STATEMENT: Access to medications is critical for people with serious mental illness and addiction. Due to research in the last decade, new medications have been developed that can have better outcomes and fewer side effects for individuals with serious mental ill-ness and addictive disorders. Studies have shown that by cutting costs in the area of mental health and substance abuse medications, states have spent more money on even more costly services such as crisis care and hospital services for the long term. Most importantly, quality of life for individuals is impaired and the individual may not fully recover to the functioning level that they had achieved before switching medications. Use of medications or procedures to reduce the risk of addiction or diversion for illicit activity from treatment is also critical.
Mental Health America of Indiana will work to ensure that persons with mental illness and addictive disorders have access to the most appropriate medications, whether they are pro-vided by Medicaid, DMHA, DOC, local jails, private insurance, or by any other payer source or in any other treatment setting. MHAI will also work to reduce the diversion and misuse of addiction medications.
PRIORITY LEVEL: I
STATEMENT: Mental health, addictions, as well as individuals with co-occurring developmental disabili-ties often fall through the cracks in our criminal justice system. Our correction facilities are often not appropriate for persons with a mental illness or addictive disorders. Diversion, when appropriate, may avoid the criminalization of mental illness and addictions and the resulting labeling that often creates barriers to housing, employment, and the ability to be a productive member of society.
MHAI will advocate for a comprehensive change in our system so as to provide for a con-tinuum of mental health and addictions treatment for patients charged with a misdemeanor or felony, both juveniles and adults. The continuum must include: a statewide pre-& post-diversion program with treatment for individuals, problem-solving courts, including mental health and drug courts, a statewide community corrections program with a mental health and addiction treatment component; re-entry programs, including treatment, employment, and sealing criminal records from the public when appropriate; as well as a forensic facility designed to treat forensic patients that includes access to appropriate mental health and ad-diction medications. Police and correction officers must receive adequate mental health and addiction education and programming. Access to funding through Medicaid and other sources when permitted must be made available to ensure access to treatment through DMHA certified community-based care providers.
ARREST AND CONVICTION ADMISSIONS
An overcrowding and an ever-expanding Department of Corrections budget is due in large part to offenders who recycle back through the system or recidivate. One of the main predictors of whether or not an ex offender will return to prison is his or her ability to get a job. Non-violent alcohol and other drug offenders often face life long barriers to securing employment due to their criminal histories. MHAI will work to improve legislation that will eliminate the barriers associated with crim-inal histories that prevent ex offenders from securing employment.
AUTISM and INTELLECTUAL DISABILITY
Individuals with Autism Spectrum Disorder or an intellectual disability, like those with mental illness or substance abuse, should be permitted to participate in a foren-sic diversion program. Further, a criminal court should be permitted to appoint a court appointed special advocate to assist a person with Autism or an intellectual disability who is charged with a criminal offense. MHAI will support alternatives to incarceration for persons with disabilities.
PRIORITY LEVEL: I
STATEMENT: Indiana, along with the rest of the nation, is experiencing a public health crisis. Prescription drug abuse has been declared an epidemic by the CDC and heroin use and overdoses are increasing at unacceptable levels. Individuals with opioid addiction are often unable to ob-tain detoxification services appropriate to their treatment plan. Some are denied coverage for inpatient detoxification services due to a medical necessity provision requiring a life-threatening situation, which opioid addiction rarely is. Outpatient detox is not always an appropriate option for all patients, as inpatient might be required for a successful outcome with Medication Assisted Treatment, severe co-morbidities and/or mental illnesses, multiple failed attempts at out-of-home detox and/or homelessness.
In the years since the National Center on Addiction and Substance Abuse released its first report on substance abuse among the nation's prison population, little progress has been made in reducing the number of inmates with substance abuse problems crowding the na-tion's prisons and jails. In fact, 65 percent of the nation's inmates met certain medical crite-ria for substance abuse and addiction, but only 11 percent received treatment for their addic-tions (The Nation's Health Online Publication). Indiana DOC estimates that over 80 per-cent come with a substance abuse issue
The National Center on Addiction and Substance Abuse found that of the 2.3 million U.S. inmates, 1.5 million suffer from substance abuse addiction and another 458,000 inmates either had histories of substance abuse, were under the influence of alcohol or other drugs at the time of committing their crimes; committed their offenses to get money to buy drugs; or were incarcerated for an alcohol or drug violation. Combined, the two groups make up 85 percent of the U.S. prison population, according to the report, "Behind Bars II, Sub-stance Abuse and America's Prison Population." The report also found that alcohol and other drugs are significant factors in all crimes, including 78 percent of violent crimes, 83 percent of property crimes and 77 percent of public order, immigration or weapons offens-es as well as probation and parole violations. Many individuals released from prison are prime candidates for Medication Assisted Treatment (MAT).
