Hi, my name is Tina Netto, and I'm the Chief Justice of the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry and other judges, and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. In this module, you're going to hear from Dr. Pinellas, who will talk to you about co-occurring disorders. We all know from being in our courtrooms that we see many offenders with substance use disorders, and almost all of them have a co-occurring mental health issue that challenges their ability to conduct themselves without committing crimes. So this module will talk not only about the addiction and science behind substance use disorder and the combination of mental health conditions, but also what kinds of behavior we can expect to see from people who suffer from those addiction issues and mental health issues. Sometimes we see folks in our courtroom and we expect them to act a certain way, and if we don't understand where they've come from, what they've struggled with, what their mental health conditions are, and how those conditions contributed to their substance use disorder, then we can impose appropriate sanctions or appropriate supervision conditions that will help them get well. So enjoy this module. Hi, my name is Dr. Debra Pinellas. It's a pleasure to be here today talking about co-occurring substance use disorders and mental illness. I'm on faculty at the University of Michigan, where I serve as the Director of the Program in Psychiatry, Law, and Ethics. I'm also a clinical professor of psychiatry. I am board certified in psychiatry, forensic psychiatry, and addiction medicine. As part of my duties, I also serve as the Medical Director for Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. I have no conflicts of interest pertaining to this presentation. I do consult to a variety of states, organizations, and government agencies on behavioral health and justice system, and I perform expert witness activities. I should note that the opinions in this presentation are mine and do not represent any government or academic or other entities with whom I am affiliated. Today we're going to be talking about co-occurring mental health disorders and substance use disorders. In this presentation, my hope is that you will be able to describe the prevalence of co-occurring mental health and substance use disorders, then describe the potential impact of co-occurring mental illness and substance use disorders on the population, and also learn about how to delineate mechanisms to better address co-occurring disorders through the court processes. Let's start by discussing prevalence of co-occurring disorders. First of all, it's important to understand what we're talking about when we speak to the term co-occurring disorders. It's become sort of a casually addressed term, and sometimes in writing you see it abbreviated as CODs, but it's also important to recognize that co-occurring can mean many different things. Comorbidity in a medical sense, and from the National Institute on Drug Abuse, means two or more disorders or illnesses occurring in the same person. They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both. You can have any number of conditions that coalesce into an individual. As we think about co-occurring disorders, it's important to distinguish which disorders we're talking about that are co-occurring. For example, we know from prevalence rates that about 50% of people with a substance use disorder will develop a mental illness, and about 50% of people with a mental illness will develop a substance use disorder. The rates are not as clear in children, but about as many youth with a substance use disorder will have a mental health condition such as depression and anxiety. Recall too, that when we speak about substance use disorder and mental illness, I'm not being specific with regard to what substance use disorder, or what type of mental illness, or even the degree of severity of the substance use disorder, or the degree of severity of the mental illness. This becomes an issue as we talk about people who might be court involved, because they might have what we would call a mild to moderate condition, or they might have a severe and persistent condition of either their substance use disorder or their mental illness. The level of intervention is going to change depending on the severity of the condition. This is true also with medical conditions that people might have. Also, when we look at these co-occurring conditions, it doesn't really speak to what else might be going on for the individual with regard to health conditions or multiple conditions simultaneously. For example, multiple substance use disorders simultaneous with mental illness, or multiple mental illnesses simultaneous with a substance use disorder. In terms, as we parse that out, in terms of co-occurring substance use disorder and serious mental illness in the past year among persons age 18 or older, this is data from the Substance Abuse and Mental Health Services Administration that looks at behavioral health statistics quality from the National Survey on Drug Use and Mental Health. Some of the data that is populated, some of the population data from what we call the NSDUH studies, again, the National Survey on Drug Use and Health. If you look at this percent among people with substance use disorder, the co-occurring mental health disorders, serious mental illness, or the percent of substance use disorders among persons with serious mental illness, you might say those are a little