On the Record with SAMHSA's Frances Harding

By John Lavitt 06/26/15

The Fix Q&A with the director of the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Prevention.

Frances Harding

As one of the most important figures in the history of evidence-based prevention programming in the United States, Frances Harding has walked a tough road in a heroic effort to save lives and raise awareness. Then again, if you called Frances Harding heroic in her presence, she would laugh and say that you’ve been reading too many comic books. Today, she serves as director of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Prevention (CSAP). Frances Harding is recognized as one of the nation’s leading experts in the field of alcohol and drug policy.

As the lead for SAMHSA’s Strategic Initiative on Prevention of Substance Abuse and Mental Illness, Frances Harding creates environments where families, institutions, and communities are empowered to manage their overall emotional, behavioral, and physical health. In addition to representing SAMHSA on interagency efforts to prevent underage drinking and prescription drug misuse, Frances Harding collaborates with SAMHSA’s Center for Mental Health Services on issues related to the connection between substance abuse prevention and mental health promotion.

Prior to federal service, Director Harding served as Associate Commissioner of the Division of Prevention and Recovery at the New York State Office of Alcoholism and Substance Abuse Services.

Later, she served as president of the National Prevention Network, an organization representing the alcohol and drug abuse prevention offices in all 50 states, and as New York State’s representative to the Board of Directors for the National Association of State Alcohol and Drug Abuse Directors. The Fix is honored to have the opportunity to interview Frances Harding and report on her years of hard work.

Can you provide us with a description of your position at the Substance Abuse and Mental Health Services Administration (SAMHSA)? Is the agency designed to help the American public in general or specifically support the treatment community?

I’ll start by briefly describing how SAMHSA is put together. We have four centers and I’ll list them in random order: first, the Center of Substance Abuse Treatment; second, the Center for Mental Health Services; third, the Center for Behavioral Health Statistics and Quality which is basically our data center, and, fourth, the Center for Substance Abuse Prevention, which I lead. The portfolio of the Center for Substance Abuse Prevention covers the mission to improve behavioral health through evidence-based prevention approaches. We fund grants that go directly to the states while also having a discretionary portfolio that focuses on our strategic prevention framework. Our work is with federal, state, public and private organizations to help support a comprehensive prevention system. In terms of national leadership, I work on the development of policies, programs and services to prevent the onset of illegal drug use, prescription drug misuse and abuse, alcohol misuse and abuse, and underage alcohol and tobacco use. I promote sustainable substance abuse practices to help enable states, communities and other organizations to spread and apply evidence-based prevention programming. 

We serve the general public as well as professional audiences. We serve communities, school-based programs, professionals, law enforcement personnel, and policymakers. We also promote drug-free coalitions. We do media campaigns, online social media efforts, trainings, and technical assistance and support services. As you can see, we pretty much do it all and fund it all. Our work is a mixture of policy programming, evidence-based practices, data collection, and response to substance abuse issues. 

SAMHSA just released new Federal Guidelines for Opioid Treatment Programs. Can you explain how these new guidelines have been updated to address the prescription painkiller epidemic that is raging like wildfire across the country?

Yes, we released the new Federal Guidelines for Opioid Treatment Programs, and we’re very proud of them. In the context of prescription drug misuse, there are a series of public health issues. We maintain a focus on prevention, medium and long-term treatment options, and recovery maintenance programs to address this problem. As part of the integrated approach, SAMHSA funds programs to implement strategies that range from community-based efforts to medication-based treatment options and right straight through to ongoing recovery maintenance efforts. We kind of do it all. 

The first version of the Federal Guidelines for Opioid Treatment Programs was first issued, believe it or not, back in 2007. They have been updated to reflect the changing landscape of medicine and treatment. We needed to address the new challenges we face. For instance, the abuse of medications and prescription opiates specifically. The new guidelines reflect the obligation of opiate treatment programs to deliver care consistent with the patient-centered and recovery-oriented standards of addiction treatment in specific and medical care in general. 

In addition, the new guidelines reflect the difference in medical technology and updates in healthcare. SAMHSA’s effort under the Obama administration has been to bring behavioral health into the overall health perspective. It’s a very important theme for us. We encompass guidelines around electronic health records, prescription drug monitoring programs, the role of non-physician authorized prescribers, telemedicine, benzodiazepine misuse in the context of opioid therapy, and the use of other recovery-oriented medications like buprenorphine. When it comes to these guidelines, there are pros and cons for each. The bottom line is that the new guidelines are pretty intricate. 

They may sound like they don’t connect, but the disparity is on account of all the different drugs that are now being used for opiate treatment and opiate abuse prevention. I know it sounds like a wide variety. I chuckle sometimes when I think of telemedicine, but in certain jurisdictions like in some of our rural states, telemedicine is just a dream. In such contexts, telemedicine has opened up the door to really stretch further. