On the Record with SAMHSA's Frances Harding - Page 3
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Since so much of your background and expertise has been focused on prevention, can you help us understand why so much more money and resources are spent on treatment as opposed to prevention? How do you believe this problem can be resolved?
I have to admit that this is one of the most difficult questions that you've had here, mostly because, being in the federal government, I have to be very careful how I answer it. As the director of the Center for Substance Abuse Prevention, we follow the National Drug Control Strategy, which was published in 2010. It focuses on what we should and should not be doing around prevention and drug use in general. Our goal is to reduce illicit drug use and its consequences in the United States. As opposed to a war on drugs, the National Drug Control Strategy now focuses on science. Substance abuse disorder is not a moral failing, but rather a disease of the brain. They work with us in both prevention and treatment, and they help provide the guidelines that we follow.
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The National Drug Control Strategy has three goals that promote and balance evidence-based public health safety initiatives. First, we try to prevent drug use before it begins. Second, we want to expand access to treatment for Americans struggling with addiction. Third, we want to reform the American justice system to break the cycle of drug use, crime and incarceration while protecting the public safety. We also want to support Americans in recovery by reducing discrimination against people in recovery for substance abuse disorders. Seeing that this is the plan for the country, you’ll see that prevention is a small piece. As the director of Substance Abuse Prevention, I needed to say that and make it clear.
Still, with so many, some would say too many, decades focusing on prevention, I would say there are a couple of things that have prevented us— excuse the pun—from succeeding to the point where I would certainly hope we would be at this point in time. First, we have difficulty documenting our success. Everything in America is focused on money. When it comes to funding prevention programs money comes by helping the leaders in the country who make the funding decisions see that prevention works. They want data to show that it works. I have the data to show that our programs work. I have the data to show that our evidence-based programs work. I implement the program in a community and I show that in that community we have reduced usage rates.
For example, a program where we have reduced drug use by young people by 25% in the first year. That was the amazing result of an actual program, but let’s just use that as an actual example. But the decision makers don’t believe it and they don’t understand what we are doing and they don’t understand why prevention has changed from the old days when we had fairs and community days and playing with puppets. All the old ways before the science became real is what they still want.
The decision makers tend to doubt, and they ask questions like, “I want to know exactly, Fran; did this intervention that you chose to put into this community, does it have a direct effect? Do you have 100% proof that it works? How can you show me that this child stopped using because of your program?”
And I can’t do that because it’s been over four years and there are so many other factors involved. It could have been a crash where eight young kids in high school in that community died because they were drinking so the community developed new rules and regulations and policies. As a result, drug use and alcohol use went down temporarily. It could have just as much been that as it could have been because of the great programming that we are providing to that same community.
That’s the number one challenge. We don’t have the type of data that this country is looking for because we are based on a treatment society. Even with doctors, we only go in when we have a problem. We tell them about our problem, and they give us medication to treat that problem or some kind of physical therapy. Our problem goes away, and we can say with some certainty that that medication, that therapy fixed the problem because now my leg doesn’t hurt anymore. We can do the same thing for someone that goes through drug and alcohol treatment. They have an assessment; they have gotten three DWIs and the assessment shows that they have an alcohol problem. They have the disease of alcoholism so we put them through treatment. They get out of treatment and go into the life of recovery. We then can see that over the last 20 years that they haven’t touched or used alcohol, they haven’t gotten another DWI, and they have become upstanding citizens. There is a direct line in terms of how treatment works that you can show the decision makers, and I can’t do that with prevention. We work in communities so I see 20 kids at a time. I can’t tell you that our prevention programming worked in child #2 but not in child #10. That’s the first challenge that we face.
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The other challenge is that we just don’t want to believe it. We haven’t been able to help our country understand that we can change attitudes and behaviors through knowledge and education. We haven’t been able to convince the parents that by changing the conditions that a young person grows up in, we’ll prevent them from using drugs and alcohol. We haven’t been able to prove that by changing the programming and offering resources to middle-aged men in this country who are facing a rapidly rising risk of suicide, we can help them and help save lives. But how can I do that? How can I prove that my prevention strategies and programming worked? In terms of what they want to see for proof, I can’t.
We are a society that needs data to tell a story. So what are we doing about it? Here at SAMHSA, we are doing our best to help our staff tell the story better. Even if a leader tied the money to seeing change, we used to say that we couldn’t show you change in less than 10 years. The problem is what government person is sitting in a chair for 10 years. It just doesn’t happen. As a result, we had to start becoming smarter in prevention and work back.
