, including an “unusually complex” application process and a “complicated web of regulations for students and supervisors.” Among the proposed solutions: improving licensing technology.  

Among the challenges all states face, according to the report: national and international licensing boards allow states to make modifications to their credential requirements. That can hamper reciprocity, which facilitates the movement of much-needed workers across state lines. 

The report also found the state had made progress helping applicants get to work more quickly through the use of temporary permits.

The N.H. Office of Professional Licensure and Certification (OPLC), which oversees the state’s 47 occupational licensing boards, plans to file standardized rules this fall to help streamline the licensing process, Executive Director Lindsey Courtney said in an email.

The OPLC also believes LADC rules should be redrafted, Courtney said, and that may be happening. According to the LADC website, the board appears to be in the process of reviewing and revising licensing and certification rules. 

Greater Nashua Mental Health’s Whitaker said the state’s move to include mental health training for MLADC certification was a major step in the right direction.

“Any substance use provider who is not able to treat the potential root cause of trauma or depression can only treat somebody so far,” she said. “They might be able to help them with the tip of the iceberg. It's going to show back up if they don't get to that root cause.”

She said another possible solution for addressing the divide between fields is for both the mental health and drug and alcohol licensing boards to require reciprocal training. “How do we refer to one another, work together, be more collaborative?”

The pandemic has underscored the need for such collaboration, Whitaker said. One survey found that 70% of Americans say the pandemic has negatively affected their mental well being, she said. “At the same time we're seeing a record number of overdoses and more alcohol and drug use,” she said. “How can we not think those two things are related? With that kind of national spotlight, we can no longer deny the connection between mental well being and addiction or alcohol and drug use.”

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.