MHAI supports access to comprehensive opioid addiction treatment programs which in-clude access to counseling, detoxification, and medication assisted treatment (MAT) agents to provide comprehensive opioid addiction treatment plans for successful recovery out-comes. This treatment must be accessible in community-based treatment, child welfare, DOC, jails as well as probation and diversion. Opioid Treatment Centers must be integrat-ed into the healthcare delivery system including use of assessments, treatment plans fo-cused on abstinence if appropriate with periodic review, therapy, all available MATs based on clinical need and informed consent, and required acceptance of Medicaid/HIP and insur-ance for services provided. MHAI will also support access to abuse deterrent formulations of opioid medications as a means to mitigate the initial abuse.
PRIORITY LEVEL: I
STATEMENT: By all accounts, there are many more persons in need of services from the Division of Mental Health and Addiction up to 200% of poverty level, than are receiving services. SED children and individuals with addictive disorders have the greatest deficits. It is im-perative that the budget for the Division of Mental Health and Addiction be increased for community services. The gap that currently exists between the need and the services pro-vided has left the system in need. Still, the total budget for State Operated facilities as com-pared the community mental health is well above the national average. MHAI supports re-directing funding to community based services when community services are most appro-priate.
Mental Health America of Indiana will work to ensure that mental health and addiction ser-vices are appropriately funded through the DMHA budget and any other funding oppor-tunity.
PRIORITY LEVEL I
STATEMENT: The incidence of smoking among those with mental illness and addictive disorders far ex-ceeds the rates of the overall population. Secondhand smoke is a serious health hazard that causes premature death and disease. According to studies, smoke free policies decrease absenteeism among non-smoking employees, reduce maintenance costs, and lower insur-ance rates.
MHAI will support comprehensive legislation calling for smoke free air throughout Indiana that includes the provision of therapeutic and pharmacological interventions for persons with mental illness or addictive disorders. MHAI will also support efforts to increase the price of tobacco through taxes or other means in an effort to decrease utilization of all to-bacco products.
More than a quarter of the American population who are too young to drink are doing so anyway according to a new report issued today by the Substance Abuse and Mental Health Services Administration (SAMHSA). Although there has been progress in reducing the extent of underage drinking in recent years, particularly among those aged 17 and younger, the rates of underage drinking are still unacceptably high. Not only did 26.6 percent of 12-20 year-olds report drinking in the month before they were surveyed, 8.7 percent of them purchased their own alcohol the last time they drank. The study used combined data from SAMHSA’s 2008 to 2010 National Survey on Drug Use and Health (NSDUH).
Reallocating or raising the alcohol tax is a new way to provide funding for mental health and addition treatment. Additionally, research shows that an increase in al-cohol taxes or the cost of alcoholic beverages causes a decrease in underage con-sumption and adult high risk drinking. Increased taxes also lead to a decrease in al-cohol-related traffic crashes, violent crimes and cases of liver cirrhosis.
Alcohol taxes have not been raised in Indiana since 1981. Adjusting for inflation, the average Indiana beer tax in 2000 was one-third of the beer tax in 1968. The more the price is increased, the greater the impact on underage drinking. Indiana is losing millions of dollars in revenue each year that the tax remains the same, result-ing in inadequate funding for the enforcement of alcohol laws and the prevention and treatment of alcohol abuse.
PRIORITY LEVEL: I
STATEMENT: Mental Health America believes that all individuals and families should have access to a broad scope of medically appropriate, evidence-based interventions in the continuum of behavioral health services and supports.
Indiana--and the country as a whole--has expanded health care coverage in a way that in-cludes Parity for mental health and addictive disorders.
