Patients with opioid use disorder often present with multiple, complex health conditions and may have unique needs. For example, it is very common for individuals with substance use disorders to have co-occurring mental health disorders. Research suggests that more than 40 percent of individuals in treatment for misuse of prescription painkillers have symptoms of or a diagnosable mental health disorder, with depression or anxiety being most common.1 The National Institute on Drug Abuse (NIDA) reports that individuals with a heroin use disorder often have nicotine dependence (66%), alcohol use disorder (25%), or cocaine use disorder (20%).1
Mental illness and substance use disorders have common genetic and environmental risk factors. Having a mental illness may contribute to substance misuse, as some people may use drugs or alcohol to self-medicate.2 While patients may feel temporary relief, substance use can exacerbate mental health symptoms.1 Similarly, substance use may change an individual’s brain structure or chemistry, which contributes to developing a mental health condition.2
Because of the high rate of comorbidity between mental health and substance use disorders, providers would ideally take a comprehensive approach that identifies and assesses both.2 It is important to know about other conditions that may jeopardize the health of individuals with opioid use disorder and their success with medication-assisted treatment (MAT). While some providers or practices will not be ready or able to offer additional mental health or substance use services, providers should screen for these conditions and try to connect patients with appropriate treatment.
Providers aim to identify patients with opioid use disorder and co-occurring behavioral health disorders by incorporating screenings for mental health and substance use conditions into the initial comprehensive patient assessment. Patients who screen positive are connected with additional treatment for these conditions.
How Do You Do It?
Identify Co-Occurring Mental Health or Substance Use Disorders
The presence of comorbid behavioral health conditions can significantly affect a patient’s engagement in treatment, adherence to treatment plans, and patient-provider interactions. Also, it can be challenging to properly diagnosis and treat comorbid disorders because it may be difficult to determine the underlying cause of overlapping symptoms.1
Screening for mental health or substance use disorders may occur at the initial intake as it can help identify certain triggering symptoms and may help identify a co-occurring disorder. Providers should consider observing patients and potentially rescreening them after they have abstained from opioid use for a period of time to help differentiate between the symptoms of substance intoxication or withdrawal and comorbid mental health disorders.1
At a minimum, providers should screen for these behavioral health conditions:
- Depression—Patient-Health Questionnaire (PHQ-9) (PDF—480 KB)
- Anxiety—Generalized Anxiety Disorder 7-item (GAD-7) (PDF—240 KB)
- Post-Traumatic Stress Disorder (PTSD)—Primary Care PTSD Screen (PC-PTSD) (PDF—750 KMB) or Life Events Checklist (LEC) (PDF—120 KB)
Other psychiatric disorders or mental health conditions that may affect a patient’s well-being and treatment for opioid use disorder include bipolar disorder, attention-deficit/hyperactivity disorder, borderline personality disorder, and antisocial personality disorder.
As discussed in the earlier section on Screening and Diagnosis of opioid use disorders, the following screening tools can be used to identify those with or at risk for substance use disorders across several conditions:
- Alcohol Use Disorders Identification Test (AUDIT) (PDF—224 KB)
- Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS)
- Alcohol Smoking and Substance Involvement Screening Test (ASSIST) (PDF—332 KB)
- NIDA-Modified ASSIST: Quick Screen (NM ASSIST)
- CAGE-AID (PDF—30 KB)
- Drug Abuse Screening Test (DAST) - 10
Provide or Connect Patients With Care
After a patient screens positive for a co-occurring behavioral health disorder, providers should gather additional information that can help inform treatment planning. This assessment should seek to3:
- Obtain a more detailed history of past mental health or substance use symptoms, diagnoses, treatments, and impairments;
- Screen for suicide risk, as risk of suicide is increased substantially among individuals with behavioral health disorders (see the next section on Suicidality for more details);
- Understand the patient’s current strengths, supports, challenges, skill deficits, and cultural needs or preferences; and
- Determine the patient’s readiness to engage and goals for treatment.
Based on the patient’s needs and preferences, providers should try to connect the patient with the appropriate treatment, whether these services are internal or external, and adjust the treatment plan as needed.
Treatment of co-occurring disorders often incorporates cognitive behavioral therapy (CBT), which helps strengthen interpersonal and coping skills. A number of platforms and applications are available that provide internet-based CBT through a computer or mobile device. These tools may be particularly useful in areas in which behavioral health services are hard to access or are unavailable.
Other behavioral therapies that have shown promise in treating co-occurring mental health and substance use disorders include dialectical behavioral therapy, acceptance and commitment therapy, and contingency management.2 In particular, PTSD may be a condition that not only requires additional, specialized treatment from another mental health provider, but also requires MAT providers and programs to take a trauma-informed approach, as discussed earlier in the Playbook.
In the past, providers would sometimes take a “sequential” approach to the treatment of co-occurring disorders, addressing only one disorder at a time. A preferred approach for patients with interrelated conditions is to develop one care plan with elements to address each condition. Treatment of co-occurring behavioral health disorders may be4:
- Parallel—Patients are treated at the same time for both co-occurring disorders in different settings. Collaboration and care coordination between providers will be key if patients are receiving parallel treatment.
- Integrated—Integrated care is a “whole person” approach that blends care for multiple conditions in one setting. Providers and the patient work together as a team to develop treatment plans and manage the patient’s needs and are ideally cross-trained in both mental health and addiction.
What Not To Do
- Don’t think of mental health and substance use disorders as separate conditions that require separate treatment. It’s important to remember that they may drive one another or impede a patient’s long-term success if untreated.
- Don’t withhold diagnosis or treatment of patients’ mental health disorder until they have stopped using opioids. Sometimes, both will need to be addressed at the same time to help a person stop using opioids.
Treatment Improvement Protocol (TIP) 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders
Pharmacologic Guidelines for Treating Individuals With Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders
- National Institute on Drug Abuse. Common Comorbidities With Substance Use Disorders. Bethesda, MD: National Institutes of Health; 2018. https://www.drugabuse.gov/node/pdf/1155/common-comorbidities-with-substance-use-disorders. Accessed June 11, 2019.
- National Institute on Drug Abuse. Comorbidity: Substance Use Disorders and Other Mental Illnesses. Bethesda, MD: National Institutes of Health; 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/drugfacts-comorbidity.pdf. Accessed June 11, 2019.
- Substance Abuse and Mental Health Services Administration. TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders. Publication No: SMA13-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. https://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA13-3992. Accessed June 11, 2019.
- Foundations Recovery Network. Chapter 3—Mental Health and Addiction Treatment Systems: Philosophical and Treatment Approach Issues. Brentwood, TN: Foundations Recovery Network; n.d. https://www.dualdiagnosis.org/resource/patient-assessments/treatment-systems/