About the Toolkit

Facts about COD1

About one-third of those with a mental illness have binged on alcohol in the past month, and 13.8 percent of those with a serious mental illness have used opioids in the past year.

Co-occurring substance use and mental health disorders (COD) can have devastating effects for the individuals and loved ones they affect.

  • Among clients receiving services in public mental health settings, up to 10 percent may have an opioid use disorder.2
  • Of 19.3 million adults with a substance use disorder (SUD) in 2019, 49 percent had a co-occurring mental illness.
  • People with COD are more likely to experience
    • Higher health care and social costs
    • Homelessness
    • Poorer treatment outcomes
    • Incarceration

Compounding these issues is the fact that 91.7 percent of people with co-occurring substance use disorder and mental illness do not get treatment for both disorders.

FDA-approved pharmacotherapies for alcohol and opioid use disorders are effective, cost-effective, and can enhance behavioral therapies to improve patient outcomes. Still, they have not yet been widely adopted, even in primary care and specialty treatment settings. This toolkit focuses on connecting mental health clinics with the necessary steps, tools, and information to incorporate pharmacotherapy for people with co-occurring alcohol use disorder (COD-alcohol) and co-occurring opioid use disorder (COD-opioid).

Unfortunately, evidence-based pharmacotherapy treatments for other SUDs, such as cocaine or methamphetamine use disorders, do not yet exist, so we do not address other SUDs in this toolkit.

We developed this toolkit to help connect vulnerable and underserved adult populations with the most-effective treatments in the places where those with mental illnesses are most likely to access care: public mental health settings.

Epidemiologic data indicate that most clients with co-occurring disorders are far more likely to receive mental health care (50 percent) than substance use treatment (20 percent).

Why pharmacotherapy?

Pharmacotherapy improves COD client outcomes when compared with counseling or support without medication treatment.

This toolkit focuses on evidence-based pharmacotherapies that are approved by the U.S. Food and Drug Administration (FDA) and that can help clients with COD.

In combination with psychosocial treatment, pharmacotherapy for COD includes long-acting injectable naltrexone, oral naltrexone, acamprosate, and disulfiram (for COD-alcohol) and buprenorphine and long-acting injectable naltrexone (for COD-opioid).

Mental health settings are likely to have psychiatrists, nurse practitioners, and other medical providers on staff, reducing the human resource barriers to incorporating pharmacotherapy treatment.

Is implementing pharmacotherapy to treat patients with COD viable for your clinic?

Before making the decision to integrate or expand COD care by using pharmacotherapy for SUDs at your mental health clinic, you’ll need to assess your clinic’s regulatory and financial environment to determine whether this process will be viable.

Consider these questions to determine viability:

  • What are the local regulations and documentation requirements for substance use treatment provision in your setting?
  • Are these medications available to your patient population?
  • Does your payer mix support substance use treatment?
    • Is pharmacotherapy covered (e.g., long-acting injectable naltrexone)?
    • Are prior authorizations needed?
    • What can be reimbursed (consider trainings, documentation, medication, psychosocial support)?

What real clients are saying

Here’s what some some mental health clinic clients had to say about pharmacotherapy and the potential to receive treatment for a substance use disorder at their mental health clinics.

On taking medications for COD

  • "I became aware of how I had to work on the mental health and the drug and alcohol together, that my awareness was what made it successful."
  • "I didn't think I'd need pharmaceuticals but did have a lot of mental health issues. . . . I did find the right kind of medicine and have been doing a lot better since. So that kind of proved me wrong because I didn't think I could rely on pharmaceuticals to help me in my life."

On receiving COD care at a mental health clinic

  • "[It] would be like a one-stop shop. Instead of going to three different places, now I could just go to two—my primary and my mental health."
  • "[It would be] nice having an all-in-one visit . . . you wouldn’t get conflicting information where one doctor might say something, [and] another one might say something that contradicts it. You’re getting all the information through one source."