We have taken groundbreaking steps toward improving access to mental health and sub-stance use disorder treatment services. Significantly, we have included mental health and substance use disorder services as well as rehabilitative services as components of the es-sential benefits package that must be offered. We have created a health care system that provides a comprehensive, culturally and linguistically appropriate behavioral health system of services and supports.
MHAI supports the State of Indiana’ program in an effort to provide mental health and ad-diction services. In particular, MHAI supports the inclusion of individuals with Serious Mental Illness or chronic Substance Use Disorders access to the Medicaid Rehabilitation Option. In addition, MHAI supports CMHCs ability to make presumptive eligibility de-terminations under the Medicaid Program to ensure timely access of services. Finally, MHAI supports health care service integration including the establishment of behavioral Health Homes as well as the ability of CMHCs to bill for primary health services when an-cillary to behavioral health services.
Mental Health America of Indiana will work to educate the public through public relations and other means of advocacy regarding the need to access mental health and addiction ser-vices at parity. MHA will also work with local, state, and federal decision makers to en-sure adequate representation of behavioral health interests in the implementation of any healthcare legislation. Additionally, MHA will be engaged with employers, insurers, and providers to ensure that the implementation provides for meaningful access to behavioral health coverage and services.
PRIORITY LEVEL: I
STATEMENT: Each year in the U.S., thousands of Americans commit suicide. Suicide is the third leading cause of death for 15-to-24-year-olds, and the sixth leading cause of death for 5-to-14-year-olds. From 2002 to 2006 suicide was the 3rd leading cause of death for young Hoosiers ages 15-19. According to the 2007 Youth Risk Behavioral Survey, of In-diana’s 9th through 12th graders, 19.1% of girls and 12.4% of boys had seriously consid-ered attempting suicide in the last year. However, suicide is clearly not reserved for the young, as the rate of growth of suicide for older adults and veterans is increasing at alarm-ing rates. The lethal means affects the outcome, as men are more likely to use guns and the rates of successful attempts are greater as a result.
Mental Health America believes that suicide is preventable and that the individual needs to have his or her illness recognized and diagnosed, and appropriate treatment plans devel-oped. Adolescents, veterans, elder Hoosiers must all be educated and trained on suicide prevention and treatment must be available when needed.
MHAI supports evidence-based suicide prevention programs to help people identify mental health problems, connect individuals with care, and de-escalate crisis situations.
PRIORITY LEVEL: II
STATEMENT: Studies have shown that stigmatization and marginalization that is fos-tered by legal and social barriers to equality can have mental health consequences. These consequences can include a mental and emotional cycle of doubt, shame, self-loathing and fear. The result is a six-fold increase in anxiety and depressive disorders and an eight-fold increase in suicide attempts by gay teens. Successful suicide amounts to a three-fold in-crease over their heterosexual counterparts. LGBT individuals exhibit a higher prevalence of excessive drug, alcohol, and tobacco use and are also over represented among the home-less population. LGBT individuals have a 58% incidence of sexual assault, while 66% re-port being verbally abused and ridiculed and 44% are physically abused at school.
Constitutional bans on same-sex marriage have the effect of institutionalizing stigma and discrimination, thereby increasing the incidence of depression, anxiety and abuse. Mental Health America of Indiana would oppose a constitutional amendment that discriminates against same-sex marriage and will support legislation providing equal rights to LGBT in-dividuals as a protected class.
PRIORITY LEVEL: III
STATEMENT: While recognizing the potential harmful effects of perinatal exposure to alcohol, opioids, and other drugs including nicotine on the health and well being of the mother and the fetus, a multifaceted approach to the problem is required. Addiction is a brain disorder leading to compulsive use of substances, and many others may create this exposure due to a lack of awareness of what constitutes at-risk use during pregnancy. MHAI recommends an ap-proach that increases public education and awareness of the risk of use to the mother and fetus during pregnancy, improved screening for perinatal exposure, improved care and ac-cess to appropriate care for pregnant women who abuse substances, and appropriate medi-cation assisted treatment for the mother and needed supports upon delivery.
MHAI would oppose punitive approaches to address this problem, as such may increase the risk to the fetus and the mother by creating a disincentive to get care and increasing the risk to both during pregnancy.
