Comprehensive Services for People With Co-Occurring Disorders: A NACo Opioid Solutions Strategy Brief

adult in therapy session

Upcoming Events

Webinar

Bridging Gaps: Collaborative Strategies for Supporting Youth Reentry Through Medicaid

Related News

Press Release

National Association of Counties Launches Disaster Reform Task Force

News

Application deadline approaching for NACo's Criminal Justice Coordinating Councils Peer Exchange

County News

North Carolina county decreases 911 non-emergency calls by connecting residents to services they need

What are comprehensive services for people with co-occurring disorders?

Co-occurring disorders are any combination of mental or substance use disorders (SUDs) that affect someone at the same time. People who live with co-occurring disorders, including post-traumatic stress disorder, anxiety, depression, bi-polar disorder and ADHD, are at greater risk of developing opioid use disorder (OUD).1–3 Similarly, people with OUD are at greater risk of developing co-occurring disorders.4,5

Comprehensive services integrate multiple forms of substance use, mental health and case management services and may include:

  • Evidence-based treatments for SUD6–8
  • Integrated SUD and mental health treatment services9
  • Housing support through a Housing First approach10
  • Transportation support11
  • Employment and educational services12–14
  • Income support15
  • Social support and peer recovery services16
  • Legal services,17 and
  • Child care.12

What evidence supports comprehensive services for people with co-occurring disorders?

Comprehensive services are proven to produce better outcomes for people with co-occurring disorders.18–20 The most effective treatment modality for co-occurring disorders is integrated SUD and mental health care.18–20 This is especially true for people with co-occurring SUDs20 and those who engage in mental health care prior to initiating SUD treatment.21–24

Strong scientific evidence supports the integration of multiple behavioral health and case management services for people with co-occurring disorders.

  • Medications for opioid use disorder (MOUD): FDA-approved medications are the gold standard treatment for OUD, proven to reduce substance use, prevent overdose and retain patients in care for longer.6,25–27
  • Contingency management: Contingency management is an evidence-based treatment for stimulant use disorders that is endorsed by the National Institute on Drug Abuse (NIDA) and the American Society for Addiction Medicine (ASAM).7,8,28
  • Housing support: Supportive housing options increase engagement and improve outcomes in both SUD and mental health treatment.29,30 Housing First programs offer housing options regardless of ongoing substance use. This approach produces substance use outcomes that are equal to or better than housing options that require sobriety or treatment participation. Further, residents in Housing First programs report less isolation, higher social integration and higher overall quality of life.10,31,32
  • Legal services: Criminal justice involvement is more common among people who use opioids.33 Unresolved criminal justice concerns, such as outstanding warrants, often bar access to housing and other basic needs. Legal services can assist in overcoming these concerns.17
  • Transportation support: Lack of reliable transportation is one of the most significant barriers to SUD treatment for people who are seeking care.34,35 Providing transportation support – including direct payments to taxi or ride share services or reimbursement for mileage or time spent – has been shown to help people stay engaged in SUD and mental health treatment even when the treatment location is far away.11
  • Education and employment services: People living with current or past OUD are more likely to be facing unemployment.36 When provided as part of a holistic suite of recovery services, educational services – including vocational counseling – predict higher rates of employment among adult participants.12,37
  • Child care services: Family-oriented systems of care, which allow parents to reside with their children while in residential treatment or managed housing, improve treatment outcomes for pregnant and parenting people.38 Similarly, the availability of child care services significantly improves access to and uptake of integrated SUD and mental health services among female patients.12

Are there risks to my community if we don’t implement comprehensive services for people with co-occurring disorders?

Yes.

People with mental health disorders are significantly less likely to receive life-saving MOUD when they need it due to treatment silos, social stigma and other systemic barriers to care.4,18,39–42

Certain populations are especially vulnerable, including young people, military veterans, pregnant and parenting people, rural residents with OUD and persons linked to treatment by the criminal justice system.12,34,43–46

Failure to meaningfully address these barriers to treatment and recovery may increase the rate of OUD and overdose among these populations and drive up the utilization of costly crisis services.

What are best practices for providing comprehensive services for people with co-occurring disorders?

  • Assess for polysubstance use and for co-occurring disorders in all standard SUD screens.47,48 
  • Support contingency management services, a proven treatment for stimulant use disorder, alongside MOUD and other recovery supports for those who need it.7,28
  • Develop supportive housing options using a Housing First approach.10,49
  • Create a public facing, comprehensive dashboard of wraparound treatment and recovery services to assist in service navigation and referrals.15 
  • Utilize existing services and funding streams to support the expansion of comprehensive treatment and recovery services, using local tax dollars and opioid settlement funds to meet any remaining need. 

