Two Roads Diverged: Reconnecting substance abuse disorder and mental health

By Melanie Plenda

Project Editor

Granite State News Collaborative

Zachary Brewster was 12 years old when he started smoking pot. By 15, he and his friends were sharing prescription pain killers. By 17, he was sent to therapy. He told his psychiatrist he was getting high every day before school —that he was high all the time, in fact —and had a problem.

The counselor diagnosed him with ADHD and prescribed Adderall.

“He asked me, do you have trouble paying attention in school and I’m thinking to myself, ‘I go to school high every day, of course I do,” said Brewster, now 32, of Hooksett. “And so, that’s where it happened.”

That was his first exposure to stimulants and what it felt like to be “sped up,” Brewster said.  The Adderall made him superhuman. Suddenly he could stay up all night, go school, go to practice, get straight As

“But the thing was I started abusing it right off the rip,” Brewster said. “And I knew how to manipulate [the therapist] and I thought, ‘Ooh this stuff is great. It keeps me awake and amped and now I can use pot and really not get tired from it.’”

Brewster graduated high school and went to college where he graduated to cocaine. That line led to smoking crack and eventually heroin.

“I didn’t have any depression problems or misbehavior issues or anxiety issues really,” Brewster said. “But after going through several years of drug addiction, everybody wanted to diagnose me with x, y and z as far as mental health disorders and they wanted to treat that, but were very cautious in diagnosing me with substance abuse.”

Brewster had a mental health disorder, for sure, but not one any of his counselors or physical medical professionals diagnosed.

“You look in the diagnostic manual for mental health disorders and they all revolve around: Is it affecting me in my personal relationships with others? Is it preventing me from going to work or school? Is it preventing me from basically functioning as a human being?” Brewster said. “All of the above were for me.”

After nearly 15 years of active addiction, Brewster has been sober since 2013 and is a Biological Sciences major at UNH Manchester. He’s hoping to graduate in the spring and head to medical school. He also works full time as a counselor at Teen Challenge, a 15-month, residential rehab center in Manchester and the place he credits with changing his life. He said he’s not sure that getting an accurate diagnosis earlier would have necessarily changed his path, but it could have shortened it.

The reticence or even inability to see and treat substance abuse as a mental health issue is not unique to Brewster’s situation — it’s actually very common, according to Peter J. Evers, Chief Executive Officer of Riverbend Community Mental Health Inc.

“The lack of education — and this happens in primary care offices —- around a lot of behavioral health disorders being a disease; and the lack of education, even sometimes from mental health counselors, to see where addictive behavior fits in with the overall clinical impression, is prevalent,” said Evers, “We need to have cross-training both in physical — primary care — mental health and substance abuse disorder, because if we don’t, we miss.”

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), most people only receive care for one disorder while the others remain untreated. In 2017, they found that about half of the adults with co-occurring substance use disorder and mental health issues did not receive either mental health care or specialty substance use treatment in the previous year, and about one in three adults with both co-occurring disorders did not receive either type of care.

The lack of appropriate diagnosis and care can be dangerous.

“The consequences of undiagnosed, untreated, or undertreated co-occurring disorders,” according to SAMSHA, “can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.”

The connection between mental illness and substance abuse has been known and recognized for decades but there are still barriers to patients getting comprehensive care. Local experts say the shift is happening, albeit slowly in New Hampshire.

Why does this happen?

In 2017, about 29.3 percent of kids aged 12 to 17 who used illicit drugs also had a major depressive episode in the previous year. Similar trends are found among adults. Among the 18.7 million adults with a substance abuse disorder in 2017, according to SAMSHA, 8.5 million — or 45.6 percent — also had a mental illness in the previous year.

“People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder,” according to SAMSHA. “Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity.”

Although the concept has been around since at least the mid-1990s, for a variety of reasons, the public, practitioners, and treatment models have been slow to reflect the notion that these are often interlinking diseases of the brain that can be successfully treated.

