‘This numbs pain’ – The connection between mental health and opioids

"The desire to push things away, to not deal with it, to forget is powerful. Sadly, opioids are probably the best thing for forgetting.”

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This syringe was designed for medication, and - in an dangerous way - that's how it is being used by many at the intersection of mental health disorders and opioid addiction. (Photo Benjamin Schachtman)
This syringe was designed to deliver medication, and – in an dangerous way – that’s how it is being used by many at the intersection of mental health disorders and opioid addiction. (Photo by Benjamin Schachtman)

Author’s note: Anecdotes and statistics agree, Wilmington is suffering an epidemic of opioid drug use. What remains unclear –– and what this series hopes to clarify –– are fundamental questions about the epidemic.

The epidemic does not have one single narrative but, instead, intertwining threads. Street heroin has a different, but related, story to prescription drugs. Likewise, there is not a stereotypical opioid user. Rather, users come from varied backgrounds. To this complicated mix of people and drugs is added the different relationships among law enforcement, health care, and treatment and recovery.

This is not to say there are no answers, only that there are no easy answers. This series will present those intertwining threads of the epidemic in an effort to help area residents to better engage with the crisis going on around them, to understand its origins, and to better understand the current state of affairs and what can be done about it.

Part IV – Mental health and opioid abuse

There is another epidemic in the shadow of the current opioid crisis, though it has not attracted the same news coverage, government funding or public discussion. Mental health disorders often appear alongside substance abuse issues, but the relationship between the two is complicated and multi-faceted.

So how do the two relate?

The U.S. Department of Health and Human services estimates at least one in four people with a major mental health issue is also dealing with substance abuse.

At the most basic level, there is the high level of overlap between the two issues. According to a Castlight Health study, those in the workforce with mental health issues were nearly three times more likely to abuse opioids. The U.S. Department of Health and Human services estimates at least one in four people with a major mental health issue is also dealing with substance abuse.

Talking about mental health often conjures inaccurate - or incomplete - ideas, said Kenny House. 'People sometimes think we're talking about homeless schizophrenics,' House said. "That's just one part of the issue. We're also talking about working class people, professionals, dealing with stress, anxiety and depression.' (Photo Benjamin Schachtman)
Talking about mental health often conjures inaccurate – or incomplete – ideas, said Kenny House. ‘People sometimes think we’re talking about the homeless, about schizophrenia,’ House said. ‘That’s just one part of the issue. We’re also talking about working class people, professionals, dealing with stress, anxiety and depression.’ (Photo by Benjamin Schachtman)

Kenny House, clinical director of Coastal Horizons, says the non-profit organization sees over one thousand clients per year for mental health and substance issues in the New Hanover County area alone. House said he sees ‘co-occurrence’ of the two issues in between 30 percent and 50 percent of the people treated at Coastal Horizons.

“It’s an aspect of the opioid crisis; not everyone picks up on this,” House said. “But it’s not a simple answer – it’s not a simple relationship between things like anxiety and depression and substance use. You can’t treat them as separate, you’d just be chasing your tail. We see a lot of co-occurrence, and we treat the issues concurrently.”

Where you see opioid addiction, you often see mental health issues, but correlation is not causation. House said many people deal with mental health without ever using an illicit substance; many people abuse opioids for reasons that have nothing to do with anxiety or depression. But when the two do overlap, and that happens a considerable amount, it is often the result of self-medication.

For lack of treatment — self medication 

Self-medication happens in the absence of clinical treatment. There’s plenty of opportunity for that to happen.

Only slightly more than one third of adolescents received treatment for episodes of major depression, according to the North Carolina Department of Health’s 2014 Behavioral Health Barometer report. Between 2006 and 2013, approximately 41,400 children between 12 and 17 had major depressive episodes that went without clinical treatment.

The percentage rates for adults were only slightly better. Between 2009 and 2013, 46.4 percent of adults with a mental health issue received treatment. That leaves over half – 656,000 people per year – with untreated issues.

Data from the North Carolina Behavioral Health Barometer, 2014.
Data from the North Carolina Behavioral Health Barometer, 2014.

“Those are big numbers,” said House. “And you have to wonder what those people did, how they tried to deal with those issues.”

Self-medicating, House said, looks different for each individual, but there are some consistencies.

House explained: “If I have an anxiety disorder, I might want to try a sedative, marijuana or an opioid, something that might help me feel calmer. If I had a depressive issue, I might want to try cocaine or amphetamines, something to help me be able to have fun, to feel, basically. I’m trying to treat myself.”

A prevalence of trauma

There seems to be a more intimate link between mental health and opioid and alcohol abuse than with other substances. Speaking with head administrators of RHA Behavioral Health, a non-profit that ance issues, Chief Operating Officer Kathy Smith said well over half of their patients deal with co-occurrence; the prevalence has changed the shape of their treatment models.

