The federal government gave the behavioral health industry a behind-the-scenes look at its strategic priorities for the coming years earlier this month.

Those priorities, outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA), include a push to better integrate behavioral health care into physical health care — and the other way around. Other efforts include expanding access to care, prevention and mental health awareness.

The five priorities outlined focus on addressing suicide, overdose deaths, youth and family resilience and the behavioral health workforce.

SAMHSA, the federal government’s top behavioral health care regulator, has also undergirded its plan with a focus on equity, trauma-informed approaches, recovery and a commitment to evidence.

“This four-year plan emphasizes a more person-centered approach and introduces a new mission and vision, key guiding principles, and priorities,” Miriam Delphin-Rittmon, assistant secretary for mental health and substance use for the U.S. Department of Health and Human Services (HHS), said in the introduction of the plan.

The plan is to serve as a roadmap for the execution of several other efforts pushed by the Biden administration and Congress over the last few years. That includes the Bipartisan Safer Communities Act, the HHS strategic plan and President Joe Biden’s unity agenda, which contained several behavioral health initiatives.

The five priorities are:

— Preventing substance use and overdose

— Enhancing access to suicide prevention and mental health services

— Promoting resilience and emotional health for children, youth, and families

— Integrating behavioral and physical health care

— Strengthening the behavioral health workforce

The new plan also represents the increased role that SAMHSA will play in addressing these challenges through various federal and state initiatives. The agency received $7.5 billion in the latest government funding bill, an increase of more than $1 billion over its budget from the year before.

The industry reacts the SAMHSA’s strategy

SAMHSA presented the plan as an aid to other federal and state government leaders developing or implementing behavioral health-related programs. However, much of the work of treatment and recovery is done by operators in the private sphere.

“This agenda is huge, complex, and high-level,” David White, CEO of BayMark Health Services, one of the largest behavioral health organizations in the U.S., told BHB. “The strategy, in most cases, is spot on, but it’s a very heavy lift for the execution phase and requires lots of great people with great abilities to impact each and every area in the way outlined.”

BayMark Health Services operates 237 addiction treatment and mental health services locations.

White said the wider behavioral health industry needs to see a “multipronged and complex dedicated implementation plan that is comprehensive and detailed.”

He also presented two concerns. On one hand, he worries that the plan doesn’t account for the evolution of opioid use disorder (OUD) treatment involving fentanyl and other synthetic drugs such as the animal tranquilizer xylazine. He also worries that an emphasis on increasing the utilization of medications for OUD undermines the use of therapy in addiction treatment. In combination, specific medications and therapy form the gold standard for treating OUD, medication-assisted treatment (MAT).

“The evidence has shown both in mental health and SUD treatment that a multidisciplinary treatment team is the best approach to having successful outcomes,” White said. “In many providers’ opinion, [medication] to treat opioid use disorder allows too many to believe that medications alone will be effective.”

The report emphasizes the removal of the X waiver, which required prescribers to undergo special training to prescribe MAT, as something it seeks to leverage into greater access to OUD treatment.

The Consolidated Appropriations Act of 2023, the most recent congressional funding bill, eliminated the X waiver. This regulatory certification was seen as a barrier to getting physicians cleared to prescribe buprenorphine, a vital medication for MAT for OUD. With its elimination, any clinician cleared to prescribe controlled substances can now prescribe buprenorphine.

Still, many experts were doubtful that eliminating the X waiver would have a major impact on increasing the use of buprenorphine in settings outside of addiction treatment provider settings.

SAMHSA maintains that MAT is underutilized. It also holds up contingency management, psychotherapy and other non-pharmacological interventions in recovery efforts. This includes harm reduction.

The role of harm reduction in prevention

Harm reduction features prominently in SAMHSA’s plans to prevent overdose deaths.

The term encompasses several community health efforts to prevent people in active addiction from dying, worsening their health or the health of others. These practices include, to name a few, clean needle exchanges, drug testing kits, safer sex kits, disease testing (HIV and Hepatitis), overdose reversal drugs and training.

“For individuals who may have a SUD or need more intensive services, SAMHSA supports a range of more targeted mitigation services, including harm reduction approaches such as distribution of naloxone and fentanyl test strips to those at high risk for overdose,” the plan states.

Some see the practices as enabling illicit drug use; others see them as a means of ensuring those in addiction remain alive and well enough to seek treatment when ready. The Biden administration previously signaled that it sees harm reduction as key to its policy efforts.

“Substance use is a chronic disease. We do not penalize people when their blood sugar goes out of whack or when their blood pressure goes a little too high,” Dr. Harsh Trivedi, CEO of the Baltimore-based behavioral health system Sheppard Pratt, told BHB. “We really do have to think about substance use in a different manner, which is that it’s going to be something that people battle over time. We can’t let a slip up mean that you, essentially, are out of treatment, which is exactly what you wouldn’t do for any other medical condition.”

Sheppard Pratt is a behavioral health and social services system that operated over 380 sites of services and employe over 5,000 people in 2022.

Trivedi, who is also the board chair of the advocacy group the National Association for Behavioral Healthcare, said integrating behavioral health into physical health, and vice versa, requires federal support for electronic health record (EHR) implementation.

Only 37% of nonfederal mental health facilities and 32% of nonfederal addiction treatment facilities that accept Medicaid use an EHR, according to a 2021 congressional research report.

Much of the discourse around greater behavioral health access through integrated care has focused on integrating behavioral health into physical care, not the other way around. Trivedi said the Maryland Primary Care Program (MDPCP) has tested making the behavioral health setting the “medical home” for patients receiving integrated care with Sheppard Pratt.

“Doing a reverse integration actually showed the most benefit,” Trivedi said. “I think the fact that [SAMHSA] is specifically pointing out kind of that integration of physical health into the behavioral health side — there’s good evidence to support that — I think it’s a positive way to go.”