Communities in Crisis

Close up of a teenage girl, she is biting her nails.

America’s growing opioid epidemic and untreated serious mental illness is having a devastating impact on communities nationwide.

Substance Use Disorders and Serious Mental Illness: A Dual Challenge

The dual challenge of America’s growing opioid epidemic and untreated serious mental illness is having a devastating impact on communities nationwide. Nearly 10 million adults have serious mental illness, and 20 million have a substance use disorder. Drug overdoses alone now top annual death rates from car crashes and gun violence. Despite the massive need for treatment and recovery services, gaps in care are alarming. Nearly nine in 10 people with a substance use disorder (88%) and more than one in three people with serious mental illness (35%) did not receive treatment for their conditions.

While national and state initiatives are vital, it is local communities that experience the human and economic costs of these dual challenges. Untreated serious mental illness and substance use disorder contribute to rising rates of incarceration, homelessness, and use of emergency services, straining local criminal justice systems, law enforcement, first responders, and community and public health resources.

These epidemics have a particularly daunting impact on rural communities, where the rate of opioid-related overdose deaths is 45 percent higher than in metro-area counties. Smaller cities and counties have a lower tax base and fewer resources, including behavioral health care providers, at their disposal, resulting in more limited access to care and treatment relative to urban centers.

Communities Respond

Cities and counties are responding by designing, funding, and launching local initiatives to alleviate the human and economic devastation of untreated illnesses and disorders in their communities. This new paper, written by Manatt Health and funded by the Robert Wood Johnson Foundation, explores how cities and counties have launched local initiatives to address the dual challenges.

Manatt interviewed and developed detailed profiles of 13 local initiatives and created a comprehensive taxonomy to categorize local program elements and features. The report describes efforts that train law enforcement officials and other first responders in de-escalation tactics, deliver therapeutic treatment in jails, and create criminal justice diversion programs that direct individuals away from incarceration and towards treatment, housing, and therapeutic and social support services.

Successful efforts typically coordinate law enforcement, criminal justice, public health, health care, and social service resources to improve access to, and deliver a broad spectrum of treatment, recovery, health, and social services for people with untreated serious mental illness and substance use disorders.

Key Findings

While local approaches vary in how they address the needs and impact of individuals with substance use disorders and serious mental illness, successful efforts are marked by factors including:

  • Collaboration and alignment between city and county agencies and community-based health and social service providers;

  • Access to health and social service benefits, including health insurance and social security, treatment and recovery services, housing, transportation, and other social supports;

  • Care coordination and management, using case workers and counselors to develop individualized care and transition plans to help clients navigate and access public and private services;

  • Community engagement and advocacy to overcome the stigma of serious mental illness and substance use disorder, and mobilize and coordinate public and private resources; and

  • Sustainable financing that leverages federal, state, local, and philanthropic funding streams.

Bright Spots

Jail and Emergency Department Diversion in Texas

Officials in Bexar County, Texas, reduced rates of incarceration, recidivism, and avoidable use of emergency response services by individuals with substance use disorder. The county established a “Restoration Center” to assist with detoxification, sobering, outpatient treatment, and in-house recovery. Combined with crisis intervention team training, the program and its associated jail diversion program diverted more than 17,000 people from jails and emergency departments, saving Bexar County taxpayers more than $10 million a year.

Safe Stations in New Hampshire

Officials in Manchester, New Hampshire, launched Safe Stations to reduce drug addiction and opioid-related overdoses by connecting people with treatment at fire stations. While not directly attributed to the program, as of early 2017 suspected overdose rates in Manchester decreased 44 percent, and the suspected fatality rate dropped 53 percent compared to 2016. Administration of overdose treatment medication by the fire department decreased and local police reported that Safe Stations gave them greater freedom to focus resources on criminal investigations.

Looking Ahead: Evaluating and Spreading Interventions

The authors report that many local programs targeting untreated substance use disorder and serious mental illness are not well understood beyond their communities. There is a significant need for thorough evaluation and widespread dissemination of successful local approaches. Specifically, more research is needed to understand what approaches communities can most readily and effectively adopt to address the impact of these untreated illnesses and diseases. More evidence will allow city and county leaders to make better informed decisions about investing in programs that improve the well-being of individuals, and help mitigate the impact they have on local communities.

About Manatt Health

Manatt Health is an interdisciplinary policy and business advisory division of Manatt, Phelps & Phillips, LLP, one of the nation’s premier law and consulting firms. Manatt Health helps clients develop and implement strategies to address their greatest challenges, improve performance, and position themselves for long-term sustainability and growth. For more information, visit


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