This lack of understanding happens for a variety of reasons, including the fact that behavioral health issues can result from a mix of biological, psychological, and social factors.

“The parts of the brain connected around the chemical imbalances in depression and schizophrenia as well are also connected to the likelihood to succumb to addiction,” said Evers. “When I say that, I mean to actually develop an addiction rather than be able to use substances in a recreational way — in a way most people do. So yes, they are incredibly connected.”

Further, the symptoms are not easy to distinguish from one another.

Jacqui Abikoff, executive director of Horizons Counseling Center in Gilford, explains it this way: when substance use disorders are active, they can mimic symptoms of mental illness. They can also trigger symptoms of mental illness or  mask the presence of a legitimate mental illness that causes a patient to self-medicate through substance abuse.

And, there comes a point in the process of misusing a substance that, regardless of how it started, the addiction takes on a life of its own and becomes its own diagnosable disorder.

When a patient finally reaches out to get help, they are left at the mercy of the service they choose.

“One of the problems is that traditionally that we have siloed the services for substance use disorders and mental health disorders,” Abikoff said. “And because of that, depending on which door you walked into, you would be looked at from the perspective of that service rather than as the whole person.”

In addition to a lack of cross-training of practitioners, stigma still plays a huge role . Fear of how others will see them can keep a patient from coming forward and being honest about the symptoms they are experiencing.

“We stigmatize mental illness in this country,” Abikoff said. “We see them as less-than the general population.

“When you talk about people with substance abuse disorders, we stigmatize them even more because we see them as people who caused their own problems … It’s the idea that if you’re mentally ill, you couldn’t help it; [but]if you have a substance use disorder, you shouldn’t have used in the first place.”

Even practitioners have their own subtle biases, Evers said.

“[W]e hire peer-support specialists both on the mental health side and the substance use disorder side and there is stigma between those two groups,” Evers said. “They can get somewhat judge-y with each other sometimes … these are people who’ve been through a training that says, ‘These are diseases of the mind,’ and … they aren’t personal choices. But it’s so deeply rooted in our history that people who are crazy are a danger to society and people who use substances have a characterological weakness.”

Changing Minds

Evers said the field should recognize that the treatments for both diseases are very similar. He said this was something psychiatrist Ken Minkoff, an expert in dual diagnosis, recognized in the 1990s and it still holds true today.

“[H]e said, ‘Look at the similarities between the treatments,’” Evers said. “This is all about being strength-based, being individual-based, meeting people where they are at in terms of their addiction and their depression, and supporting them through that with peers, with medications and individual therapy.

“And really there’s not too much difference between treating addiction and treating mental health.”

Abikoff would like to change the way communities talk about substance abuse disorders. She pointed out that while we talk about sleeplessness, lack of energy, and change in appetite as symptoms of depression, we don’t often refer to the use of marijuana, methamphetamine or fentanyl as symptoms of a problem — we see it instead as a behavior.

If these “behaviors” were instead treated as symptoms of a substance abuse disorder, more people could be properly diagnosed and treated.

Ultimately, Evers said, the key to treating these illnesses together is more cross- education and training among the professions and an integration of care.

“If you don’t integrate, you fail,” [W]e [need] the patient or the client at the center of the puzzle so that they feel that they are the expert in their own recovery and that the addiction specialist and the mental health specialist and the primary care specialist are all on the same page. That way you get the best outcomes ….”

Are we there yet?

New Hampshire is on the road to better, more integrated treatment for substance abuse disorders in the context of mental health but the changes are a big lift, Evers said.

That said, there are some glimmers of hope.

For example, Evers said community health centers across the state are in the process of applying for Section 1115 Medicaid Demonstration Behavioral Health Waivers. This is a waiver that allows practitioners to use federal funds on treatments not typically allowed under the provisions of Medicaid.