bit different than the 50% statistics that I put forward before. Remember that when we look at population studies, it really depends on how the studies are done. The NSDUH study is a survey study where individuals are asked about their drug use and mental health. You may see that the percentages look a little bit lower, and that may be partially related to under-reporting. In another set of data looking at comorbid substance use disorders, it's important to look at how an individual with one substance use disorder might also have another substance use disorder. This is, again, separate from how they may also have an underlying mental illness. For example, individuals with alcohol use disorder might also have almost 24% might have nicotine dependence, 10% might have a marijuana use disorder, 3% a cocaine use disorder, or about 4% with a prescription opioid use disorder, or a heroin use disorder at about 1%. If we flip it and look at, for example, somebody with a prescription opioid use disorder, about 35% of those individuals will have an alcohol use disorder. Almost half will have a nicotine dependence, and about 20% will have a marijuana use disorder. You can see that as we parse out amongst individuals what's going on for them, many will have multiply occurring conditions. Again, this is separate from what will be their co-occurring mental health disorder. In terms of prevalence rates for the justice-involved population, and this has to do with the criminal justice-involved population, which is different than those you might see in the civil system, we see if we look at the general population, there's about a 4% prevalence rate of serious mental illness. In the jail population, those rates are much higher, about 17%, over four times higher than in the general population. Among individuals with serious mental illness in the justice system, about three quarters will have a co-occurring substance use condition. If we flip the data and look at individuals with substance use disorders, you can see that about 80% of people who are arrested tested positive for some substance use. About 70% of jail inmates have a substance use disorder. If we look at individuals with a substance use disorder, about a quarter of them will have a serious mental illness. This, again, just to remind people when we talk about serious mental illness, wouldn't necessarily include those with other types of mental health conditions, like anxiety, depression, that's not as impairing of functioning. In specialty courts, anyone working in a specialty court can attest to the fact that there's a large overlap in the population. Data varies, but some studies have suggested that for drug courts, at least 30% to 40% of them have a diagnosable mental illness, in addition to their substance use disorder that's the subject of attention in the drug court. In mental health courts, about 75% to 80% will have substance use disorders. Many states are coming up with co-occurring courts, and many jurisdictions have co-occurring models. Also, we see in the models for drug courts and mental health courts, more and more attention being paid to the co-occurring disorders and looking at plans, treatment plans, to address the dually occurring conditions so that we're looking at individuals more holistically. Now, you might be asking, why do these disorders co-occur? There is a lot emerging in science and research related to the co-occurrence of substance use disorders and mental illness. We can look at it in different ways. Individuals might have common risk factors that make them more likely to have an emerging mental illness or an emerging substance use disorder. Just taking individuals without these use disorders, they may have underlying risk factors that contribute potentially to incurring these conditions. Also, substance use disorders can put people at risk of developing a mental illness. If one starts with a substance use disorder, that individual may be more likely to develop a mental illness down the road. Also, mental illnesses may put people at greater risk for developing a substance use disorder. This can be an important relationship that we see emerging for individuals who start with one or the other and then develop a secondary condition. What are the common risk factors for individuals? Again, this is a very hot area of research, and it can be complicated research to look at and hard to understand at times. To just broadly summarize why these disorders co-occur, some of the common risk factors that I want to talk about include genetics, environment, something called epigenetics, and then how structural development in the brain can impact the later development of these conditions. With regard to genetics, we know more that people with a particular gene who also smoke marijuana as youth, for example, are at increased risk of mental illness. Genes can determine whether a substance makes people feel good or not good, for example. An individual who might use a particular drug might also, for example, be somebody that is more or less likely to develop a use disorder. We don't know everything about that, that there is to know for sure, but when you think about it, somebody who's prescribed an opioid to control pain might be more or less susceptible to developing that use disorder partially related to their genetic makeup. Research is really focusing on this issue because then it can help us understand in terms of prescribing. We're also learning more, for example, about genes and pain