The Crisis of Under-treatment of Severe Substance Abuse Disorder

December 23, 2018   Dr. Thomas G. Kimball

Published in The Doctor Weighs In, December 23, 2018. View the Article Here

We are in the midst of a crisis of untreated and undertreated mental health and substance use disorders. The negative impact and consequences for individuals, families, communities, and our nation are staggering. We, as a nation, are hurting.

A primary factor that is fueling this crisis is difficulty accessing meaningful and extended help for those who suffer from these disorders. Barriers to care include the following:

  • The cost of treatment
  • Lack of coordination and information flow across areas of care

Adding to the problems with access are the shortage of mental health providers in general and the lack of training on mental health and substance use disorders specifically. Without meaningful interventions to overcome these barriers this crisis will only get worse over time.

How big is the problem?

Just shy of 44 million people over the age of 18 in the United States suffer from a mental illness. That is around 18% of the U.S. population – or almost 1 in 5 Americans.

Approximately 20 million people suffer from a substance use disorder—that’s over 8% of Americans. Almost 8 million of them have a co-occurring disorder, the presence of both a mental health disorder and a substance use disorder [1].

It is important to note that every person who suffers from mental health and/or substance use disorders are connected to several other people. Family members, friends, and associates experience the negative aspects of a loved one who is struggling with these disorders and the barriers to accessing care.

These “co-sufferers” worry, experience stress, and expend a significant amount of resources (i.e., emotional, physical, and financial) in an effort to help their loved one. Thus, the true impact and consequences of this mental health/substance use crisis go way beyond just the individuals who suffer. The exact magnitude is difficult to measure.

Barriers to mental health and substance abuse treatment


The cost of getting appropriate care can be substantial with the impact varying by the ability of the individual or family members to pay. Cost is frequently given as the reason care is not accessed in the first place [2].

For example, inpatient/residential substance use treatment can range from $0 out-of-pocket costs when covered by insurance or subsidized by state and federal government funds. It can exceed $60,000 a month for elegant residential treatment.

The demand is very high for “no cost” treatment so it is extremely difficult for most qualified candidates to access it.

Although the Affordable Care Act (ACA) did help many gain access to treatment by providing coverage for mental health and substance use disorder, it also came with some negatives. Namely, the treatment industry has had a difficult time keeping up with new demand. This scarcity of space for those that suffer has also driven up the cost of treatment. Even when a large portion of the cost is covered by insurance, many people have a hard time meeting the out-of-pocket costs (co-pays, co-insurance, deductibles) to go to treatment.

Coordination of care

One of the most difficult challenges for those suffering from mental health disorders in combination with severe substance use disorder is the lack of integration or even coordination between mental health services and substance use services. Given the high prevalence of co-occurring mental health and substance use disorders, such integration seems like a no-brainer not only to improve access to treatment but also to improve efficiency and to reduce costs.

Health care systems have often created artificial silos of information that hinder the coordination of meaningful care. Integration of information (e.g., screening and assessment, medication, etc.) would provide the mechanism to improve access to care and increase the quality of care on both sides.

Given the nature of addiction/severe substance use disorder, those who suffer often present for help first for their mental health disorder or from an associated physical health condition. Once identified and when information is shared, health care providers can have the appropriate conversations about treatment options breaking down barriers [3].

To be fair, the creation of electronic medical records (EMRs), digital versions of patient records, have gone a long way in the sharing of medical records. However, addiction treatment providers often do not use EMRs or do not use EMRs compatible to share information with EMRs used by other traditional health care providers.

Lack of mental health professionals in general

According to the Merrick Hawkins 2017 Review of Physicians and Advanced Recruiting Incentives [4]:

For only the second time in 24 years, Merritt Hawkins has conducted the Review, psychiatrists were second on the list of our most requested recruiting assignments, reflecting a severe shortage of mental health professionals nationwide.

At the time where mental health and substance use disorders are at crisis levels, we are experiences a “severe” shortage of mental health professionals. This is scary. Untreated, such difficulties create a host of problems impacting all of us.

Further from the National Council Medical Director Institute’s report on “The Psychiatric Shortage [5].”

The coverage of, and increasing demand for, psychiatric services is occurring at the same time as a growing shortage of outpatient and inpatient programs. The lack of access has created a crisis throughout the U.S. health care system that is harmful and frustrating for patients, their families, and other health care providers and is becoming increasingly expensive for payers and society at large.

It is important to note is that this trend is projected to get worse over time.

Lack of mental health professionals trained to treat substance use disorders

Adding to the crisis is that many psychiatrists and other mental health providers do not receive appropriate training in identifying, having compassion for, assessing, and then treating those who suffer from severe substance use disorders/addiction. Even if we had enough mental health providers to meet the demand, mental health disorders and specifically severe substance use disorders need specialized training and a particular skill set to be effective.

A Nation in Crisis

Our nation experiencing a scary and powerful mental health and substance use crisis. All of us have felt the consequences of the crisis. Together we must find a way to overcome the barriers of cost, coordination of care, and the shortage of mental health providers trained to do this work. Promising solutions may be found in providing access to care through telehealth and other remote and creative engagement strategies.

In addition to these, we must find ways to reduce the cost. And we must ensure that providers are able to easily communicate with each other via their electronic medical health records. It is also critical that medical educational institutions recruit and train mental health providers who will have the needed skills to treat people who suffer from severe substance use disorder with or without a co-existing mental health disorder.


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