According to the Kaiser Family Foundation, this waiver will allow states to use Medicaid funds to pay for substance use and/or mental health services in “institutions for mental disease; will expand community-based behavioral health benefits; expand Medicaid eligibility to cover additional people with behavioral health needs; and finance delivery system reforms, such as physical and behavioral health integration or alternative payment models.

Riverbend, for example, could put behavioral health clinicians in primary care practices so that doctors are supported, Evers said. The organization could provide provide psych consultation to the primary care providers and ask primary care providers and psychiatric providers to apply for waivers in order to be able to prescribe Buprenorphine — the standard of care for outpatient opioid detox.

“All of these things are integration,” Evers said. “In some ways, all of the community mental health centers are doing this, because they’ve all been pulled into this 1115 waiver, but it’s on a very small scale.”

“… [W]e’re making an effort and we’re trying to show this is the way to go forward but really there hasn’t been a wholesale … allocation of funds towards value-based care yet — that comes in a few years I’d bet.”

And despite the small amount of money the waiver would provide, it has the potential to generate outcomes that show this method of care is better for the overall health of the patient. Then, Evers said,  “that’s sort of irresistible to insurance companies and the federal government who say, ‘Oh yeah there has to be a different way of providing healthcare other than just generating encounters of care and then not measuring anything.’”

However, Abikoff said that integrated care is still a ways off

“[W]e’re not there yet,” she said. “Not enough of our workforce is trained in the nuances of truly integrated care.

As for Zachary Brewster, he’s hoping that his minor in psychology and his experience with addiction and recovery will make him a better doctor someday.

“You may have someone in there that you are treating as a primary care doc for diabetes, yet they’re already diagnosed with anxiety or depression,” he said. “So, having a knowledge of that background and having a level of empathy for that kind of thing, makes you a better provider.

“I think the more well-rounded and balanced you can be, the better you are at caring for another human life. At the bare essentials of it, that’s what medicine is and it’s a very, very high calling.”

[This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit]

A journey through NH's mental health system

By Roger Carroll, Laconia Daily Sun

Part 1 -- Emergency Room 

It was the week before Thanksgiving and my world had changed from that of a working journalist with the freedom to come and go as I pleased to being held in a locked psychiatric facility where staff checked on me every 15 minutes to make sure I was OK.

“Are you here voluntarily?” one of the other patients asked warily.

I was, but I wasn't free to leave.

Read the full story and view video at our partner outlet The Laconia Daily Sun

From Abstinence to Harm Reduction Advocates Say Medication Assisted Treatment for Substance Abuse is Saving Lives

Those suffering from asthma, diabetes and heart disease can pick up medications to treat their chronic conditions at any number of pharmacies — without stigma. Yet, those with substance use disorder, another chronic condition, are treated differently even in accessing their medications.

“To have to go to an identified location every day to get medication for your chronic illness is just discriminatory on its face,” said Kevin Irwin, director of operations for the Seacoast-area Integrated Delivery Network, speaking specifically of methadone clinics that dispense a synthetic opioid as part of medication assisted treatment (MAT) for those addicted to opioids.

“Lots of people receive medications for chronic illnesses, whether it’s for a month or it’s for a lifetime or any time in between,” Irwin continues, “and we would never make people do that for their depression medication, for their diabetes medication, for their tobacco patch. Right? We would never make people do that.”

Irwin leads one of several regional networks, or IDNs, which aim to improve care transitions between providers, promote integrated physical and behavioral health as well as build mental health and substance use disorder treatment capacity. His work has led him to advocate for easier access to MAT services.

“It’s fundamentally discriminatory and in as much as it is discriminatory, it has a lot of built-in limitations,” he said.  “A lot of people can’t, or don’t want to, or aren’t able to do that. Who the hell would want to?”

Methadone is not the only medication assisted treatment available in New Hampshire. In fact, methadone clinics are relatively rare in New Hampshire —there are only about a dozen throughout the state — because of the high regulatory hurdles that need to be cleared to start and maintain one.