Related COD-alcohol publications

Methodology

We used implementation science approaches and organizational theory to guide the development of this toolkit. According to these approaches, there are several steps to take to plan for the effective delivery of an evidence-based practice, including assessing needs, establishing goals, identifying approaches to meet the needs and goals, and modifying the practice to address the context and resources.

To begin to assess the overall needs, context, and resources of public mental health clinics, we conducted interviews with administrators, surveys of and focus groups with clinical staff, and surveys of and focus groups with clients obtaining care in community mental health clinics within the Los Angeles County Department of Mental Health (LACDMH). LACDMH is one of the largest public mental health systems in the United States, with eight service planning areas covering 4,752 square miles, and including ethnically and racially diverse urban, suburban, and rural populations.

We queried staff about the need for pharmacotherapy to treat alcohol and opioid use disorders in their settings, including what resources were needed for implementation and/or what resources they found helpful to address SUDs with medications. We asked clients about their perceptions of pharmacotherapy and supportive care for their COD at the mental health clinic to better understand what their concerns were and what information they would like to help them make decisions about engaging in treatment.

We collected these data from clinic administrators, staff, and patients to identify facilitators and barriers to delivering medication for SUD treatment in these settings.

We then scanned existing literature, implementation tools, and provider or clinic resources to address the identified facilitators and barriers and adapted existing resource materials or created our own if needed resources did not exist.

We then developed the toolkit; presented it to a stakeholder workgroup within LACDMH that consisted of leadership, program heads, and practitioners; and modified it as we obtained feedback. As a final step, we conducted usability testing and obtained quality assurance review from co-occurring mental health and substance use treatment experts from across the United States to ensure that the toolkit was generalizable to a diverse group of mental health systems. The next step is to study acceptability, feasibility, and implementation approaches in clinics that are using the toolkit.

The toolkit was created by RAND in partnership with LACDMH and the University of California, Los Angeles (UCLA). RAND is a nonprofit, nonpartisan research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous.

Development of and research reported in this toolkit was supported by the National Institute On Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, both of the National Institutes of Health, under Award Numbers R34DA046950 and R34AA02548. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

See references

Authors

Katherine E. Watkins, Allison J. Ober, Sarah B. Hunter (RAND)

Brian Hurley (Los Angeles County Department of Health Services)

John Sheehe, Jeremy Martinez (LACDMH)

Elizabeth Bromley, Derjung M. Tarn, Ivan Beas, Alanna Montero, Michael McCreary (UCLA)

Erika Litvin Bloom, Catherine C. Cohen, Maria Gardner, Isabel Leamon (RAND)

Acknowledgments

We would like to acknowledge the following individuals who assisted in the development of this toolkit:

LACDMH: Lisa Benson, Curley Bonds, Yen-jui “Ray” Lin, Andrew Tunks, and members of the COD workgroup. We also thank staff and clients who participated in focus groups, interviews, and/or surveys that were instrumental in designing the toolkit. These staff and clients were from the following LACDMH clinics: Antelope Valley, Arcadia, Compton, Downtown, East San Gabriel, Edelman, Northeast, Rio Hondo, Santa Clarita, South Bay, and West Central.

RAND Corporation: Sarika Bharil, Emily Cantin, Chris Ivany, Praise Iyiewuare, Colleen McCullough, Peter Mendel, Haley Okuley, and Mahlet Tebeka.

We would also like to thank our usability testing participants, including Dr. Flavio Casoy from the New York State Psychiatric Institute and Dr. Joe Sepulveda from the Hillcrest Family Health Center.

We are also indebted to our quality assurance reviewers, including Sherry Larkins at UCLA, Heather Gotham at Stanford, and Audrey Burnam, Alex Dopp, Jeanne Ringel, and Paul Koegel at RAND.

Notes

1 Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health, Rockville, Md., HHS Publication No. PEP20-07-01-001, NSDUH Series H-55, 2020a.

2 Ober, A. J., S. B. Hunter, C. M. McCullough, I. Leamon, M. McCreary, I. Beas, et al., “Opioid Use Disorder Among Community Mental Health Clinic Clients: Prevalence, Characteristics and Treatment Willingness,” Psychiatric Services, forthcoming.

References