management. As we think about the development of treatment in the future, we will know more about how to really target treatments for individuals based on genetics and responses. Similarly, environment can be a contributing risk factor. The stress of one's environment might make for changes in that individual, and it might make for a risk factor that leads to the development of either a mental health condition or a subsequent substance use disorder. Many of you may be familiar with the ACEs study, the Adverse Childhood Experiences study, which examined what exposure prior to the age 18 to these adverse childhood experiences, which include household dysfunction, abuse, neglect, the discord, the existence of mental illness in a parent, the incarceration of a parent, those kinds of factors where a parent might be removed. The traumatic circumstances that happen prior to the age 18 while the brain is developing can contribute and be risk factors for subsequent mental illness and substance use disorders and all sorts of other downstream consequences that we know can occur. This is where we get into something called epigenetics, which basically means the things surrounding our genetics that can be defined as changes that affect how genetic information is read and acted on by cells in the body. For example, a stressor or a trauma that occurs can change the epigenetics and how our genes subsequently are interpreted and read and acted on by cells in the body. And then that can potentially trigger a susceptibility to developing a mental illness or a substance use disorder. And again, we're learning more about this. And then last but not least is just brain development itself, brain development that can be impacted from in utero brain development to anything from a traumatic brain injury that can occur later in life or from, let's say, toxic stress, lead exposure, anything that can impact how brain is developing in the developmental years and even as adults can put people at risk for developing mental illnesses, as well as developing risk factors for substance use disorders. So these are ways that these disorders can co-occur because both are impacted, both mental illness, mental illnesses and substance use disorders can be impacted by genes, environment, these epigenetics, as well as just structural brain changes. So other things that are important to realize is that mental illness can lead to a substance use disorder. Besides these risk factors, just having, if you start with a mental illness, you may be more likely to develop a substance use disorder. So for the longest time, people talked about the self-medication hypothesis, which argued that individuals were trying to medicate a mental illness away to relieve mental health symptoms. For example, to relieve anxiety or to relieve depression or to relieve the sequela of a traumatic experience, people would use substances to medicate those feelings away and then found themselves, quote unquote, medicating themselves with drugs or alcohol more and more and more until that became a problem in and of itself and made actually, ironically, made those depression, anxiety, and trauma symptoms even worse. Also mental illness can lead to brain changes that can change the reward pathways that then create a propensity towards developing substance use disorder. Also substance use disorders can lead to mental illness. Substance use disorders, as we know, create changes in the brain and changes in reward pathways for how we respond to the substances that we might be using, and those can also lead to contribute to the experiences of having more mental illness, more anxiety, depression, thinking impairments, cognitive impairments, and the like that can contribute. That gets into a little bit more about the types of co-occurring disorders and the impact that they have on individuals that I want to talk about next. Let's talk a little bit about these. Really, this is an abbreviated list because there can be any type of co-occurring disorder, as I said in the beginning, that one can occur with the other. All of the factors that I described above might help lead to a pathway that leads one particular individual to develop one type of condition versus another type of condition. Very commonly, we see substance use disorders and the mood disorders, mood disorders including depressive disorders and bipolar disorder. We might also see substance use disorders and anxiety disorders, panic disorder, for example, generalized anxiety disorder, people feeling afraid to go out and socialize. All of these can be contributing. We might see substance use disorders and psychotic disorders. In fact, sometimes this becomes hard to tease out. For example, we might see people with cocaine use disorder or methamphetamine use disorder who also have psychotic conditions. They might be paranoid, they might hear voices, they might see things, and these then start to co-occur. Even when we look back at somebody's history, it's not always easy to sort out which came first, the substance use disorder or the psychotic disorder, or whether, again, the psychotic disorder or the person's innate vulnerabilities led to the development of both of these conditions. Doing a lot of work in the realm of people, for example, asserting the insanity defense, that's often something that has to be teased out as to whether this was a mental illness or whether this was voluntary intoxication related to a substance. There is a high co-occurrence of attention deficit