Providers who have been authorized by the federal government, such as doctors, nurse practitioners and physician assistants, can also prescribe buprenorphine and naltrexone. The process for getting this medication requires weekly check-ins at first to refill the prescription. These visits are reduced as the patient stabilizes and ideally continues with treatment. But access to this therapy, and specifically to providers offering it, isn’t always easy to come by.

And access is critical to the $45 million hub and spoke opioid treatment model rolled out by the state earlier this year — the success of similar models historically relies heavily on MAT and easy access to it.Read the whole story at partner outlet NH Bar News

After years of neglect state seeks to restore mental health services

Once ranked among the nation’s best, New Hampshire’s mental healthcare system has steadily eroded since the turn of the century, and grown more distressed in the past decade as the demand for mental health services has far outrun the capacity to provide them.

In January, the NH Department of Health and Human Services released a 10-year plan to restore the system — the third of its kind in the past decade. The plan proposes an initial investment of $21.7 million in the next biennium to jump-start the process.

In his budget address, Gov. Chris Sununu said, “We’re not going to slow-roll this plan over 10 years,” adding that with budgeted funds and executive actions, two-thirds of the recommendations will be addressed immediately. He acknowledged that “these efforts will not fix the system overnight,” but expressed confidence that New Hampshire would once again “set the gold standard for the rest of the nation.”

Read more in our partner publication The Laconia Daily Sun

Numbers tell the story in Vermont Hub and Spoke

By all measures, Vermont’s Hub and Spoke System has been a significant success.

It is a self-sustaining program that has contributed to more people getting treatment per capita in the state, a reduction in opioid-related deaths and no wait times for people seeking treatment, according to Mark Levine, the commissioner of Vermont’s Agency of Human Services.

Read more in our partner Manchester Ink Link

Safe, for now: Future of Safe Station not clear in wake of Hub and Spoke

 Julian Bush says he’s running out of room on his body to garland tattoos, as he points to the “Reckless” ink laced around his neck.  

“It’s another addiction,” the 34-year-old said, tugging his cap tighter around his forehead.

But Bush delineates the crowded body art from the addictions he’s suffered most of his life. He started smoking pot when he was 7. By age 11, he was drinking with his friends. By high school, he was on to hard drugs: cocaine and amphetamines. During sophomore year, he left school and took odd jobs in the construction industry, where he saw other workers abusing substances. “I thought it was normal,” he says.

And while Bush says he grew up in an addict home, he doesn’t blame his environment or his parents for letting heroin seduce him. Looking back, he was self-medicating. “I never felt like I fit in,” says Bush. “I was always an outsider.”

No one wants to get hooked on heroin, or any other opioid. Researchers explain that opioids barrage the brain with dopamine, a naturally occurring chemical messenger that plants a sense of feel-good calmness in the body. Inhale, ingest or smoke the drugs once, and the opiates rewire the brain’s circuitry, signaling the addict to restore the body to its tranquil state with more drugs.

For Bush, this ultimately meant needing a package of dope to get up and shower –  to live.

Read more in our partner The Nashua Telegraph

State seeing lack of psychiatrists


Feb 6, 2019 Updated Feb 6, 2019

LACONIA — For two years, Maggie Pritchard has been trying without success to find a psychiatrist to lead the mental health unit at Franklin Regional Hospital.

The difficult recruitment effort is a symptom of a larger problem.

There is a lack of psychiatric professionals in New Hampshire, and that translates into longer waiting times for patients seeking mental health services, said Pritchard, executive director of Lakes Region Mental Health Center, which has providers serving the Franklin facility and Lakes Region General Hospital.

Read More at our Partner Laconia Daily Sun and check back soon for The Granite State Collaborative’s special look at the workforce shortage in New Hampshire and potential solutions to the problem.

Evolution of Ambulance Services

Judi Currie

Business NH Magazine,

GSNC Partner

 Among the state’s biggest health challenges are the raging opioid crisis and the lack of resources for mental health needs, especially for those who are homeless. And on the front lines addressing these issues are ambulance crews.