What are some examples of successful efforts to provide comprehensive services for people with co-occurring disorders?

The Maintaining Independence and Sobriety Through Systems Integration Outreach and Networking (MISSION) model is an evidence-based intervention designed to meet the needs of people living with co-occurring SUD and mental health disorders through dual-recovery therapy, peer support, vocational support and trauma-informed care.50 When implemented in tandem with permanent supportive housing, the MISSION model has been shown to significantly improve substance use and mental outcomes and keep people housed.29

The California Department of Healthcare Services recently implemented a Health Homes Program to provide Medicaid-eligible residents with chronic and complex physical and behavioral health conditions (including SUDs) with comprehensive care management, coordinated care delivery, transitional care, family support and access to social support services. Patients who accessed the Health Homes Program showed better engagement in SUD treatment and fewer emergency room visits and hospitalizations. After Medicaid reimbursements, the average cost of operating the Health House Program was less than $500 per person per month.51

Tagged In:

Author

Jennifer J. Carroll, PhD, MPH

Dr. Carroll is a medical anthropologist, research scientist and subject matter expert on substance use and public health. She is currently an Assistant Professor of Anthropology at North Carolina State University.

Additional Resources

Pathways Housing First Institute

Pathways Housing First Institute offers online resources, consultation, virtual and on-site training, and other forms of direct technical assistance to communities seeking to implement the Housing First model.

The MISSION Model

The MISSION Model provides access to practical guides, trainings and webinars for implementing the MISSION Model by request through their website.

Rural Health Information Hub (RHIhub)

RHIhub hosts a comprehensive series of online toolkits to support community leaders and healthcare practitioners in navigating a broad scope of treatment and recovery service models including supportive housing and services for people with co-occurring SUD and mental health disorders.
 

