SAMHSA last month released its Interim Strategic Plan

After 988’s Launch, Experts Emphasize More Work Needed

Understanding Trauma-Informed Care in the PALTC Setting

Back to table of contents Previous article Next article ProfessionalFull AccessDEA, SAMHSA Release Temporary Rule Extending Telemedicine FlexibilitiesTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:11 May 2023https://doi.org/10.1176/appi.pn.2023.06.6.2AbstractThe rule extends the full set of telemedicine flexibilities adopted during the COVID-19 PHE through November 11. Additional flexibilities will extend to established patients until November 11, 2024.The U.S. Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) issued a temporary rule on May 10 that extends telemedicine flexibilities adopted during the COVID-19 Public Health Emergency (PHE). The temporary rule is effective today, May 11, and extends the full set of telemedicine flexibilities adopted during the COVID-19 PHE for six months (through November 11). Additional flexibilities will extend to established patients until November 11, 2024.“Access to evidence-based treatment is a pillar of the HHS Overdose Prevention Strategy,” said Miriam E. Delphin-Rittmon, Ph.D., the Health and Human Services (HHS) assistant secretary for mental health and substance use and the leader of SAMHSA, in a press release issued by SAMHSA. “We strongly support policies that promote access to effective and safe treatment for opioid use disorder, including through telemedicine platforms, and ensuring continued access to necessary controlled medications past the COVID-PHE.”This development is the latest in a story that began back in February, when the DEA announced two proposed rules (Docket No. DEA–407 and Docket No. DEA–948) for the prescribing of controlled medications via telemedicine. There was a 30-day public comment period for the proposed rules, which ended on March 31.The nation cannot afford policies that make it more difficult for patients to get the medications they need, says APA CEO and Medical Director Saul Levin, M.D., M.P.A.APA filed two letters with the DEA in response to the proposed rules during this time, recommending that the DEA “focus on balancing common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment” and consider ways to extend flexibilities made during the COVID-19 PHE. These comments were just two of the tens of thousands of comments that the agency received.DEA Administrator Anne Milgram on May 3 announced that the agency had received “a record 38,000 comments on its proposed telemedicine rules” and would delay releasing the two permanent rules that were set to go into effect when the COVID-19 PHE ends. “We take those [38,000] comments seriously and are considering them carefully,” Milgram said.The SAMHSA release noted: “For any practitioner-patient telemedicine relationships that have been or will be established up to November 11, 2023, the full set of telemedicine flexibilities regarding prescription of controlled medications established during the COVID-19 PHE will be extended for one year—through November 11, 2024.”“We recognize the importance of telemedicine in providing Americans with access to needed medications, and we have decided to extend the current flexibilities while we work to find a way forward to give Americans that access with appropriate safeguards,” Milgram said.“We are pleased that the DEA is taking the time to consider carefully the impact the proposed rules would have on patients, many of whom rely on telehealth as a means of accessing care,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “At a time when the nation faces both a mental health crisis and an opioid crisis, we cannot afford policies that make it harder for patients to get the medications they need.” ■ResourcesThe temporary DEA rule “Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications”Proposed DEA rule “Telemedicine Prescribing of Controlled Substances When the Practitioner and the Patient Have Not Had a Prior In-Person Medical Evaluation”Proposed DEA rule “Expansion of Induction of Buprenorphine via Telemedicine Encounter”Statement from the DEA Administrator Anne Milgram on COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications ISSUES NewArchived

