How Behavioral Health Care Has Changed Since the Opioid Crisis

Throughout the 1980s and 1990s, drug use was one of the biggest hot-button issues in the U.S. The widespread presence of programs such as the police-directed D.A.R.E. in schools and the prominence of ad campaigns like "Just Say No" shaped a generally negative perception of drug addiction.

The War on Drugs also peaked during this era, although its origins extended well back to the early 20th century, when substances such as marijuana and heroin were initially restricted. Another watershed moment was the passage of the Comprehensive Drug Abuse Prevention and Control Act of 1970, which mandated recordkeeping and categorization of all pharmaceuticals based on their addictiveness.

The History of Opioid Crises in the US

While there has been significant cultural evolution since that time, as demonstrated by the spread of marijuana legalization in many states, more progress is necessary to align addiction treatment guidelines and practices with the current opioid crisis. Opioids have extensive histories as both prescribed and illicit drugs, and the fundamental challenge they present – as uniquely powerful analgesics that are nevertheless highly addictive – has long bedeviled the healthcare sector.

For example, opioids were liberally dispensed during and after the Civil War, for every condition from chronic pain to menopausal discomfort, according to a report from the Substance Abuse and Mental Health Services Administration and the Center for Substance Abuse Treatment. Opioid prescriptions were eventually curbed as more people entered sanatoriums struggling with addiction.

However, the marketing of heroin as a legitimate cough suppressant and the proliferation of hypodermic drug delivery created a new wave of problems in the 20th century. Early responses included the passage of the Harrison Narcotic Act of 1914 requiring opioid labeling, the establishment of specialized facilities such as New York's Riverside Hospital and the development of substances such as methadone, levo-alpha acetyl methadol, buprenorphine and naltrexone.

These efforts laid the groundwork for modern opioid treatments combining regulatory and medical dimensions, plus they were quantum leaps beyond the unscientific cures delivered in 19th century sanatoriums. There's still work to be done in improving opioid treatment, though. Consider the following two contrary trends:

• First, drug overdoses, driven by opioids like fentanyl and similar compounds, are now the leading cause of death among Americans under 50, according to the U.S. Centers for Disease Control and Prevention (CDC). At least 59,000 people died from drug overdoses in 2016, putting the total above peak deaths from car crashes, guns and HIV, all of which were reached decades ago.
• Second, deaths per 100,000 individuals from cardiovascular disease were cut in half between 1980 and 2014, thanks to improved treatment and healthcare access, according to FiveThirtyEight. Moreover, heart disease is always categorized and treated as a medical problem rather than as a wrongdoing to each patient afflicted with it.

To eventually make the opioid trendline resemble the one for cardiovascular disease, health system stakeholders including providers, insurance plans and governmental agencies must invest heavily in behavioral health initiatives. Early progress on this front is leading to positive results, but more collaboration, funding and treatment will be critical to reverse the current trend.

Opportunities to Curb Opioid Deaths Among Behavioral Health Patients

Opioid prescriptions quadrupled from 1999 to 2015, according to the CDC. At the same time, this massive increase has disproportionately affected specific populations, namely those with mental illnesses and residents of rural and under-served areas.

According to a study in the Journal of the American Board of Family Medicine, patients with mental health disorders receive half of the 115 million opioid prescriptions issued each year. The relationship between mental illness and opioid consumption is complex, but one hypothesis is that opioids may provide relief from both the mental and physical pain experienced by affected individuals. Additionally, mental illness may complicate the perception of pain, which is already inherently subjective. Without any consistent, objective framework for assessing pain in individuals (although it is sometimes regarded as a vital sign, pain can't be objectively measured like pulse or blood pressure), physicians may overprescribe opioids to mentally ill patients, increasing the probabilities of fatal overdoses.

New models of pain management have shifted the conversation around opioid prescription.

An anesthesiologist speaking to Kaiser Health News stated as much, while a psychiatrist in the same article claimed that opioids were not effective long-term treatment of pain for these patients and should be bypassed in favor of alternatives such as behavioral interventions. There is great variation from patient to patient as to why opioids are prescribed, how patient prescription adherence is monitored, and the long-term goals of opioid use, which makes tackling this crisis a complicated endeavor.

Independent medical review is one valuable tool for assessing the necessity of opioid treatment based on the specific details of a patient's record and history of opioid use. At Advanced Medical Reviews (AMR), an independent medical review organization, a nationwide network of state- and specialty-matched physician reviewers assesses opioid prescriptions and usage for medical necessity, based on current, evidence-based behavioral health guidelines.

As Megan Kaufman, General Manager of AMR, explains, "The opioid crisis has been one of the most alarming public health issues of the last decade. At AMR, our work depends on our physician reviewers and all our staff keeping informed of the latest guidelines, regulations and recommendations of care. Our services - independent medical reviews - are a piece of a larger effort to ensure that patients receive quality healthcare. Our contributions are one way that patients, providers, policy makers, and the industry at large can continue to evolve our understanding of what works best for those that suffer from or may be at risk of addiction."

There are quite a few factors that are important to note when looking at how we got here. For example, mental healthcare services are not easily accessible everywhere. Rural America has higher opioid addiction rates than suburban or urban parts of the country, a problem compounded by its shortage of providers. In 2016, there were fewer than 10 in-patient psychiatric facilities in Maine for treatment of mental illnesses. Patients' proximity to these facilities are also a factor in states like Nebraska, according to VICE.

Expanded access to behavioral health treatment, in tandem with greater use of alternative therapies, present a few viable opportunities to prevent thousands of overdose deaths each year. There have been changes in the recommendations, guidelines and processes deemed suitable for behavioral health patients, from the CDC to municipal governments, that have helped recalibrate how healthcare providers and payers approach treatment.

New Approaches to Opioid Management for Behavioral Health Patients

The CDC recommends specific tactics for achieving better outcomes for behavioral health patients amid the opioid epidemic, including:

• Improved guidance for distinguishing drug use from abuse and overdosing, to direct individuals to the right facilities and services.
• Adherence to safer prescribing practices by physicians, along with increased training in naloxone administration by first responders to treat an overdose.
• Broadened initiatives for treating addiction and reducing unsafe injections that lead to HIV and Hepatitis C infections.
• Considering alternatives, including cognitive behavioral therapy, exercise and more effective/less risky pain medications such as acetaminophen and ibuprofen.

Populations at risk from opioids have already benefited from the increasing availability of naloxone without a prescription at major pharmacies in more than 40 states. The Health Resources and Services Administration also announced a $200 million investment in health centers and rural health organizations to boost access to mental health services as well as substance abuse treatments.

A new approach to behavioral health patients with drug addictions has been a critical need for years, and the opioid crisis has heightened the urgency of finding a feasible way forward. There are signs of positive developments, and close coordination between healthcare providers, payers, utilization review partners and government officials will be essential to sustaining this momentum.