  1. Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence. 2019;197:78-82. doi:10.1016/j.drugalcdep.2018.12.030
  2. Hassan AN, Foll BL, Imtiaz S, Rehm J. The effect of post-traumatic stress disorder on the risk of developing prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. Drug Alcohol Depend. 2017;179:260-266. doi:10.1016/j.drugalcdep.2017.07.012
  3. National Institute on Drug Abuse. Common Comorbidities with Substance Use Disorders Research Report - Part 1: The Connection Between Substance Use Disorders and Mental Illness. National Institute on Drug Abuse. Published April 2020. Accessed March 12, 2024. https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness
  4. Ford BR, Bart G, Grahan B, Shearer RD, Winkelman TNA. Associations Between Polysubstance Use Patterns and Receipt of Medications for Opioid Use Disorder Among Adults in Treatment for Opioid Use Disorder. J Addict Med. Published online August 27, 2020. doi:10.1097/ADM.0000000000000726
  5. Cicero TJ, Ellis MS, Kasper ZA. Polysubstance Use: A Broader Understanding of Substance Use During the Opioid Crisis. Am J Public Health. 2020;110(2):244-250. doi:10.2105/AJPH.2019.305412
  6. Carroll JJ, Asher A, Krishnasamy V, Dowell D. Linking People with Opioid Use Disorder to Medication Treatment. Published online 2022. Accessed June 8, 2022. https://www.cdc.gov/drugoverdose/pdf/pubs/Linkage-to-Care_Edited-PDF_508-3-15-2022.pdf
  7. Brown HD, DeFulio A. Contingency management for the treatment of methamphetamine use disorder: A systematic review. Drug Alcohol Depend. 2020;216:108307. doi:10.1016/j.drugalcdep.2020.108307
  8. Volkow N. Five Areas Where “More Research” Isn’t Needed to Curb the Overdose Crisis. National Institute on Drug Abuse. Published August 31, 2022. Accessed September 9, 2022. https://nida.nih.gov/about-nida/noras-blog/2022/08/five-areas-where-more-research-isnt-needed-to-curb-overdose-crisis
  9. Mueser KT, Gingerich S. Treatment of co-occurring psychotic and substance use disorders. Soc Work Public Health. 2013;28(3-4):424-439. doi:10.1080/19371918.2013.774676
  10. Tsemberis S, Gulcur L, Nakae M. Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis. Am J Public Health. 2004;94(4):651-656. doi:10.2105/AJPH.94.4.651
  11. Whetten R, Whetten K, Pence BW, Reif S, Conover C, Bouis S. Does distance affect utilization of substance abuse and mental health services in the presence of transportation services? AIDS Care. 2006;18(sup1):27-34. doi:10.1080/09540120600839397
  12. Paino M, Aletraris L, Roman P. The Relationship Between Client Characteristics and Wraparound Services in Substance Use Disorder Treatment Centers. J Stud Alcohol Drugs. 2016;77(1):160-169. doi:10.15288/jsad.2016.77.160
  13. Kedia SK, Schmidt M, Dillon PJ, Arshad H, Yu X. Substance use treatment in Appalachian Tennessee amid COVID-19: Challenges and preparing for the future. Journal of Substance Abuse Treatment. 2021;124:108270. doi:10.1016/j.jsat.2020.108270
  14. Degan TJ, Kelly PJ, Robinson LD, Deane FP, Smith AM. Health literacy of people living with mental illness or substance use disorders: A systematic review. Early Interv Psychiatry. 2021;15(6):1454-1469. doi:10.1111/eip.13090
  15. Health Management Associates. Delaware Community Gap Analysis: Opioid Wrap-Around Services. Published online August 2019. Accessed September 18, 2022. https://dhss.delaware.gov/dhss/dph/files/dcga_opioidwasvcs.pdf
  16. Waye KM, Goyer J, Dettor D, et al. Implementing Peer Recovery Services for Overdose Prevention in Rhode Island: An Examination of Two Outreach-Based Approaches. Addict Behav. 2019;89:85-91. doi:10.1016/j.addbeh.2018.09.027
  17. U.S. Substance Abuse and Mental Health Services Administration. Boston’s Homeless Court Provides Legal Assistance. SAMHSA. Published 2020. Accessed September 18, 2022. https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/homeless-court-helps-overcome-barriers
  18. Chan YF, Huang H, Bradley K, Unützer J. Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care. J Subst Abuse Treat. 2014;46(2):106-112. doi:10.1016/j.jsat.2013.08.016
  19. Zaller N, Gillani FS, Rich JD. A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness. AIDS Care. 2007;19(9):1128-1133. doi:10.1080/09540120701335196
  20. Jeffirs SM, Jarnecke AM, Flanagan JC, Killeen TK, Laffey TF, Back SE. Veterans with PTSD and comorbid substance use disorders: Does single versus poly-substance use disorder affect treatment outcomes? Drug Alcohol Depend. 2019;199:70-75. doi:10.1016/j.drugalcdep.2019.04.001
  21. Naeger S, Mutter R, Ali MM, Mark T, Hughey L. Post-Discharge Treatment Engagement Among Patients with an Opioid-Use Disorder. J Subst Abuse Treat. 2016;69:64-71. doi:10.1016/j.jsat.2016.07.004
  22. Amodeo M, Chassler D, Ferguson F, Fitzgerald T, Lundgren L. Use of mental health and substance abuse treatment services by female injection drug users. Am J Drug Alcohol Abuse. 2004;30(1):101-120.
  23. Finlay AK, Stimmel M, Blue-Howells J, et al. Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program. Adm Policy Ment Health. 2017;44(2):177-187. doi:10.1007/s10488-015-0708-z
  24. King VL, Brooner RK, Peirce J, Kolodner K, Kidorf M. Challenges and outcomes of parallel care for patients with co-occurring psychiatric disorder in methadone maintenance treatment. J Dual Diagn. 2014;10(2):60-67. doi:10.1080/15504263.2014.906132
  25. Mattick RP, Breen C, Kimber J, Davoli M. Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2009. Accessed January 30, 2014. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002209.pub2/abstract
