Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Pregnant women who are incarcerated are more likely to have mental health and substance use disorders (MH/SUD) than the general population.[3] Unfortunately, these individuals do not consistently receive the care they need, including medication to treat SUDs.[4] In addition to SUD treatment, pregnant women who are incarcerated often need care for mental health conditions, such as postpartum depression or depression related to pregnancy.[2] Many incarcerated individuals are primary caretakers,[5] and incarcerated parents experience higher rates of depression, anxiety, and increased stress due to the lack of contact and forced separation from their children.[6] Informed care for pregnant women and primary caregivers who are incarcerated, including adequate screenings and treatment for MH/SUD issues, should be a mandatory federal requirement.[1][2]

Instrumental Activities of Daily Living (IADLs) are the activities we do every day to maintain an independent lifestyle and are a crucial tool for assessing and ensuring quality of life.[2] They include cooking, cleaning, transportation, laundry, and financial management.[3] IADLs are traditionally closely associated with Activities of Daily Living (ADLs) which are concerned with basic self-care skills such as eating, bathing, and mobility; and both are used by occupational therapists to determine the balance of independence and support a person needs when recovering from a physical or cognitive injury, or older adults facing physical or cognitive decline.[3] While IADLs are assessed for all hospitalized patients, individuals with a mental health or substance use disorder (MH/SUD) may experience challenges beyond IADLs. MH/SUDs can impair a person’s ability to make and hold appointments, shop for basic necessities, and other activities that impact quality of life. Additionally, their IADLs may never be assessed if they are never hospitalized. Those experiencing MH/SUD could benefit from the support IADL assessments and support services offer.

The number of incarcerated individuals with a mental health or substance use disorder (MH/SUD) continues to increase and conditions in correctional facilities can exacerbate these issues.[4] Many criminal legal system employees lack the necessary training to support an incarcerated individual with MH/SUD.[5] Similar to the recruitment incentives currently available through the Bureau of Prisons, there should be a federal incentive for criminal legal system employees to obtain training on MH/SUD issues and screening techniques.[1][2][3][6] With the knowledge, skills, and understanding to successfully identify and screen for MH/SUD,[5] employees can identify individuals in crisis and provide more appropriate interventions.[7]

In 2016, the CDC developed a “Guideline for Prescribing Opioids for Chronic Pain.”[2][3] To align with new evidence, the CDC updated its 2016 recommendations in the 2022 “Clinical Practice Guideline for Prescribing Opioids for Pain”[3] to go beyond recommendations for chronic pain (>3 months) and included management of acute (<1 month) and subacute (1-3 months) pain, as well as recommendations for primary and non-primary care prescribers.[3] In an effort to improve the safe prescribing of these drugs, the Food and Drug Administration (FDA) also incorporated guidelines, including the CDC guidelines, into its Risk Evaluation and Mitigation Strategies (REMS) for providers who prescribe opioid analgesics.[4]

CMS should require the use of similar guidelines for prescribers.[1] Medicare prescription drug plan sponsors are required to develop drug management plans (DMPs) for individuals with a history of an opioid-related overdose.[3] However, there is no required training for individuals who prescribe opioids for pain in Medicare. In addition, CoPs for Medicare and Medicaid do not include recommendations for prescribing opioids for pain.[5] To align with the CDC’s updated recommendations for prescribing opioids for pain, CMS should require trainings for prescribers and incorporate the guidelines into CoPs.[1]

IMDs are facilities of 16 beds or more that are primarily engaged in diagnosing and treating MH/SUD.[3] These facilities can provide timely and comprehensive care to patients with MH/SUD needs. However, Medicaid beneficiaries experience significant barriers to their services due to CMS’s exclusion of those facilities from coverage for patients between the ages of 21-64.[3] Most Medicaid beneficiaries receive no federal reimbursement toward their care when treatment at an IMD is required.[3] No patient should be denied coverage due to the type of facility required for their care. Establishing Medicaid state plan options for residential care that include IMDs would be an incremental improvement. However, eliminating the IMD exclusion under Medicaid is vital for long-term improvements in access to care.[1][2]

Inpatient treatment for mental health and substance use disorders (MH/SUD) are a critical part of the continuum of care. While about 87 percent of free-standing psychiatric hospitals accept Medicare and/or Medicaid, there is a 190-day lifetime limit on inpatient psychiatric treatment services under Medicare Part A.[3][5] This discriminatory lifetime cap affects many individuals with MH/SUDs, particularly those individuals with disabilities caused by their MH/SUD who may be enrolled in Medicare for decades and may have multiple inpatient stays over time.[6] Particularly given that this lifetime limitation does not apply to any other treatment covered by any government payer, Congress should eliminate this arbitrary restriction.[4]