Now we are looking at what we call Indicator Change. Indicator Change shows how we have increased our presence in a school, or the opportunities available to parents, or we have made more tools available to young people. In a year’s time, we can show through Indicator Change how our programs are affecting a particular community. We can say that in this particular community we have been able to make a change because we have saved five lives through the work of our programming. We are looking at those Indicator Changes at a community level, school level or family level and combining them with our long-term data down the line. You can talk to a legislator or a government office that is funding these programs and show them two things: First, the immediate turnaround change which in the long-term might affect the overall community, then tie it with the overall long-term goals.
A problem with prevention always has been the gulf between not showing change as people want to see it as opposed to showing change the way that we want to see it with these evidence-based, long-term programs. We are working in a subject matter that most people don’t want to talk about. They don’t want to have responsibility. But I really, really do believe that parents are the key to most of our problems with youth. I don’t mean that they help cause the problems, but they are the key to help solve the problems.
It’s very difficult to have a parent feel like they are the only parent that is disciplining their young person who’s 18 and wants to have a party when everyone else is doing it. They let them have the party because they figure it will be okay because they are there to supervise it or they just give in to the pressure. Plus, it’s difficult for most parents in this country to even find the time to go to an education course centered on these issues. I’m not putting the blame on the parents, or the child or the teachers. That’s not how we work. We work in communities, and we recognize that everyone has a piece to contribute to help with these problems.
It’s a tough field to know what should be done to break the cycle of drug use and crime and abuse and loss. I am lucky to have a dedicated staff to help me with this work. Plus, the country is lucky to have a group of people that dedicate their lives to this work for very, very low pay. In fact, the lack of recognition for the prevention workforce is based on a lack of understanding of the value of prevention and the methods used. It’s so much different than treatment. It’s very hard. So what are we doing about it?
What we are doing about it is we are learning. It seems that we might be learning slowly, but we really are learning, and we are on a fast track. We are looking to the success stories in health and implementing the lessons learned from them. How is it possible that I know the four things that I have to do to reduce my chances of heart disease? How is it possible that I know how to detect for breast cancer myself? How it is possible that I know the dangers of tobacco and how did we get so far with the tobacco industry?
We are learning from their successes, but we deal with the substances of alcohol and drugs, a taboo that no one wants to talk about. They’ll talk about heart disease, but they won’t talk about substance abuse-related issues and they certainly won’t talk about mental health issues. We are trying to break this discrimination against the work that we do and learn from our predecessors in the health field that have had success. That’s what keeps me going everyday. We get an inch closer to getting people to see that someone that’s living with an addiction or someone that’s living with a mental illness are your family members, your neighbors, your co-workers and everywhere else. We are all over because it’s just another disease. If we can break that wall and I know we’re close, then we can move forward and have less deaths related to abuse and undetected mental health issues.
Your latest prevention effort directed at underage drinking has been the current “Talk. They Hear You.” campaign. In that campaign, you created a game for children to play. Can you discuss the details of this campaign, the game and how it’s working so far?
“Talk. They Hear You.” has been one the most successful media campaigns that SAMHSA has done in a very long time. We have gotten parents to understand their role in talking to their young people. We have learned from this that one of the roadblocks of parents talking to these young people is they didn’t know what to say and they didn’t know how to approach it. If you remember about 10 years ago, the Partnership For Drug Free American had this campaign around parents talking to their kids about drugs. They had a teddy bear in a chair, and parents were talking to the teddy bear. The whole campaign was based around practice before you talk to your kids. That was an incredibly successful program.
When we empower parents with the right things to say and show them through media how this process can happen, we are getting so many more parents willing to talk to their kids about these issues. The other key is get to them young. It is easier for parents to talk to 11, 12, 13-year-olds than it is for them to talk to 15, 16, 17-year-olds. This seems like an aha moment that we probably should have already known, but that emphasis has contributed to the success of this campaign.
The only part of your question that I found problematic is when you asked about the game. We don’t have a game. What appears as a game is the actual tool and mobile app for the parents. I think the reason why people think it’s a game is because it’s animated. It’s animated for a purpose because it’s very important for the federal government to put something out there that doesn’t offend a certain culture and it can be a lot harder than you think. When you use animation, you can get away with using a lot of different colors and situations and language that you can’t get away with in real life.
This tool not only allows parents to listen to the animated conversation, but it also allows them to interact with it. They can send in messages and get their questions answered by trained professionals. It has been an incredible technique that has really helped. We are starving in this country for more of this type of educational material that is interactive and can be easily accessed from practically anywhere. It can be shared with the greater community and, if all parents and educators are working with the same tools and sharing the same message, it becomes a lot easier to share and break through the barriers we previously discussed.