  26. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207. doi:10.1002/14651858.CD002207.pub4
  27. Comer SD, Sullivan MA, Yu E, et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006;63(2):210-218. doi:10.1001/archpsyc.63.2.210
  28. American Society of Addiction Medicine. ASAM Urges HHS to Decrease Barriers to Contingency Management for the Treatment of Addiction. ASAM. Published July 6, 2020. Accessed September 15, 2021. https://www.asam.org/advocacy/national-advocacy/standardize-it-delivery-of-care/asam-advocacy-blog/2020/07/06/asam-submits-letter-requesting-hhs-to-support-a-two-year-waiver-for-contingency-management-in-addiction
  29. Smelson DA, Perez CK, Farquhar I, Byrne T, Colegrove A. Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals. J Dual Diagn. 2018;14(4):247-256. doi:10.1080/15504263.2018.1506195
  30. Miller-Archie SA, Walters SC, Singh TP, Lim S. Impact of supportive housing on substance use–related health care utilization among homeless persons who are active substance users. Annals of Epidemiology. 2019;32:1-6.e1. doi:10.1016/j.annepidem.2019.02.002
  31. Kirst M, Friesdorf R, Ta M, et al. Patterns and effects of social integration on housing stability, mental health and substance use outcomes among participants in a randomized controlled Housing First trial. Social Science & Medicine. 2020;265:113481. doi:10.1016/j.socscimed.2020.113481
  32. Nelson G, Patterson M, Kirst M, et al. Life changes among homeless persons with mental illness: a longitudinal study of housing first and usual treatment. Psychiatr Serv. 2015;66(6):592-597. doi:10.1176/appi.ps.201400201
  33. Winkelman TNA, Chang VW, Binswanger IA. Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use. JAMA Netw Open. 2018;1(3):e180558-e180558. doi:10.1001/jamanetworkopen.2018.0558
  34. Salameh T, Hall L, Crawford T, Hall M. Perceived barriers to mental health and substance use treatment among US childbearing-aged women: NSDUH 2008-2014. Women Health. 2021;61(10):1007-1015. doi:10.1080/03630242.2021.2003501
  35. Parish WJ, Mark TL, Weber EM, Steinberg DG. Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers. American Journal of Preventive Medicine. 2022;63(2):225-232. doi:10.1016/j.amepre.2022.01.021
  36. Rhee TG, Rosenheck RA. Association of current and past opioid use disorders with health-related quality of life and employment among US adults. Drug Alcohol Depend. 2019;199:122-128. doi:10.1016/j.drugalcdep.2019.03.004
  37. Atherton WL. The Impact of a Vocational Counseling Based Substance Abuse Intensive Outpatient Program upon Work and Well-Being: A Pilot Study. Published online 2011. Accessed September 12, 2022. https://thescholarship.ecu.edu/handle/10342/3705
  38. Chou JL, Cooper-Sadlo S, Diamond RM, Muruthi BA, Beeler-Stinn S. An Exploration of Mothers’ Successful Completion of Family-Centered Residential Substance Use Treatment. Fam Process. 2020;59(3):1113-1127. doi:10.1111/famp.12501
  39. Burnam MA, Watkins KE. Substance abuse with mental disorders: specialized public systems and integrated care. Health Aff (Millwood). 2006;25(3):648-658. doi:10.1377/hlthaff.25.3.648
  40. Drake RE, O’Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat. 2008;34(1):123-138. doi:10.1016/j.jsat.2007.01.011
  41. Harnish A, Corrigan P, Byrne T, Pinals DA, Rodrigues S, Smelson D. Substance Use and Mental Health Stigma in Veterans With Co-Occurring Disorders. J Dual Diagn. 2016;12(3-4):238-243. doi:10.1080/15504263.2016.1245066
  42. Nam E, Matejkowski J, Lee S. Racial/Ethnic Differences in Contemporaneous Use of Mental Health and Substance Use Treatment Among Individuals Experiencing Both Mental Illness and Substance Use Disorders. Psychiatr Q. 2017;88(1):185-198. doi:10.1007/s11126-016-9444-0
  43. Chan YF, Dennis ML, Funk RR. Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. J Subst Abuse Treat. 2008;34(1):14-24. doi:10.1016/j.jsat.2006.12.031
  44. Lu W, Muñoz-Laboy M, Sohler N, Goodwin RD. Trends and Disparities in Treatment for Co-occurring Major Depression and Substance Use Disorders Among US Adolescents From 2011 to 2019. JAMA Netw Open. 2021;4(10):e2130280. doi:10.1001/jamanetworkopen.2021.30280
  45. Dunne EM, Burrell LE, Diggins AD, Whitehead NE, Latimer WW. Increased Risk for Substance Use and Health-Related Problems Among Homeless Veterans. Am J Addict. 2015;24(7):676-680. doi:10.1111/ajad.12289
  46. Snell-Rood C, Pollini RA, Willging C. Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction. PS. 2021;72(8):935-942. doi:10.1176/appi.ps.202000312
  47. Simon CB, Tsui JI, Merrill JO, Adwell A, Tamru E, Klein JW. Linking patients with buprenorphine treatment in primary care: Predictors of engagement. Drug Alcohol Depend. 2017;181:58-62. doi:10.1016/j.drugalcdep.2017.09.017
  48. Najt P, Fusar-Poli P, Brambilla P. Co-occurring mental and substance abuse disorders: A review on the potential predictors and clinical outcomes. Psychiatry Research. 2011;186(2):159-164. doi:10.1016/j.psychres.2010.07.042
  49. Kerman N, Polillo A, Bardwell G, et al. Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review. Drug and Alcohol Dependence. 2021;228:109052. doi:10.1016/j.drugalcdep.2021.109052
  50. UMass Chan Medical School. About Mission Model. The MISSION Model. Published 2022. Accessed September 18, 2022. https://www.missionmodel.org/mission-model
  51. Pourat N, Chen X, O’Masta B, Warrick A, Haley LA, Zhou W. Second Interim Evaluation of California’s Health Homes Program (HHP). Published online March 2022. Accessed September 18, 2022. https://healthpolicy.ucla.edu/publications/search/pages/detail.aspx?PubID=2273