hyperactivity disorder and substance use disorder, and there may be that risk, that co-occurring risk for one to develop into the other, and so we have to tease that out as well. Hyperactivity disorders often relate to substance use disorders as well as trauma-related disorders, post-traumatic stress disorder, acute stress disorder, and the like that co-occur with substance use disorders, and then substance use disorders go along with eating disorders as another example of a co-occurring disorder. Other types of things that we have to take into account are the co-occurring medical conditions that we might see, for example, pain co-occurring with depression, anxiety, and substance use disorder, traumatic brain injury. One of the most profound examples of that that we see and that are often seen in courts involve veterans who may have been exposed to improvised explosive devices when they've been deployed and seen combat. They may have traumatic brain injury. They may end up with pain conditions. They may end up using substances. They may have post-traumatic stress conditions, and all of that can occur together. There is data that really looks at traumatic brain injury also as being a factor that's kind of under-recognized in the world of thinking about people who are high-risk takers, somebody who might be likely to get into a bar fight or a car accident or something like that, may have a history of traumatic brain injury. They may also be substance using and also have some additional mental health conditions. Infectious diseases, ironically with COVID-19, we're seeing this as well as being a risk factor, these underlying conditions. Conditions related to poor healthcare, cardiovascular issues, people with endocarditis, commonly seen in individuals with severe opioid use disorder related to bacterial infections with use of dirty needles. And then cancer as well. We see a lot of cancer co-occurring often because people are also smoking, and that can be a mixed risk factor for all of this to co-occur. And so thinking about as we see individuals, their whole health is important. What are the chronic conditions that they're living with? The continuity of care that they receive as they move through courts in different systems can be very fragmented. So treatment of a condition may not get the attention that it would if they weren't court involved. And care is often delivered in emergency rooms, which isn't the best place to get continuity of care. It's important to realize how serious this is. And I like to cite this study because it was one of the earliest studies. There's been subsequent studies that have looked at similar data. But this study out of Washington State studied 30,000 prisoners who had been released out of the Washington State prison system and tracked them. And larger numbers than what would be expected for general population rates died in the follow-up period. Death rates were seen as three and a half times higher than the general population. And death rates for inmates with serious mental illness were almost 13 times higher in the 14 days following release. And the primary causes of death among those individuals included drug overdose, heart disease, homicide, and suicide. So taking care of co-occurring disorders as people move in and out of systems is a matter of life and death that's important to attend to. Another place that's important to think about is in the impacts on child welfare. The prevalence rates for parental alcohol and other drug use as a contributing factor as a reason for removal of children in the United States is huge. And you can see that it has increased by almost 17% since 2000, when we look at data since 2000. It highly correlates with the opioid epidemic of course, and is very important to be thinking about. It's also really important to be thinking about as we're looking at issues related to racial and ethnic disparities and some of the concerns about structural racism within some of the, what throughout American society, very important to think about child welfare impacts of policies and equity as we move forward and think about these removals and think about the issues related to co-occurring substance use and how it can impact child welfare. Not only for the parents, by the way, but also for the children and multi-generational impacts. So what are some mechanisms to address co-occurring disorders for judges and courts? There are evolving treatment approaches, mental illness and substance use disorders because they can present together are important to think about in terms of addressing them simultaneously, which came first may or may not be obvious. As I said before, sometimes a timeline can be helpful. When I do case conferences for people that are court involved, for example, we try and understand timelines. Very often we see very early exposure to trauma, very early exposure to substances. And so understanding how they co-evolved can be helpful in teasing out what interventions may be helpful. From a treatment perspective, the approaches have shifted. When I was in training, we looked at these things as serial problems that needed to be addressed. In fact, we would say to patients, I can't address your mental health condition until we address your substance use condition or vice versa. And that has really shifted. The conversation has shifted to say, we have to look at these problems simultaneously and address treatment simultaneously. And more and more, we're trying to develop these integrated models of