PRIORITY LEVEL: II
STATEMENT: Indiana has the fourth largest number of National Guard members in the country. A large number of these individuals, reservists, and other members of the armed forces have served or are serving in Iraq (OIF), Afghanistan (OEF), and other war zones. Veterans frequently return home with significant mental health and substance abuse disorders including prob-lems in readjusting to family and civilian life. Post traumatic stress disorder (PTSD), trau-matic brain injury, and suicide are major concerns. Many are unable to access services for themselves or their families through the Veterans Health Administration (VA) and may al-so not qualify for Medicaid or public mental health system services. This problem is exac-erbated by the overall shortage of qualified mental health and addiction professionals throughout the State and specifically professionals trained to work with veterans.
MHAI will work to ensure access to quality mental health and addiction services for all veterans through VA administered services or services provided and reimbursed outside the VA system of care.
PRIORITY LEVEL: III
STATEMENT: The statistics describing the health, mental health, and safety issues affecting today's youths are concerning, yet represent a minute image of the overall of our priorities as a state. Par-ents and families still maintain the primary responsibility for ensuring healthy and safe en-vironments that are crucial to child and youth development. However, many parents and families lack adequate support systems and financial and emotional resources to carry out this task. In a rapidly changing and demanding society where children are increasingly in-fluenced by peers, media, technology, and negative public images, it is unrealistic to expect that even the average American family is capable of creating a thriving environment without any reliance on external formal and informal support systems in place. The state must re-quire minimum standards to ensure mental wellness and safety in environments including schools, childcare, child welfare and any arena that the state has authority.
Abused and neglected children are the state's most vulnerable, and overwhelmingly impacted by the Indiana Department of Child Services. MHAI supports services that provide for mental health treatment and safety.
The prevalence of mental illness, addiction and serious emotional disorders in chil-dren and youth under age 18 is oftentimes not adequately or appropriately diag-nosed. At the same time, the efficacy of early treatment for mental illness, addiction and serious emotional disorders is proven and the benefits have been demonstrated.
Mental Health America of Indiana supports and will work to guide and create, op-portunities for systematic, standardized and regular screening of children for mental illness, addiction and serious emotional disorders and youth in any and all appropri-ate settings including but not limited to public and private schools; child welfare; ju-venile courts; and primary care settings. Any screening program must:
MHAI supports all efforts to avoid stigmatization as well as the parent’s right to opt out. Once an illness is identified, treatment must also be made available.
Each year in the Indiana, public school personnel are regularly using restraint and seclusion to control student behavior. In a survey of approximately 1351 (67%) of Indiana’s public schools by the U.S. Department of Education, Indiana schools re-ported using mechanical restraints, seclusion or physical restraints 1650 times dur-ing the for the 2009-10 school year. Thus in Indiana in every school day on average at least nine children were being subjected to the use of mechanical restraints, seclu-sion or physical restraints.
As a result of the widely recognized risks of restraint and seclusion use, Indiana passed a statewide statute and is developing regulations and policies governing the use of mechanical restraints, seclusion or physical restraint in the public school setting.
MHAI supported the legislation and is a member of the Seclusion and Restraint Commission that is developing regulations, policies and guidelines that are uniform and statewide.
Children or adults who are bullied can experience negative physical, school, and mental health issues. Children who are bullied are more likely to experience depres-sion and anxiety, increased feelings of sadness and loneliness, changes in sleep and eating patterns, and loss of interest in activities they used to enjoy. These issues may persist into adulthood. Bullying can also lead to health complaints and de-creased academic achievement—GPA and standardized test scores—and school participation. They are more likely to miss, skip, or drop out of school. A very small number of bullied children might retaliate through extremely violent measures. In 12 of 15 school shooting cases in the 1990s, the shooters had a history of being bullied.
Mental Health America continues to support legislative action and implementation to reduce bullying among children and adults.
Trauma is a near universal experience of individuals with behavioral health disor-ders. According to the U.S. Department of Health and Human Services Office on Women’s Health, 55%--99% of women in substance use treatment and 85%--95% of women in the public mental health system report a history of trauma, with the abuse most commonly having occurred in childhood. An individual’s experience of trauma impacts every area of human functioning—physical, mental, behavioral, so-cial, and spiritual. The economic costs of untreated trauma-related alcohol and drug abuse alone were estimated at $161 billion in 2000. The human costs are incalcula-ble.
