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]