All of Us

Mental Health and Substance Abuse

by Mike Critelli

Opioid related deaths skyrocketed during the pandemic. According to the Center for Disease Control, there were nearly 92,000 drug overdose deaths in 2020, a 30% increase from the prior year. Overdose deaths spiked up again in the first half of 2021. An examination of causation produces a multitude of reasons:

  • Progression from addictive prescription opioids to heroin to fentanyl

  • Availability - the result of more active drug cartels across Mexican borders into the United States, and more lucrative drug trafficking opportunities in heroin and fentanyl

  • Public policy and institutional leaders such as corporate CEOs, educational system leaders, healthcare system CEOs, and military leaders lack a comprehensive culture of health strategy.

The opioid crisis has a direct correlation with mental health issues, obesity, and other health concerns. Isolation and loneliness caused by the various Covid-19 lockdowns have seemingly exacerbated mental health disorders, triggering an increased incidence of substance abuse and related behaviors, such as domestic abuse and suicide. Contributing to these stress levels are politically divisive news outlets promoting fear mongering for ratings. The coping mechanisms for some when dealing with this fear, anxiety, and burnout have led to the abuse of various “self medicating” substances. 

Unfortunately, the U.S. healthcare system is currently not designed to address these issues, instead unintentionally acting as a contributor to the opioid crisis. The current standards of care, payment systems,and regulatory provisions promote:

  • Over-reliance on opioid medications, incentivizing quick, simplistic answers to complex physical and mental health needs.

  • Withdrawal of popular nonopioid analgesics due to cardiovascular risk and acetaminophen toxicity.

  • An inability to access a treating physician, leading to finding drugs from alternative, more dangerous sources.

  • The transition to heroin and fentanyl, sadly often easier and less expensive to procure, because of tighter controls on the prescribing of opioids.

What does a future combating this crisis and shifting the statistics from increasing to decreasing entail? A different approach to pain, both mental and physical: 

  • Addressing obesity that causes and/or worsens musculo-skeletal injuries. 

  • Reducing common, daily, stress and pain disorders with improved ergonomics, with a focus on more stretching and movement. 

  • Better training fitness counselors and more education to assist individuals with chronic pain. 

  • Further training and education regarding the rehabilitation processes before and after surgery. 

For severe illnesses, alternative therapies are needed to produce less pain and need for longer management. Guided rehab managing pain more precisely after surgeries with more appropriate recovery times will be essential. 

Under certain conditions, pain is a signal of another pathology, such as diabetic neuropathy. Excessively powerful pain relievers hinder better monitoring of these conditions. This validates incorporating a broader range of pain management techniques. These include:

  • Physical therapy. 

  • Yoga. 

  • Meditation. 

  • VR tools. 

Regarding the necessary staff to implement this new structure, one option is to redeploy mental health and substance healthcare professionals working in prisons to community healthcare settings, and to move that part of the jail and prison population requiring mental health and substance abuse treatment therapies to these settings. 

In addition to restructuring of healthcare professionals, there are significant care gaps that need to be addressed and restructured regarding Medicaid. The current system makes long term recovery difficult and demonstrates the lack of priority for mental health as a chronic condition. Such issues that need to be addressed include:

  • Complicated coverage rules for payment for institutional mental health services rendered in non-psychiatric hospitals lead to a disservice for those in need of therapeutic assistance. 

  • Medicaid doesn't pay for care provided for more than 15 days a month in “institutions for mental disease” (IMDs), which are psychiatric hospitals or other residential treatment facilities that have more than 16 beds.

  • The need to deploy the best available data resources on off-label therapies for mental health and chronic pain issues, such as tricyclic antidepressants for painful diabetic neuropathy, providing equitable coverage for them and revisiting standards of care that inappropriately exclude them.

  • Medicare patient satisfaction survey pain management questions have created the unintended consequence of over-prescribing.

Mental health and substance abuse conditions need to be destigmatized. With a more open dialogue, those in need of help may be more willing to ask for it. With a step by step approach to addressing this multifaceted crisis, the negative statistics can turn in a more positive direction. As a first-world country with access to the top doctors, medicine, and technology in the world, the number of people suffering should be decreasing, not increasing.

Comments by Charter Member Dr. David Seitz, MD: 

Relative to progression and availability, Dr. Seitz notes:

Although the drug cartels are involved, of course, the medical/legislative establishment has made the problem worse. By adopting the Prescription Monitoring Program, disciplining "bad" doctors, etc. the patients who were getting low-potency opioids "legitimately" (meaning from physicians) had nowhere to turn other than the streets. The cartels took advantage of that which led us to where we are today.

Dr. Seitz made this comment about his efforts to convince lawmakers that the Prescription Monitoring Program, although well intentioned, would have serious unintended consequences:

I…explained that if this were to be put into effect, one needed to consider what patients would do when their source of opioids (their physicians) was removed and drug treatment and pain management were not part of the plan.

He made this comment about the tendency of lawmakers, the media and the public to want quick-fix solutions to complex chronic disease issues. Mental health and substance abuse issues are not usually acute conditions that, when treated, lead to a permanent “cure.” They are chronic conditions that require long-term, active, collaborative management by patients, their families, and caregivers.

It seems we gravitate towards easy and incomplete solutions - rather than take on the burden of a lengthy but eventually successful process where we move forward incrementally, keeping our eyes open and our expectations reasonable.

In this comment, he pointed out one of the obstacles that needs to be removed if we are to explore a wider range of therapies for both mental health and substance abuse patient treatment:

You mention off-label prescribing as well as non-traditional (non-Western) therapies. Both are important, but litigious states like NY pose a problem for physicians as such therapies are not considered "standard of care" and malpractice lawsuits loom large in a state with no caps on rewards.

In effect, even if patients are willing to pay and/or insurance carriers or self-insured employers are willing to pay for a broader range of mental health and substance abuse therapies, policymakers who want to take steps to make these options available have to address “standards of care” issues that arise in medical malpractice litigation.