care, although it is still evolving as we look across systems. Some of that has to do with some of the challenges with funding and some of the silos in services, but more and more treatment systems are trying to look at substance use, mental health and physical health all together in integrated care models. Specialty courts, for example, as I said early on, are also looking at this. We have drug courts, we have mental health courts, we have family drug courts that really look holistically at the youth and the parents, homelessness courts, co-occurring courts, and more that are increasingly, and I encourage you through thinking about this presentation to think about how do we look at this individual holistically and not just take one problem at a time. And even if you're not running, for example, a family court, I like to tell the story about a mental health court that I was sitting and observing once where one of the participants came in with her baby in a basket, she had a two-week-old baby that she had taken on the bus and came to the, she didn't wanna miss her appointment with her mental health court, her parents. And it was really remarkable how she had her journey of getting to the mental health court with this little baby in tow. But what dawned on me is in the mental health court, there wasn't really anything that was done to address the needs of this little baby, but it turned out that in that particular state, there was a referral that could have been made to screen the baby because the baby had been born to somebody that had high risk factors. And therefore, that baby was eligible for some additional services and supports. So it's important, even if you're not working, for example, in a family drug court, but to educate yourself about this multi-generational approach to thinking about, for a parent who might have mental health or substance use conditions, that could put them at, their children at risk. There may be opportunities for screening of those babies and those children and getting them referred into treatment and services. As we look at drug courts and mental health courts, there are some differences and similarities. The similarities are that they're all aimed to try and decrease future arrests, decrease the amount of time people spend in jail, improve symptoms, improve sobriety, improve employment tenure, improve housing access, and improve treatment linkages. They also try and look at these criminogenic risk factors and the risk-need-responsivity paradigm, which states that there's eight recognized risk factors that put people at increased risk of criminal justice involvement. The eight risk factors being antisocial behavior, antisocial personality patterns, antisocial cognitions, antisocial attitudes, family or marital discord, poor school or work performance, and few leisure or recreation activities, as well as substance use, which is ironically a risk factor, one of the big eight risk factors in and of itself for criminal justice involvement. That's probably not a surprise for people that are involved in the justice system, but it means that if we have to tackle the very problem that's bringing them into the justice system is one of the very issues that we need to address. Now, some authors would say in this paper by Skeen, Stedman, and Manchik from 2015 said, the risk-need-responsivity paradigm is a very important paradigm as we look at models of addressing, reducing criminal recidivism. But when we look at individuals with serious mental illness, we have to be careful to really pay attention to the types of treatments and interventions that we're offering and make sure that they are adjusted to a population that may have underlying mental health conditions that also need their own attention. Even though mental illness is not considered a criminogenic risk factor, it is considered a responsivity factor that should be looked at by addressing symptoms of mental illness and also recognizing that what puts people at risk for criminal behavior isn't necessarily the mental illness, but other factors, although sometimes it could be symptoms of mental illness. And so we have to look at people holistically. Again, the responsivity as a principle, responsivity factors as a principle needs further research and support. The other thing that this paper spoke to is the cognitive behavioral treatments that are sometimes offered to address criminal thinking are sometimes modified for populations with serious mental illness, but there may not be as much literature supporting how that modification is being made. So it's important to think about how you're addressing those criminogenic risk factors. Some of the differences between drug courts and mental health courts, for example, too, are important to highlight as we think about what do we need to look at for co-occurring conditions? So for example, in a drug court, there's gonna be a drug-related underlying charge that's usually gonna get you in to the drug court, whereas a mental health court might have varying originating offenses. Also drug courts often will target high-risk, high-need individuals from a criminogenic perspective, whereas mental health courts have variable entrance criteria, perhaps related to a mental health diagnosis, which is different than a criminogenic risk factor. Sanctions and advancements are structured in a drug court more so than in a mental health court, which is more flexible, and drug testing is often the mainstay, whereas in a mental health court, if substance