Heroin or Hydrocodone? Opiates or opioids? The conversation about this epidemic is often peppered with technical terms and names. Check out our appendix of terms.

One change, according to Clinical Director Sharlena Thomas, was taking into account the relationship between psychological trauma and opioid use. Trauma, whether from physical, sexual or mental abuse, can leave people dealing with intrusive and nightmarish memories, as well as symptoms of anxiety and depression.

Thomas said, “the desire to push things away, to not deal with it, to forget is powerful. Sadly, opioids are probably the best thing for forgetting.”

Likewise, House said, “when you’re dealing with trauma, you’re in pain, this numbs pain.”

House also said that self-medication of trauma symptoms was very common in his practice.

“You don’t assume it, but you almost assume it,” House said. “To put it a better way, it’s so prevalent that you have to be ready for it. That’s why so much of our staff is trained for dealing with trauma.”

Treatment’s dwindling funding

Whether rooted in trauma or genetics – or other factors, some still not well understood – mental health has a powerful relationship with opioid addiction. So why aren’t more people getting help for mental health issues, perhaps before turning to self-medication?

Part of the answer is funding, which has suffered a series of setbacks since the 1980s.

National Institute for Mental Health funding from 1998 until 2015. Despite several funding bumps, inflation has decreased the impact of spending while the cost of treatment has gone up. (Courtesy NIMH)
National Institute for Mental Health funding from 1998 until 2015. Despite several funding bumps, inflation has decreased the impact of spending while the cost of treatment has gone up. (Courtesy NIMH)

President Ronald Reagan’s 1981 budget reconciliation established block grants – large lump sum funding packages the states could appropriate as they felt necessary – but cut federal funding for mental health care by 30 percent. More recently, the three years following the 2008 financial collapse saw states cut a collective $5 billion dollars from mental health funding.

Just last year, the 2016-2017 North Carolina budget cut $152 million from regional managed care organizations like Wilmington’s Trillium, the government-run agency that directs state funding to groups like RHA and Coastal Horizons.

Regional health care agencies have been able to avoid losing beds, but new programs and expansions have been shelved or canceled. And, according to House, because funding is often earmarked for both mental health and substance abuse, the increased demand for funding to fight the opioid epidemic has limited money for treating anxiety and depression.

The problem no one wants to acknowledge

Port City Daily spoke about getting people with mental health into treatment with health care professionals at RHA, Coastal Horizons and New Hanover Regional Medical Center. In each case, funding was not the primary concern. Stigma was.

Social stigma, which as much as anything else ties mental health to substance abuse, comes from the community, House said.

Mike Page, an outreach worker for North Carolina Harm Reduction Coalition, said, "those who are dealing with trauma, with mental health issues, they don't want to talk about it. They'll talk about shooting up, about scoring, all that. Sometimes there's a clear issue underneath it, but it's harder to get at." (Photo Benjamin Schachtman)
Mike Page, an outreach worker for North Carolina Harm Reduction Coalition, said, ‘those who are dealing with trauma, with mental health issues, they don’t want to talk about it. They’ll talk about shooting up, about scoring, all that. Sometimes there’s a clear issue underneath it, but it’s harder to get at.’ (Photo by Benjamin Schachtman)

“It’s not just denial, a ‘we don’t have a problem’ issue,” House said. “It’s a ‘we don’t talk about that.’ That can really isolate people – people who are already feeling isolated by their anxiety or depression, people who are already feeling isolated by their opioid use.”

House said this silent stigma makes people with mental health issues more likely to try and self-medicate – it also makes those with substance abuse issues less likely to seek out treatment.

RHA’s Thomas said when people do talk about mental health and addiction, the language used is also part of generating stigma.

“Instead of heroin addict we could say a person addicted to heroin, instead of schizophrenic we could say a person with schizophrenia,” Thomas said. “Some would say that its semantics, but the language reduces people to their symptom or their issue, it makes conversations harder.”

Olivia Herndon, director of public and mental health at the South East Area Health Education Center, said addressing stigma is one of her major goals.

“I try to put it in the perspective with a more physical medical issue,” Herndon said. “If your neighbor had cancer, what would you do? Would you take them a casserole, help drive them to treatment, of course you would. If your neighbor was addicted to heroin, if they had anxiety attacks, you might not respond the same way. You might stay away. That’s where education comes in, that’s something we can change.”

Monday: with a better idea of who is using opioids and why, we turn to current efforts to deal with the epidemic.

Part I – The epidemic, by the numbers

Part II – Opioids: from heroin to prescription pills to and ‘psycho synthetics’

Part III – The many changing faces of opioid addiction

Part IV – Mental health and opioid abuse

Part V – The power and potential risk of harm reduction

Part VI – Opioid demand, the fear of detox and the path to treatment

Part VII – The opioid supply: from cartels and gangs to family and friends

Opioids: An appendix for readers