Behavioral health care, which addresses mental health and substance use, has been neglected by our health care system. People with severe mental illnesses and other chronic conditions such as diabetes, asthma, heart disease, and obesity, die earlier than do people without such conditions. Behavioral health conditions may not be properly addressed because of a lack of community resources and poor health insurance coverage for such conditions. The federal government — in partnership with states, communities, consumers, families, and the private sector — has responded with proposals for health care reform that include mental health care. In 2009, federal agency partners helped frame the agenda for health care reform. Their focus was on creating a holistic, person-centered health care system, achieved through a public health model that addresses the broad determinants of health and mental health. In particular, they focused on prevention, early intervention, and the use of technology to increase access to and quality of health and mental health services. The federal response to behavioral health care reform has been guided by 3 seminal documents that have influenced and reflected change in mental health systems and services. Reports by the Surgeon General (1), New Freedom Commission on Mental Health (2), and Institute of Medicine (3) made all of the following clear: Mental health is essential to overall health. Mental illnesses are real disorders and treatment is effective. Recovery is the expected outcome of treatment and services. Services must be consumer- and family-driven and evidence-based. Soon after the release of the New Freedom Commission's final report in 2003, the US Department of Health and Human Services (HHS) charged its Substance Abuse and Mental Health Services Administration (SAMHSA) with leading efforts to transform the mental health system in this country. SAMHSA organized a collaborative effort among more than 20 federal agencies and offices to ensure that people with mental and substance use disorders have every opportunity for recovery. Along with other agencies and offices in HHS, the federal partners include the US departments of agriculture, defense, education, housing and urban development, justice, labor, transportation, and veterans affairs, as well as the Social Security Administration and the Equal Employment Opportunity Commission. The federal partners are guided in their work by the Federal Executive Steering Committee, a group of assistant secretary-level professionals who ensure that resources will be available and promised actions will occur. Efforts to improve systems of care for people with mental illnesses have been extensive. Together, SAMHSA and its federal partners developed a specific agenda to create consumer-centered, recovery-focused, evidence-based, quality-driven systems of care for people with mental health problems. Transforming Mental Health Care in America: The Federal Action Agenda: First Steps (4), released in 2005, and Transforming Mental Health Care in America: The Federal Action Agenda: A Living Agenda (5), published in 2008, chart a vision for a transformed mental health system, delineate specific objectives to achieve this vision, and highlight progress made. The Federal Executive Steering Committee has focused on critical issues to ensure both full community integration for people with mental health problems and broad recognition of the role of mental health in overall health. Some of these issues are countering the social exclusion of people with mental illnesses through public education, preventing suicide, and increasing employment opportunities for people with psychiatric disabilities, mental illnesses, and emotional disturbances. Efforts to expand the reach of care include collaborating with the criminal and juvenile justice systems to provide access to mental health care, addressing the mental health needs of marginalized groups such as refugees and homeless people, and improving mental health care services for children and adolescents. Research is needed to understand concurrent mental and physical disorders, develop new medications, promote evidence-based mental health best practices, and put research findings into practice. The committee's accomplishments include a collection of federal resources on disaster behavioral health, a compendium of primary care and mental health integration initiatives across participating federal agencies, and a research study on evidence-based programs that integrate primary care and mental health. Meeting the needs of people with existing mental illnesses is a challenge. Countering discrimination, undoing the fragmentation of services for physical and mental illnesses, and managing costs and limited resources are first steps toward a transformed mental health system. Wisely investing in the future while making the best use of limited resources will enable us to share the hope of recovery.