use isn't really the primary issue, there may or may not be drug testing, although often there is, but it may not be the primary issue, and we're not always looking at this as a co-occurring, from a co-occurring lens. Again, important to think about these as differences. Flexible approaches to graduation are more common in mental health courts, whereas graduation criteria are more fixed. And so as we look at co-occurring disorders, and specialty courts, we wanna look at where along the lines of having a structured program like we do for drug courts to a more refined person-centered program that we do in mental health courts, can come together and really think about, you know, getting the best of both possible worlds, but addressing the co-occurring disorders, addressing the trauma, and considering the recidivism risk carefully as we look at the individuals with those co-occurring disorders. So the National Drug Court Institute came out with six steps to improve your drug court outcomes for adults with co-occurring disorders, and included the steps of knowing who your participants are and what they need, again, looking at them holistically, adapting court structure to the co-occurring condition as opposed to just one or the other, expanding treatment options beyond just traditional drug treatment, targeting case management and community supervision for the co-occurring challenges that individuals may have, expanding mechanisms for collaboration across mental health systems and substance use systems, and then educating the team on co-occurring disorders. Process considerations might include screening and identification of co-occurring disorders, not just one or the other, linkage to appropriate treatments and sanctions and rewards with more flexible approaches, and graduation considerations, as I've already mentioned. The general principle of care are really applicable for all court-involved individuals. And so as court officials, being aware of the nature of co-occurring disorders and how to think about them more broadly can help you identify linkages and knowledge of local practitioners who might be able to address the multiple needs that individuals present with. Recognized treatments for co-occurring disorders, for example, cognitive behavioral therapies can help change harmful beliefs and behaviors. Dialectical behavioral therapy was designed specifically to reduce people who have histories of self-harm behaviors, and including suicide attempts, thoughts, or urges, cutting, and even drug use. And that's a type of approach that's really well-researched now for individuals with co-occurring disorders. Assertive community treatment emphasizes outreach to the community and an individualized approach to treatment for individuals, particularly with serious mental illness who have revolving patterns of utilization where they're in and out of the hospital quite frequently. Therapeutic communities are a common form of long-term residential treatment that focus on re-socializing an individual. Contingency management gives vouchers and rewards to people who practice healthy behaviors. Treatments like multisystemic therapy and brief strategic family therapy, among others, have been shown to be helpful in addressing comorbid substance use disorders and other mental illness. If you're working with individuals under the age of really 25 to 30, we could say, but in particular with youth, brains are still developing and vulnerabilities can emerge during that important brain developmental period. At the same time as vulnerabilities can emerge, we can also help people build resiliencies. And so by treating the underlying mental health conditions, we can avert later substance use disorders. And by treating the substance use disorders, we can help prevent later mental illnesses and set the individual youth on a trajectory to be a more productive and functional adult. There's ways to learn about screening of co-occurring disorders. Here's an example from SAMHSA, that basically a compendium of screening and assessment tools available that are targeted for individuals and might be used in the justice system. And then once people are screened, further assessments can lead to referring individuals to proper levels of treatment. With regard to youth and thinking about child welfare situations, it's important to know about the CARA legislation under Title V, which amends aspects of the Child Abuse Prevention and Treatment Act, CAPTA, which amends the amendments include developing plans of safe care for infants that require states that receive CAPTA grants to address the health and substance use disorder treatment needs of the infant and the family or caregiver and specify a system for monitoring whether and in what manner local entities are providing services in accordance with state requirements. This is really important because there may be this notion that if there is a substance using parent, that there's gonna be an inevitable removal. The goal with CAPTA is to really try and prevent child abuse and also prevent child abuse, including child neglect, and really try and maximize the ability of children to stay with parents who may have co-occurring substance use or mental health and mental health conditions, but make sure that they stay with them in a safe way. And that's where these plans of safe care for infants that are born to mothers with substance use disorders are really gonna be important in terms of making sure that there's a whole plan that can address