In an analysis of records from two Baltimore community mental health centers, Johns Hopkins Medicine researchers found that people with serious mental illnesses such as schizophrenia or severe bipolar disorder were 20 times more likely to use heroin than the general population. The researchers also discovered that only one in seven of these patients received medication for opioid addiction. The researchers note that this may be in part because addiction treatment programs weren’t designed with serious mental illness in mind.

In their study published in the February 2021 issue of Psychiatry Research, the investigators note that specialized treatment programs and greater awareness among addiction treatment providers of underlying mental health conditions may be required to meet this underserved population’s needs. More aggressive treatment of the mental disorders also may be necessary to reduce the disparity.

Evidence-based programs for treating substance use disorders employ medications such as buprenorphine or methadone, as well as services such as group therapy, doctor appointments and drug testing.

“People with serious mental disorders don’t do well in this type of structured treatment setting. They may not be organized enough or may seem distracted, they may feel uncomfortable in groups or they may make other people uncomfortable,” says study senior author Stanislav Spivak, M.D., assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. “Similarly, the negative symptoms that accompany serious mental disorders such as apathy, ambivalence or social withdrawal, can decrease these patients’ ability to fully participate in treatment.”

“Providers who treat substance use disorders need to be made aware of these symptoms as potentially being related to an underlying mental illness, and they shouldn’t dismiss these patients as disinterested or intentionally trying to be difficult,” he explains.

After reviewing the records of 271 patients with severe mental illness, researchers found that 32% said they used heroin compared with 1.6% of the general population reporting heroin use. Of those patients with a history of drug use, 15% were treated with medications typically prescribed to treat substance abuse. About 59% of these patients were taking at least one anti-psychotic medication, and those people were four times more likely to also be treated for addiction. Patients that scored high on questionnaires measuring social avoidance symptoms were less likely to be treated for their substance abuse.

“There are likely many factors as to why drug use is so much higher in people with severe mental illness,” says study lead author (and senior author Spivak’s wife) Amethyst Spivak, J.D., who started out as a researcher at the Johns Hopkins University and is now a board member of the National Trafficking Shelter Alliance. “Some of it may be due to self-medication. However, much of the issue lies in that this is a vulnerable group of people. They may have poor coping skills, are more likely to be exposed to drugs and may be less likely to push back when offered drugs.”

She adds that exposure to drugs is greater in low income neighborhoods and, unfortunately, people with serious mental illness are more likely to be impoverished.

Because this was a small study focused on one city, the researchers say they now need to see if these trends are representative of people with mental illness across the nation.

The researchers note that this research was only possible after a large gift from an anonymous donor.

Spivak is available for interviews.