1. 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.

2. 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

3. 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 (
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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Questions?