The mental health crisis in America collides with the opioid crisis in dangerous ways, worsened by social isolation and loneliness brought on by COVID-19. Among the millions of people with opioid use disorder, more than half have a mental illness, and up to 30% of deaths associated with opioid overdose are thought to be due to suicide: a leading cause of death for people between the ages of 10 and 34.

The way we identify and treat mental health, substance use, and pain remains fragmented, even though these conditions have always been intimately connected. Although help is available to treat these individuals, only a fraction of people in need get help.

One reason is that effective treatment often combines several components: medications, peer support, group therapy, and links to community services, such as access to food banks, housing services, employment counseling, and educational training.

Because this type of care can be difficult to access, scientists funded by the NIH Helping to End Addiction Long-term® Initiative are optimizing it by breaking the treatment into parts and testing different combinations that may be effective and could be covered by insurance.

Diverse group of people sitting in a circle talking

Parts of the Whole

One treatment model, Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) involves several different providers: clinical care staff including a case manager and specialists, nurses, social workers, counselors, and peer recovery coaches.

On top of their health conditions, people who have both mental illness and opioid use disorder often experience other life challenges, such as homelessness and involvement with the criminal justice system. Minority populations, such as African Americans, Hispanics, and veterans, are disproportionally affected.

HEAL funding is determining whether certain pieces of the multi-part treatment are effective enough on their own or paired in ways that may be more accessible, and affordable, for real-world use.

This research study involves 1,000 research participants with both mental illness and opioid use disorder. Separating them into five groups, the researchers are testing different combinations of the interventions that make up MISSION: ranging from the most intensive and expensive version (containing all parts) to the least intensive and least costly option (medications for opioid use disorder only).

The innovative research design allows the team to be flexible with treatments and meet people’s most immediate basic needs at the same time.

“For example, it wouldn’t be uncommon for somebody early on in this study to get housing support, while we’re also bringing them to recovery meetings, and offering group-based therapy,” explains David Smelson, Psy.D., of the University of Massachusetts Chan Medical School in Worcester, who developed MISSION.

To measure effectiveness of each part on its own or in combination, the research team will test several outcomes. These include:

  • Improvements in mental health
  • Increased likelihood of being employed
  • A better chance of finding a safe and stable place to live
  • Reduced substance use
  • Fewer legal problems that can be shown to be attributable to receiving care through this treatment. 

Although Smelson predicts that the combined treatment will lead to improved outcomes better than its parts alone, one part could be driving the outcome of the whole intervention. Or perhaps two parts are better than one, he suggests. That’s what the research will determine.

Engaging an Important Community: Insurers

The team designed the research study with Medicaid, the federal and state program that serves people with limited income and resources. By checking in with this crucial partner up front, the HEAL research team makes it more likely that the findings will reach many people in need, and quickly.

As a result of this advance collaboration, Medicaid committed to funding an affordable, leaner version of the treatment, even if it happens to be marginally less effective than the full, more costly version of the program.

Longer term, the researchers plan to work with additional insurers, to better inform economic evaluations of the combined therapy and their treatment costs.

“HEAL has given us the opportunity to systematically understand what’s driving outcomes, make a more efficient and effective intervention, and tailor it to healthcare system needs,” Smelson says.

Read About this Project on NIH RePORTER

Learn more about Supporting Treatment Access and Recovery for Co-Occurring Opioid Use and Mental Health Disorders.

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Learn More About This Research Program

Learn more about the Optimizing Care for People with Opioid Use Disorder and Mental Health Conditions research program.

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National Institute of Mental Health (NIMH)

Learn more about NIMH's role in the NIH HEAL Initiative.

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