The 911 responders are the first health care providers on the scene for potential overdoses, are the default primary care provider to the homeless, and often the most public-facing part of the heath care community.  Working in the field gives emergency medical service (EMS) providers a deep knowledge of the most vulnerable segments of the population and enables out-of-the-box thinking to help solve some of the state’s most difficult health care issues.

In recent years, EMS providers and the state have developed ways to use mobile integrated health care to create pilot programs that address unmet community health care needs in the field.

Nick Mercuri, chief of strategy and planning for the NH Division of Fire Standards and Training and Emergency Medical Services, says these pilot programs use emergency medical services in a new way. “It is using us to try to prevent the next emergency call. The classic scenario is that we respond, but we don’t prevent,” Mercuri says, explaining emergency responders could do more than respond to emergencies. They could prevent them.

The state has approved eight pilot programs so far. Some are focused on lowering hospital admissions for congestive heart failure and chronic obstructive pulmonary disease (COPD); one involves a mobile crisis team to divert appropriate patients away from emergency departments; and another seeks to reduce readmission rates and provide safety assessments in patients’ homes.

Those efforts will be enhanced by $119,297 in federal grants the National Alliance on Mental Illness-NH received in September from the Department of Health and Human Services to fund crisis intervention training for NH’s first responders.

Taking On the Drug Crisis

The first pilot program approved by the state was the Safe Station protocol, which is intended to create a safe place where someone dealing with substance misuse and seeking recovery can come to a participating fire station and ask for help. The firefighters on duty provide a medical assessment, and if there is cause for concern, they call in EMS. The program also offers an alternative to hospital emergency departments for those who may not need immediate medical attention, but need immediate help to start recovery. 

Chris Stawasz, regional director for American Medical Response (AMR), which has emergency response contracts with Manchester, Nashua and Candia, says he’s been in the industry for almost 30 years and has never seen anything like the current drug crisis.

“Manchester is ground zero for the opioid crisis,” Stawasz says. “Last year we had 877 overdoses and 67 of those were fatal. If 67 people died of car accidents, the public outcry would be huge for traffic studies and more policing,” he says. “Our typical overdose case is a 25- to 30-year-old male who has been to college; but overall this crisis doesn’t discriminate. The power of this drug is unexplainable; it gets you hooked and it won’t let go.”

But Stawasz says they are making headway. Year to date, Manchester’s fatality rate decreased 26 percent, and overdoses are down 12 percent. “It had been increasing by double digits, so that’s progress,” Stawasz says. Meanwhile, more than 4,000 people have taken advantage of Safe Station in Manchester since it launched in 2016.

Strafford County has also been particularly hard hit by the opioid crisis and has the highest rate of Narcan (the overdose reversal drug) administration, according to state figures. In Dover, the largest city in the county, Fire Chief Eric Hagman says his department has responded to more than 400 overdoses in 10 years. The city joined a lawsuit against the opioid manufactures,[1]  marketers and distribution companies. Dover also has the Safe Station program in place, called Community Access to Recovery, an effort led by the Dover Police Department.

Last year, the NH Department of Safety received a federal grant to allow EMTs to make a return visit to a home where an overdose occurred. According to Mercuri, they will provide CPR training, Narcan and information about treatment and recovery services. “If we can train an individual’s family or support network, they can provide help even before the EMTs arrive,” Mercuri says.

Breaking Down Barriers

Stawasz says the crisis has helped break down silos in health care, an important change since the issues of substance abuse, mental health and homelessness are so intertwined. He says for many of their patients AMR is the primary care provider. “The homeless have no PCP; if something goes wrong, they call 911,” Stawasz says. “Half of our business model is mental health issues.”

Knocking down silos means finding new ways for emergency responders to help patients. Stawasz says AMR will be working with a local hospital on a plan aimed at preventing re-admission for congestive heart failure. The plan would call for paramedics to visit patients at home after they have been discharged to make sure they are following the doctor’s instructions. “By working with a cardiologist and having our paramedics go out into the field, we can help keep people out of the hospital and on a steady path back to good health,” he says.