PRIORITY LEVEL: II
ISSUE: The mental health and addiction workforce has long been plagued by shortages, high turn-over, and a lack of diversity. There is certainly a need to train other health care providers as well as individuals in recovery to address behavioral health needs. Indiana must strengthen recruitment, retention, and training of specialist behavioral health providers and improve the financial and technical assistance infrastructure to better support and sustain the workforce. The pressing challenge is to scale up strategies to have a meaningful impact on the size and effectiveness of the workforce in light of the implementation of the Affordable Care Act. The aging and increasing diversity of the US population, combined with the expanded ac-cess to services that will be created by health reform, make it imperative to take immediate action.
MHAI will support behavioral health development programs, certificate and training of other healthcare professionals, loan forgiveness, and any other means to address the imme-diate workforce shortage, including parity in reimbursement for Addiction Counselors and Recovery Coaches as well as telemental health for behavioral health counselors.
PRIORITY LEVEL: I
STATEMENT: Indiana’s commitment to the provision of mental health care is stated in the Constitution. This commitment has historically taken the form of serving large numbers in state hospitals to now serving individuals in the least restrictive setting, with only a small proportion served in state institutions. However, Indiana must insure that consumers of mental health and addiction services have access to the full continuum of care, including inpatient psychi-atric services. The state must also insure the quality of these services and whenever appro-priate, ensure that they are evidence-based.
MHAI will advocate to ensure access to appropriate and quality services. Specifically, MHAI will work to ensure that an appropriate, evidenced-based, continuum of mental health services, including addiction services, are provided by appropriately credentialed personnel for current patients and individuals for whom long term services are appropriate. The Association will advocate for the provision of services in the least restrictive setting and the appropriate use of inpatient beds. Adequate funding must be made available and all dollars generated from potential efficiencies must be reinvested in the mental health system. Evaluation measures must be put into place with appropriate metrics tied to performance and payment.
PRIORITY LEVEL: III
STATEMENT: The process of determining guilt and imposing sentence is necessarily more complex for individuals with mental illness. A high standard of care is essential with regard to legal representation as is a psychological/psychiatric evaluation for individuals with mental ill-ness involved in death penalty cases. As it is the policy of our state is to treat those with mental illness, clearly mental illness should always be taken into account during all phases of a potential death penalty case. At a minimum, the death penalty should not be an option for those with severe mental illness.
MHAI will support legislation that prohibits the use of the death penalty for those with se-vere mental illness.
LEVEL OF PRIORITY: III
STATEMENT: Harm reduction is a set of practical strategies aimed at reducing the negative consequences associated with drug use. Harm reduction incorporates a spectrum of strategies from safer use, to managed use, to abstinence to work to minimize the harmful effects of drug abuse. Drug use is a complex, multi-faceted phenomenon that encompasses a continuum of behav-iors from severe abuse to total abstinence and some ways of using drugs are clearly safer than others. MHAI supports the non-judgmental provision of services and best practices to people who use drugs and the communities in which they live in order to assist them in re-ducing attendant harm.
MHAI supports access to naloxone by individuals, family members, first responders and community organizations to reduce overdose deaths from drug abuse. MHAI will also support needle exchange programs when such are designed to reduce the incidence of HEP C and HIV. MHAI recognizes that Harm Reduction is an important first step that must be followed with comprehensive treatment and recovery.
PRIORITY LEVEL: III
STATEMENT: As a disease, addiction has biological, psychological, behavioral and social components. Treatment of the disease is critical, but ongoing recovery support is equally important. Re-covery housing plays a vital role in the social and behavioral aspects of this disease. Main-taining abstinence for individuals in recovery from substance use is a challenging task. Post-treatment relapse rates vary across studies and definitions of relapse but often exceed 50% within 12 months of treatment. For example, one study found approximately 65% of individuals exiting substance abuse treatment did not remain abstinent two years following the end of substance abuse treatment. Among a sample of over 2,200 participants, another study found a 69% relapse rate at a one-year follow-up. A study conducted by the NIDA determined that 30-day treatment centers were approximately 30-35% more successful in treating addictions. The same study found that if clients transitioned from residential care into some form of aftercare for 6 months or more that the success rates increased to 65-70%.