the family need in the safest way possible. Also important to think about the APIC model of transition for people in the justice system for reentry. It's 10 guidelines for effective transition planning to help make sure that individuals are appropriately assessed with planning and coordination. And there's implementation guides that are available that people can use. The ASAM criteria are another important tool in the toolbox that moves away from the cookie cutter approach to delivering care and instead looks at the criteria for the level of care that an individual needs if they have substance use conditions. And medications that you've heard about a lot already in the medication assisted treatment discussions, very important to incorporate into integrated solutions as we look at individuals with co-occurring behavioral health needs, meaning co-occurring mental health and substance use disorders. There's data that we've identified in Michigan and other places. These are slides from some work we've done with our Mental Health Diversion Council, but that really show that the more we can engage people in mental health treatment, the more we can see follow-up post-release. So the idea of doing in-reach and reentry coordination for people with serious mental illness who have co-occurring conditions, it can be very powerful way of helping people remain in treatment after that transition out of prison or jail. Also important to think about are the conditions of confinement. The Vera Institute has really done a lot of work looking at what are the conditions of confinement. This is, believe it or not, on the right, a picture of a prison, not in the United States, but important to think about what we have in the United States compared to what might be possible as we think about re-imagining how treatment can be maximized while people are confined, if jail and prison are gonna be inevitable in our society, perhaps not at the same rates they currently are, but what can be done within those institutions. And so as a justice professional, it's important to know what's happening within the institutions to maximize the ability to provide care and continuity of care. I've worked very hard on this model in several different settings, both in veterans treatment courts, mental health courts, drug courts, as well as reentry services. It's just one model funded through a variety of SAMHSA grants initially that really looks at providing a manualized approach to wraparound supports with case management and peers that work across the justice interface and into the community to support individuals and make sure that they get their various needs met. And then thinking about stratifying how to work with individuals with co-occurring conditions and coordinating between their functional needs from their substance use disorder and their mental health condition with how much supervision they will need based on their criminogenic risk. And so we're not taking a cookie cutter approach, but putting people with high criminogenic needs and risks in with people who have high functional impairments and need really tight integrated services with regular coordination between the treatment system and the criminal justice system. But then leaving those that are more able to function independently, less monitored and less supervised so we don't end up with violations that result in more incarceration than is necessary. And then also thinking about how as justice professionals and behavioral health professionals, we can collaborate across systems. Every state has a single state authority for mental health. Every state has a single state authority for substance use. Sometimes those are combined into one agency. Sometimes they're separate. Medicaid as an entity that is a very important player in treating people that become involved in courts who have co-occurring disorders, but also thinking about those private insurance capabilities, the correctional and justice system and how the often contracted health care providers, mental health care providers and substance use providers can coordinate with community-based services, child welfare systems, school systems and other collaborators who might work together to address co-occurring disorders simultaneously. Important to think about episodes of care versus seamless care, and the importance of seamless care to avoid those bad outcomes like I described in the reentry population. Disruptions of care in chronic illnesses can be a critical area of consideration as individuals move in and out of the justice system and other systems. And thinking about making sure that medications stay consistent, that information is shared across systems so one provider to another knows what happened before and advocating for consistent patient or person care can be helpful and also hard. But this is a place where trainings like this can be helpful to have people think about these issues. And so I'm gonna stop there. I've provided you an overview about the prevalence of co-occurring disorders as well as the impact of co-occurring disorders and some strategies in approaching treatment for them and addressing them through courts and court-involved individuals by educating yourselves and partnering with other stakeholders to achieve better outcomes for all. Thank you very much for your attention to this presentation. I really appreciate being able to speak to you. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

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