Stawasz says as AMR starts to look at other types of mobile integrated health care plans, the real advantage is sending a paramedic in to treat the issue rather than the old model of stabilizing for transport. “It’s someone who’s well-qualified and can do whatever might be needed,” he says. “All the while, the patient is at home rather than in the hospital being treated, where it is more expensive and they could be exposed to other illnesses.”

No Stable Funding

Hagman wants to see more of these programs in Dover. “The idea is to treat people or guide people with their medical care before needing an ambulance transport, or in the period immediately after returning home from the hospital,” he says. Hagman says the issue at the moment is funding and finding the required partnership with a local hospital and/or Visiting Nursing Association.

Most mobile integrated health plans are funded through insurance carrier grants, Hagman says, and Dover has not been able to tap into the right one. There is also no payment or billing stream where an ambulance crew doing mobile integrated work can bill an insurance company and be paid. “We are simply trying to get the pieces to fall into place. We all see mobile healthcare as the next way to serve the citizens in Dover,” Hagman says.

Scott Schuler, regional director of operations for Transformative Healthcare, says while his organization has not submitted a mobile health care proposal, it is looking into it as part of a larger examination of finding the best way to deliver care. Transformative runs Stewarts Ambulance Service in the Lakes Region; Lifeline, which serves Concord Hospital, Exeter Hospital and Southern NH Hospital in Nashua; and Fallon Ambulance Service in Massachusetts.

“We are very interested in looking at the New England market and finding a sustainable model,” Schuler says. “There are major changes going on around the country, but there are very few programs that are financially sustainable models without some sort of grant funding. They are doing well, and with mobile integrated health care you can immediately see the cost savings. But it’s a little more difficult tracking patients over a 30- to 90-day window” due to the complexities of managing multiple health records from different medical facilities.

Gary Brock, director of EMS and emergency preparedness at Frisbie Memorial Hospital EMS, a unit of Frisbie Memorial Hospital in Rochester, says Frisbie has a history of piloting initiatives, including being the first hospital-based paramedic service in New England.

Among Frisbie’s current initiatives is a mobile integrated health program that helps people who frequently visit the emergency room for chronic medical conditions to manage their care more effectively, Brock says. That requires coordination among health care providers and agencies.

“The success of a system is contingent on the integration with existing services; relationships with community public health centers, visiting nurse organizations, medical specialists and primary care providers; and ensuring that patients are obtaining the right services [that integrate directly with] most of the system,” Brock says.

He explains that heart attacks, sepsis and COPD are three of the top killers in the greater Rochester area, and northern Strafford County has been identified as one of the sickest populations in NH. The region is also plagued by an opioid epidemic that has been unrelenting despite efforts made thus far, he says.  As a hospital-based ambulance and mobile integrated health program, Brock says it ensures hospital-level oversight and advancements in treatment.

Brock says Frisbie’s mobile integrated health program is in the third year of a four-year pilot, and the NH Department of Health and Human Services is preparing to introduce the program into permanent rule that all EMS providers would be able to adopt. The hospital funded two years of the pilot program, with the other two funded by grants.

“There has been success in obtaining reimbursements from insurers in other states, and we will seek to have the same for New Hampshire after the program becomes permanent rule,” he says. Typically, treatment by emergency responders is not covered if the patient is not taken to a hospital.

This year, Anthem Blue Cross and Blue Shield in NH began reimbursing EMS providers in certain instances for providing care to consumers without transporting them to a hospital. According to Stephanie DuBois, director of public relations, it is “part of our continuing efforts to collaborate with providers to make health care simpler, more affordable and more accessible. We value the relationship we have with health care professionals and recognize that we can work together to improve the health care system for consumers.”

Mercuri says additional funding through a Substance Abuse and Mental Health Services Administration grant has been approved, and he anticipates the number of plans to double in the next year because of the federal grants.