In 2012, you gave testimony about SAMHSA’s efforts to address the problem of alcohol and substance abuse in the Native American population. In the face of the dark statistics, including the fact that Native Americans suffer by far the highest rate of alcohol poisoning due to binge drinking, what can be done by SAMHSA? Can anything stem this ongoing problem in the Native American community as a whole?
Yes, we believe it can be addressed, but again, it comes down to staffing and money. Over the last year, SAMHSA has established a new office to address this challenge; the Office of Indian Alcohol And Substance Abuse, and this office is focused on two different things. SAMHSA is responsible for the Tribal Law And Order Act. The Tribal Law And Order Act (TLOA) sits under the SAMHSA Office of Tribal Affairs and Policy. Their job is to connect with tribes and bring prevention, treatment and recovery to the tribal communities.
The Tribal Law And Order Act helps to address crime, alcohol abuse, and substance abuse in tribal communities and places a strong emphasis on decreasing violence against American Indian and Alaska Native women. The act is in partnership with the Department of Justice, the Department of the Interior and the Bureau of Indian Health Services. It authorizes new guidelines for handling sexual assault and domestic violence crimes while providing better and more comprehensive services to victims. It also encourages development of more effective prevention programs to combat alcohol and drug abuse among at-risk youth. In terms of alcohol use across the board, the act is focused on helping tribes develop Alcohol Action Plans to help reduce rates of use and abuse within the tribes.
In our budget, we have additional grants designed to help tribal communities with the issues of alcohol use and substance abuse while specifically targeting the issues of suicide prevention and excessive alcohol abuse within the tribes. Suicide and excessive drinking are the two major risk factors in the tribes right now. We also offer a grant that delivers technical assistance and training, specifically only to tribes, and it’s a braided program. It has dollars directed at substance abuse prevention, substance abuse treatment, and mental health services. I think it’s one of our biggest successes with the tribes. It’s not an answer, but it has given a lot of people in the tribal communities exposure to the tools and education needed to help with these problems.
Does it do enough to? Absolutely not. President Obama has made tribal issues one of his priorities between now and the end of his administration. This priority has helped us and all of our sister agencies with health and human services focus on tribal issues. We will get ahead of this, but it’s just been a little long in coming. We have made tribes eligible to apply for all of SAMHSA’s grants and programs across the board as well.
You were the moderator at the 2015 National Rx Drug Abuse Summit. What is the purpose of this summit? Can you tell us about SAMHSA’s efforts to promote a cross-system collaboration to address prescription drug misuse? What was the summit’s outcome?
The biggest outcome of the summit was that they want more. That was the most direct outcome. It took us about a year to put this summit together. We did it in partnership with ASTHO, the Association of State and Territorial Health Officials. We brought them together because of the rising need to do more around prescription drugs. There is no other ulterior motive, there was no money attached to this. At SAMHSA, we do have the Partnership for Success grants where the states need to address either underage drinking or prescription drug misuse. The grants are all about providing data.
We have a drug testing advisory board that helps with drug testing across the country that contributes to addressing the prescription drug problem as well. The most recent update is now we have not only the traditional urine tests, but also an oral fluids test that we are just releasing now. It is an easier way to test. You just swab the cheek, and most people are not offended by that procedure. We believe it’s not so difficult so the potential elimination of urine testing for treatment programs will be a welcome addition. But we are not stopping there. We are very close to having hair testing for prescription drugs and other medication misuse as well as alcohol and other major drugs. I heard someone at a conference say, “Well, why are you stopping there?” They were focused on testing nails so that could be on the horizon as well, but it’s not a current project.
The summit was designed to give the states all of this information and more, strong technical assistance, so they can go forward over the course of the next year and address this problem. ASTHO were our partners in this project. We spent three days at the summit with representatives from 10 different states that attended so we could provide them with the latest information. The top leaders came and addressed the conference, including Dr. Nora Volkow of NIDA and leaders from the FDA and SAMHSA as well. Then we had top research scientists come and present their latest findings about prescription drugs in regards to the issues that the states were most concerned with having addressed.
It was a wonderful conference. Each of the states that participated were allowed to bring in 10 representatives from the health and human services profession to the summit, including prevention and treatment professionals, physicians, and law enforcement officials. We call these meetings policy academies, and they are tremendously effective. The reason why they are so effective is you work for hours in small groups, highlighting the problems specific to each state. At the same time, SAMHSA held a meeting for all 50 states that focused on prescription drug monitoring programs. In the future, I believe the focus for these meetings will be on both opiate abuse and medicated-assisted treatment.
John Lavitt is the Treatment Professional News Editor at The Fix.