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Treatment More Effective than Prison for Dual Diagnosis

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It cannot be overstressed or repeated often enough: Substance use disorder (SUD) and mental illness are often co-morbid or co-occurring. It also is known as a dual diagnosis. According to the National Institute on Drug Abuse (NIDA), “people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true.”

The Substance Abuse and Mental Health Services Administration (SAMHSA) 2014 National Survey on Drug Use and Health (NSDUH) put hard numbers on that likelihood: almost 44 million adult Americans have had “some form of mental illness,” more than 20 million have had a SUD, and almost 8 million from those two groups have had both.

How many of the nation’s prison population merits a dual diagnosis is unknown but is believed to be a higher percentage than in the general population. If the White House succeeds in placing more drug users in prison, that rate will probably increase even more. As one commentator wrote, “if we’re arresting tons of people for drug possession, drug use, drug selling, drug dealing, it makes perfect sense that we’ll pick up people with mental illness.”

The question is whether comorbid drug offenders will get better or worse in prison. Currently at least one of two co-occurring disorders is missed, so it doesn’t get treated. That’s a problem because co-occurring disorders are often related. Someone with a mental illness might use drugs in an attempt to self-medicate. Occasionally alcohol or drug abuse might cause or trigger a mental illness. When only one disorder is treated, not only does the second disorder remain, but the first might recur. Both need to be treated, and often simultaneously.

The desire to incarcerate more drug users seems to be based on a punitive Puritan mindset: substance use — addiction, alcoholism — is a conscious choice, the result of a decision to be bad and/or escape reality, and is evil. The best evidence now is that it is more like a genetic predisposition, a chronic brain condition that responds poorly to imprisonment or forced treatment. Former US Surgeon General Vivek Murthy compared it to diabetes, hypertension, asthma and other medical conditions that don’t receive similar approbation. Cognitive behavioral therapy (CBT), sometimes coupled with medication-assisted treatment (MAT), such as Suboxone or methadone is the most effective treatment.

The president’s commission on the opioid epidemic suggested more money be put into substance abuse treatment centers that offer CBT and MAT. Let’s hope the White House doesn’t put all its eggs in the law enforcement and punishment basket.