Back to table of contents Previous article Next article Government NewsFull AccessSenate Committee Solicits Input on State of MH SystemLeslie SinclairLeslie SinclairSearch for more papers by this authorPublished Online:15 Mar 2013https://doi.org/10.1176/appi.pn.2013.3b13AbstractExperts tell a Senate committee that the mental health system is overburdened, many patients don’t get needed help, and earlier and improved detection could change that reality.The Senate Health, Education, Labor, and Pensions (HELP) Committee, convened a meeting January 24 to discuss—for the first time in six years—the mental health of Americans. Prompted by the Newtown, Conn., school shooting and in anticipation of the changes the Affordable Care Act will bring about, committee members solicited input at the hearing they dubbed “Assessing the State of America’s Mental Health System.”“It seems to me that the questions before us are ‘who needs help’ and ‘who’s there to provide the help’,” said Sen. Lamar Alexander (R-Tenn.), the committee’s ranking member.Pamela Hyde, J.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), was the first to provide testimony. “Behavioral health is a public-health issue, not a social issue, and it can be tackled and addressed with an effective public-health approach,” she said, while noting that SAMHSA’s National Survey on Drug Use and Health indicates that only 38 percent of adults with diagnosable mental health problems and only 11 percent of those with diagnosable substance use disorders receive treatment.“Prevention works, treatment is effective, and people do, in fact, recover,” she stressed, but obstacles including cost, access, and recognition of mental health disorders are the primary reasons treatment is not received by many who need it. Hyde pointed to upcoming changes associated with the Affordable Care Act that will extend the reach of mental health treatment to more Americans, saying “Medicaid is already the largest payer of mental health services, and the Affordable Care Act will extend Medicaid coverage to as many as 17 million hardworking Americans.”Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH), also presented testimony and emphasized that most mental disorders begin early in life, yet patients often wait years for diagnosis and treatment. “The lesson we have learned from cancer and heart disease, diabetes and AIDS, is that the secret to having the best outcomes is early detection and early intervention…yet we don’t do that.” Moving forward, NIMH will support research on earlier diagnosis and quicker delivery of appropriate treatment, be it behavioral or pharmacological, he said. Medical Director James H. Scully Jr., M.D., submitted testimony on behalf of APA. “This hearing comes at a critical time when our leaders in government are faced with difficult choices about where to allocate limited resources,” he noted. “Nevertheless, I believe the current state of our nation’s mental health system is weak and demands immediate and significant attention by Congress and the administration.” Scully’s testimony presented five key areas through which the mental health system could be strengthened to ensure the mental health and well-being of all Americans:Mental Health Parity. APA urges issuance of a final rule on the Mental Health Parity and Addiction Equity Act of 2008. In the absence of a final rule, APA is concerned that access to critical mental health services will be jeopardized for millions of Americans. APA also supports reintroduction of the Medicare Mental Health Inpatient Equity Act, which would increase access to coverage for the most seriously mentally ill people. A Commission on Mental Health. APA supports the idea of a new commission—either presidential or congressional—to conceptualize how the nation’s mental health system can meet the needs of all Americans. Investing in Existing Mental Health System Components. APA supports investment in biomedical research, initiatives to develop and implement new treatments for addiction, and state block grants for mental health and substance use activities, suicide prevention, and jail-diversion programs for people with mental illness. Support for Graduate Medical Education. The ability of the U.S. mental health system to deliver high-quality care in a coordinated and cost-effective manner is dependent upon an appropriately trained workforce. As a physician specialty society, APA strongly supports the preservation of funding for both direct graduate medical education and indirect graduate medical education, programs that support 16,000 residencies each year. Early Intervention and Prevention Services for Youth. As a vulnerable population, children and adolescents are especially in need of early intervention and prevention services.Scully also brought to the committee’s attention the initiative APA launched through the American Psychiatric Foundation, called “Typical or Troubled?,” to train school personnel to make the distinction between students who are “just being adolescents” and students who demonstrate early signs of mental illness, saying “this program represents the type of early intervention and prevention strategy that could serve as a national model.” ■A video of the committee hearing as well as written testimony are posted at http://www.help.senate.gov/hearings/hearing/?id=b2048a10-5056-a032-529c-340d7ae5f237. Scully’s testimony is posted at http://www.psychiatry.org/advocacy--newsroom/advocacy/apa-submits-testimony-to-congress-on-the-state-of-americas-mental-health-system. ISSUES NewArchived

Patients seeking treatment for opioid use disorder face more challenges during pandemic

It's not just about integrating mental health and substance use (commonly referred to as “behavioral health”) anymore. The federal government for some time has been promoting merging these with primary care; in other words, giving primary care providers the job of treating mental illness and substance use disorders. Last week, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced the availability of $6 million, to be given to three awardees, for coming up with ways to integrate primary and behavioral health care. “The purpose of this program is to: (a) promote full integration and collaboration in clinical practices between physical and behavioral health care; (b) support the improvement of integrated care models for physical and behavioral health care to improve overall wellness and physical health status; and (c) promote the implementation and improvement of bidirectional integrated care services, including evidence‐based or evidence‐informed screening, assessment, diagnosis, prevention, treatment and recovery services for mental and substance use disorders and co‐occurring physical health conditions and chronic diseases through integrated care.” Applications are due May 20. For more information, go to https://www.samhsa.gov/sites/default/files/grants/pdf/fy‐2024‐pipbhc‐states‐sm‐24‐003.pdf.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has taken another step toward merging mental illness and substance use disorder (SUD) with its new Office of Recovery that blends both. Peers (differentiated from professionals) with “lived experience” of having either SUDs, mental illness, or both in the SAMHSA‐preferred terminology of “co‐occurring” will be key to this new office, which was announced last fall (see Advocates hold hope that SAMHSA office will deliver for recovery support, ADAW Oct. 11, 2021; https://onlinelibrary.wiley.com/doi/10.1002/adaw.33218).

