Kaiser Permanente Institute for Health Policy ADDRESSING THE CHALLENGES OF SERIOUS MENTAL ILLNESS AND THE OPIOID CRISIS: A COURSE CORRECTION Elinore F. McCance-Katz, MD, PhD Assistant Secretary for Mental Health and Substance Use Substance Abuse and Mental Health Services Administration Kaiser Permanente Institute for Health Policy November 6, 2017 Washington, D.C.

MENTAL AND SUBSTANCE USE DISORDERS IN AMERICA: 2016 2016 National Survey on Drug Use and Health MENTAL AND SUBSTANCE USE DISORDERS IN AMERICA: 2016 PAST YEAR, 2016, 12+ Among those with a mental illness about: 1 IN 4 (25%) had a serious mental illness Among those with a substance use disorder about: 1 IN 3 (33%) struggled with illicit drugs 3 IN 4 (75%) struggled with alcohol use 1 IN 9 (11%) struggled with illicit drugs and alcohol 3.4% (8.2 MILLION) 18+ HAD BOTH substance use disorder and a mental illness 7.5% (20.1 MILLION) People aged 12 or older had a substance use disorder 18.3% (44.7 MILLION) People aged 18 or older had a mental illness .3% .2% *No statistically different changes from 2015

Major Challenges of Our Time Serious Mental Illness Over 4 million Americans affected by psychotic disorders, serious major depression—35% get no treatment at all Jails and prisons have become de facto mental institutions Over 2 million in jails and prisons 50% with SUDs (http://www.prisonerhealth.org) 15-20% with SMI (Torrey EF, et al. 2014) Opioid Crisis: Over 2 million Americans addicted to prescription pain medications and/or heroin Over 63,000 drug overdose deaths in 2016

Congress’ Creation of Assistant Secretary for Mental Health and Substance Use 21st Century Cures Act: Section 6001: Establishes an Assistant Secretary for Mental Health and Substance Use to head SAMHSA Requires the Assistant Secretary to: Maintain a system to disseminate research findings and EBP to service providers to improve prevention and treatment services Ensure that grants are subject to performance and outcome evaluations; conduct ongoing oversight of grantees Consult with stakeholders to improve community based and other mental health services including for adults with SMI and children with SED Collaborate with other departments (VA, DoD, HUD, DOL) to improve care to veterans and service members and support programs to address chronic homelessness Work with stakeholders to improve the recruitment and retention of mental health and substance use disorder professionals

Recognition of Need by President Trump Opioid crisis: HHS developed plan of action immediately upon taking office; steadfast implementation Appointed commission to provide further recommendations and guidance Serious mental illness: Recognition of need for treatment, need for expansion of court-ordered treatment Need to address medical communication needs of families

Refocusing of SAMHSA Maintain a system to disseminate research findings and EBPs to service providers to improve prevention and treatment services Small agency/small budget/big job: requires a focus on the most seriously ill/tackling the biggest issues in behavioral health: People living with SMI Opioid Crisis

SMI: Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) Public/Federal partnership to review current issues in addressing SMI, federal program review, and recommendations to Congress for better coordination of SMI and SED services at SAMHSA and other agencies Assure programs incorporate best practices/EBPs for treatment of SMI: Psychotropics/psychotherapies ACT/FACT, crisis intervention, hospital beds, AOT CJ diversion program expansion Peer support, Housing, Employment

National Mental Health and Substance Use Policy Laboratory Will promote evidence-based practices and service delivery models through evaluating models that would benefit from further development and through expanding, replicating or scaling EBPs across a wider area Main focus on SMI: particularly schizophrenia and schizoaffective disorder as well as other serious mental illnesses Focus on EBP and service models for substance disorders with focus on OUD Closer relationships with NIH

Priorities: SMI Early Intervention/Ongoing support: FEP programs, ACT, crisis intervention programs Integrated care to meet both mental and physical health needs in one setting Diversion from incarceration to care Access to care: parity Transitional Age Youth Effective medical treatment of psychosis: TA/Centers of Excellence Clozapine for treatment refractory schizophrenia Long acting medications AEs: Metabolic syndrome/Medical illnesses/Tobacco/Co-occurring SUDs Suicide Prevention Understanding links between poorly treated pain/depression/addiction/suicidality Zero suicide; Focus on veterans and service members

OPIOID CRISIS: A PUBLIC HEALTH EMERGENCY HHS Five-Point Opioid Strategy Strengthening public health surveillance Advancing the practice of pain management Improving access to treatment and recovery services Targeting availability and distribution of overdose-reversing drugs Supporting cutting-edge research 1 2 3 4 5

SAMHSA/HHS: Ongoing Programs Addressing the Opioid Crisis Support for evidence-based prevention, treatment, recovery services for opioid use disorder STR grants to states Block grants to states* TA to states/providers/other federal agencies (HRSA, IHS, DOJ) on EBP: MAT, psychotherapies, PDMP, toxicology screens* Naloxone access/First Responders/Peers Pregnant/post partum women/NAS CJ programs with MAT* Recovery Coaches* Training programs: ATTCs, PCSS, CIHS Family inclusion in medical emergencies: overdose

HHS: Ongoing Programs Addressing the Opioid Crisis CDC/OASH: Consumer communication campaign Enhanced PDMP programs, interoperability, integration into EHR, flagging of overdose risks Safe and appropriate opioid prescribing Guidelines for use of opioids in chronic pain Committee to address pain management issues Prescriber education National Center for Health Statistics: more timely data release of monthly overdose death statistics Public health technical assistance: community education, prevention efforts HRSA, IHS: direct clinical services NIH Research on new treatments for OUD; non-opioid analgesics

Workforce Development Continue SAMHSA training initiatives: ATTCs, PCSS-type programs DATA waiver training in pre-graduate settings: Medical, advance practice nursing, physician assistant programs Encourage national certification programs for peer workforce With HRSA: Encourage entry to the field through incentives: e.g.: loan forgiveness programs: NHSC Integration of BH including OUD treatment into primary care/FQHCs

Priorities: Opioid/Other Substances Work with states on program development for OUD: Establishment of EBP in clinical settings MAT and psychosocial therapies with community recovery supports Enhanced TA: Clinician/state government partnerships Review of SAMHSA initiatives with other substances

How will we Know What We’re Doing is Working How will we Know What We’re Doing is Working? Performance and Outcome Evaluations CBHSQ/Policy Lab: Internal Review of data collection systems and ability to evaluate: e.g.: NSDUH GPRA data collection system Review process of how evaluations are conducted Begin process of OMB approval for outcome variables ahead of FOAs External evaluation: NIH,CDC, ASPE collaborations

Stakeholders and SAMHSA Establish a partnership with stakeholders that includes a core set of common goals that all can represent to their communities/states/Congressional reps Agree that there will not be enough BH providers in the foreseeable future so work together to fund training in all BH specialties and increase access to care Bring in new stakeholders with aim of increasing workforce Work together toward parity for treatment of MH/SUD Bring these perspectives to federal government Consistent message of advocacy

Assistant Secretary Wishlist Access to evidence-based behavioral healthcare MAT and psychosocial services available nationally without delays Community behavioral health centers that focus on SMI Develop a strong partnership between psychiatric medicine and community recovery supports/peers Increase SAMHSA assistance to families: focus SMI/opioids Prioritize supported housing for those affected by SMI/SUD Eliminate criminal records for minor drug offenses Effective interventions in BH for transitional age youth Control the swing of the pendulum as regards opioid analgesic prescribing

Questions?