An outbreak of hepatitis A in a number of states highlights the vulnerability of individuals suffering from both mental illness and substance abuse. Those most at risk —the homeless and formerly incarcerated—deserve “compassionate, evidence-based solutions,” says a TCR columnist.
Several states are in the midst of hepatitis A virus outbreaks. San Diego and the surrounding region are among the hardest hit, but southeast Michigan has more reported cases and more deaths. Utah, Colorado and Kentucky also have experienced outbreaks.
Understanding these outbreaks requires acknowledging the links between homelessness, addiction and mental illness—and it requires more than a single solution.
Hepatitis A is typically a disease spread by human contact with already-infected individuals or pieces of their stool that are too small to see. High-risk groups include the homeless, the incarcerated (and those released from prison) and drug users—all groups that have some overlap. The homeless and the incarcerated also suffer from mental illness and are drug users, a condition known as a dual diagnosis or co-occurring disorders, and the deficiencies of health care in many prison facilities make incarceration a key risk factor.
According to a 2009 National Coalition for the Homeless (NCH) fact sheet, the Substance Abuse and Mental Health Services Administration found that “20 to 25 percent of the homeless population in the United States suffers from some form of severe mental illness,” compared to only six percent of the population as a whole.
A one-year study of people with serious mental illnesses examined by California’s public mental health system found that 15 percent were homeless at least once in the previous 12 months.
In addition, the NCH fact sheet found that “some mentally ill people self-medicate using street drugs, which can lead not only to addictions, but also to disease transmission from injection drug use.”
The Los Angeles Times cites experts who say that 50 percent to 70 percent of homeless people with severe mental illness (SMI) also have problems with alcohol or drugs.
The likelihood of homelessness also is increased when you have a mental illness, an addiction disorder and a disease such as hepatitis A. None of these conditions is going to go away if you are homeless and have no access to health, substance abuse or mental illness services.
If only one of the three gets treatment, the other two remain, and the third may return because they are all connected.
In 2016, Kevin Fischer, executive director of the National Alliance on Mental Illness (NAMI) of Michigan, suggested on Michigan Public Radio that closing all the state mental hospitals in the 1990s by then-Gov. John Engler resulted in an “explosion in homelessness.”
The mentally ill were supposed to be sent home, but many ended up on the streets because the private mental health system and the patients’ families were not prepared to handle them.
Joel John Roberts, CEO of People Assisting The Homeless (PATH) Partners, says many people in the mental health field put the blame on Ronald Reagan, then governor of California, who they say released more than 50 percent of the state’s mental hospital patients and abolished involuntary hospitalization of people with mental illness.
“This started a national trend of de-institutionalization,” Roberts wrote.
Then, as president, Reagan ended funding for federal community mental health centers. No one expected the mentally ill to wander the streets. The feds thought the states would take care of them. The states thought private insurance or family would take care of them.
Somewhere, somehow, they were wrong.
To get these outbreaks under control, and to prevent future outbreaks, we need more support for mental health and substance abuse treatment, and better harm reduction strategies (including clean needle exchanges and safe injection sites).
Some of that funding could come from Medicaid if the Trump administration eliminates the Institutions for Mental Diseases (IMD) Exclusion, which prohibits Medicaid funds going to mental health providers with more than 16 beds. There’s bipartisan agreement that this rule, which dates back to 1965, needs to go. The executive branch can, has, and does issue exemptions for this rule, and Trump has pledged to speed up the process.
But virtually no one thinks the rule needs to remain.
More than money is needed. Sometimes only one co-occurring disorder is apparent. First responders need to be trained to look for and recognize both.
In 2017, the Michigan Department of Health and Human Services (MDHHS) & Michigan Association of CMH Boards wrote, “Supports and services for persons with co-occurring mental health and substance use disorders must be the norm for all agencies across the network.”
The department added this was because “it is more prevalent than addiction-only or mental illness-only among the people served by MDHHS providers. Practitioners in every program at all levels of care must be competent to address comorbidity in mental health and substance abuse treatment.”
Effective treatment, according to the NAMI, requires not only that both be treated—but preferably at the same time. It’s called integrated intervention, and often involves detoxification, inpatient rehabilitation with psychotherapy, supportive housing, maybe medications (either to treat mental illness symptoms or to control addiction) and self-help/support groups.
The Michigan House of Representatives’ bipartisan House C.A.R.E.S. (Community, Access, Resources, Education, and Safety) Task Force’s final report recommended that crisis intervention training (CIT) for first responders should include “information on signs and symptoms of mental illnesses” and “co-occurring substance use disorders.”
It also recommended that trial and pre-trial practices “should assess defendants to determine whether the person has a serious mental illness, co-occurring substance use disorder” and so benefit from “mental health services.” Better and more consistent efforts must be made to screen for mental illness and co-occurring substance disorders during the booking process, the task force said.
But that’s if the individual ends up in the mental health or criminal justice system. There are harm reduction practices that can save lives even if the person with mental health and substance-use disorder remains out of the system.
One is providing maintenance drugs (medication-assisted treatment or MAT) such as buprenorphine (brand name Suboxone, also available as an implant, Probuphine, that only needs to be replaced every 90 days) or methadone to addicts to prevent withdrawal, and there are drugs for mental illnesses such as depression, bipolar disorder, schizophrenia, and psychosis.
Another—although hep A isn’t as likely to be spread this way—is providing intravenous drug users with a safe injection space. These spaces are also known as safe consumption sites, fix rooms, drug consumption room (DCR), supervised injecting facilities, and shooting galleries. But they share the following characteristics: a clean facility, with clean needles, the availability of testing supplies to make sure the drug is unadulterated, and a nurse to administer naloxone in case of an overdose.
They not only save lives—no deaths have been reported at any such site around the world, including Canada and Australia—they also save money.
Editor’s Note: San Francisco is set to become the first in the U.S. to introduce safe injection spaces, with two sites scheduled to open in July.
A recent study estimated that such strategies could save an average US city $3.5 million per year and that some could save more (Baltimore: $6 million). The American Medical Association likes the idea, as do the Clinton Foundation and the Johns Hopkins Bloomberg School of Public Health.
Some in the anti-drug camp oppose harm reduction in particular, and substance abuse treatment in general. They prefer incarceration to rehab. Their position on the mentally ill is less clear, but maybe they feel that, too, is the result of a poor personal choice.
Maybe paying for these sinners to go to dual diagnosis treatment centers seems like rewarding bad behavior. The result: we have a homeless problem, an opioid epidemic, and hepatitis A outbreaks,
Punishment isn’t working, and science and public opinion now believe addiction is like a disease. It’s time to look for compassionate, evidence-based solutions.
Stephen Bitsoli, a Michigan-based freelancer, writes about addiction, politics and related matters for several blogs. He welcomes readers’ comments.