Recovery housing, an evidence-based practice recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Housing and Urban Development (HUD) must meet standards of quality in order to be effective. The National Alliance of Recovery Residences (NARR) has developed quality standards for recovery housing that includes comprehensive nomenclature, national standards to promote quality, and a certifi-cation program. It has 20 state affiliates, INARR (Indiana Alliance of Recovery Residenc-es) being one.
MHAI supports increased access to Recovery Residences and certification for quality as-surance.
PRIORITY LEVEL: I
STATEMENT: Nationally, deaths involving opioids have more than quadrupled since 1999. The sharp rise in opioid overdose deaths closely parallels an equally sharp increase in the prescribing of these drugs. Opioid pain reliever sales in the United States quadrupled from 1999 to 2010. Similarly, the substance abuse treatment admission rate for opioid abuse in 2010 was seven times higher than in 1999. Significantly, Indiana’s overdose death rate for 2010 (14.4 per 100,000 population) is above the national rate (12.4 per 100,000 population). Every ef-fort must be made to prevent the inappropriate prescribing which leads to Opioid Use Dis-order. These efforts should include:
MHAI will work to ensure appropriate evidence based prescribing of prescription opioid medications.
PRIORITY LEVEL: I
STATEMENT: MHAI was the leader in creating the Addiction Treatment Team model through legislation which would incentivize comprehensive treatment through professional teams, including a licensed prescriber, counselor, and certified recovery coach. These teams can operate as a mobile unit, but the funding source is limited to Recovery Works and should be expanded to Medicaid/HIP. As consumers in rural areas are relatively spread out, it becomes finan-cially unviable to send mobile units to these Mental Health Care Professional Shortage Ar-eas based on current reimbursement models. Expanding the funding sources for Addiction Treatment Teams and Assertive Community Treatment teams allows for greater utilization and penetration into rural and underserved areas, through an approved and existing federal program allowing service expansion to our most vulnerable Hoosiers.
MHAI will support expanding funding for Addiction Treatment Teams and Assertive Community Treatment Teams.
LEVEL OF PRIORITY: I
STATEMENT: Marijuana is the most-used drug after alcohol and tobacco in the United States. According to SAMHSA data, in the past year, 4.2 million people ages 12 and up met criteria for a substance use disorder based on marijuana use.
Marijuana’s immediate effects include distorted perception, difficulty with thinking and problem solving, and loss of motor coordination. Long-term use of the drug can contribute to respiratory infection, impaired memory, and exposure to cancer-causing compounds. Chronic use can also lead to compulsive vomiting requiring medical visits and hospitalization for Cannabinoid Hyperemesis Syndrome. Heavy marijuana use in youth has also been linked to increased risk for developing mental illness and poorer cognitive functioning. Studies show that marijuana use has been tied to psychotic behavior and may increase the likelihood of Opioid Use Disorder.
Symptoms of cannabis use disorder include disruptions in functioning due to cannabis use, the development of tolerance, cravings for cannabis, and the development of withdrawal symptoms, such as the inability to sleep, restlessness, nervousness, anger, or depression within a week of ceasing heavy use. Cannabis use can be particularly damaging to young people. Still scientific studies of cannabis may yield formulations and protocols that increase its utility and decrease the potential for physical damage to the lungs and airways as well as addiction. MHAI supports scientific research to determine the potential medical benefits of cannabis available by prescription as permitted by the FDA. This does not include the illegal use of marijuana for recreational or "medical purposes".
Criminalization of drug use can be a major barrier to getting people to initiate and accept treatment. It may also affect future employment, even when the charge is on a minor. While many American cities and states have legalized or decriminalized cannabis use and minimal possession, while retaining prohibitions of public use, only Indiana and Oregon have proposed to reduce penalties across the board for other drugs. Drug courts and other specialized treatment courts have provided an alternative to criminal sanctions, and some help for co-occurring mental health conditions. MHAI supports treatment for drug use generally (including cannabis use) in lieu of incarceration, whenever such does not pose a public safety risk.
MHAI supports the decriminalization of cannabis use such that treatment is made available in lieu of incarceration, but does not support the legalization of cannabis for recreational or “medical purposes” except as approved by the FDA.
PRIORITY LEVEL: III