If you are in recovery from a substance use disorder (SUD), a peer would be another person in recovery from a SUD. At least, that's the purist way of thinking, before the word “peer” came into common usage. For years, the Substance Abuse and Mental Health Services Administration (SAMHSA) has endeavored in various ways to promote the blending of SUDs and mental illnesses, mainly in terms of the recovery workforce. Most recently, SAMHSA's publication, Peer Support Specialists: A Growing Mental Health and Addictions Workforce, adds further confusion to the issue. We asked experts in the field to comment.

Inertia Mires Bills to Fix Biased Medicare Copay

Personal Accounts: "Doctor's Standing Orders"

In an interview last week with Mental Health Weekly, former Substance Abuse and Mental Health Services Administration (SAMHSA) Assistant Secretary for Mental Health and Substance Use Elinore McCance‐Katz, M.D., Ph.D., who announced her resignation last month, reflected on SAMHSA's achievements and national priorities, especially amid COVID‐19, and the need for increased funding to address the mental health and substance use disorder needs of Americans.

There is a growing body of evidence that screening, brief intervention, and referral to treatment (SBIRT) is effective in reducing drinking and substance use problems. Based on the outcomes from MOSBIRT, Missouri’s Substance Abuse and Mental Health Services Administration (SAMHSA)-funded SBIRT program, individuals receiving brief interventions show reductions in risky use, along with improvements in employment, housing, legal involvement and physical and mental health. As numerous studies indicate a cost savings of $3.81 to $5.60 for each dollar invested in screening for risky use, the most promising approach to sustaining SBIRT services in Missouri after SAMHSA support expires is to fund the state Medicaid codes already on the state’s fee schedule, thereby allowing for reimbursement of SBI services. To that end, an analysis of the Medicaid fee schedules of the 50 states and DC was conducted to determine which states currently have SBI Medicaid codes H0049 and H0050, as well as the American Medical Association’s Common Procedural Terminology (CPT) codes 99408 and 99409, on their schedules. The analysis indicated that 22 states have either the Medicaid or CPT codes with associated billing amounts on their Medicaid fee schedules. The average billing rate for screening is about $25 per unit, with rates of around $40 per unit for brief interventions. This information was presented to the Missouri governor’s budget office and resulted in rate setting and coverage of SBI services at federally qualified health centers and community mental health centers across the state. A rationale for supporting SBI services nationally is provided, along with recommendations for petitioning state budget offices to fund the Medicaid codes based on lessons learned from the MOSBIRT project.

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) has issued practice guidance to adolescent substance use disorder (SUD) treatment services. The purpose of the document is to better inform SUD services for adolescents across the states. NASADAD expects that language in the document can be incorporated into contracts with treatment providers to ensure that evidence‐based, high‐quality treatment is delivered to adolescents ages 12 to 18. The project, which was funded under a subcontract to JBS International, under a Substance Abuse and Mental Health Services Administration (SAMHSA) contract, originated in the states themselves, said Henrick Harwood, NASADAD's director of research, in an interview with CPU. “Many of the states had been putting together their own documents,” he said. “Each state was inventing their own guidelines, their own practices, on how to manage and purchase youth services,” he said. “SAMHSA said, ‘We can help to resource this,’ and gave us a grant to work with the states.”

SUMMARY The Substance Abuse and Mental Health Services Administration (SAMHSA) describes alcohol related problems with older adults as “underestimated, underidentified, underdiagnosed, and undertreated” (SAMHSA, 2004, p. 1) and describes the phenomenon as an “invisible epidemic” (SAMHSA, 2004, p. 1). The purpose of this review is to address the prevalence and consequences of alcohol abuse in the older adult population by emphasizing the heterogeneity of factors contributing to, and providing a context for, the understanding of alcohol abuse in aging families. Issues surrounding the sensitivity and specificity of assessment of older adult alcohol abusers are covered. Strategies for intervention at both an individual and family level are also included. Although much of the literature available on older adult alcohol use and misuse addresses the consequences, assessment, and intervention from an individualized perspective, this review concludes that a family-oriented approach to intervention may best serve the needs of older alcohol abusers and their support network of family and friends.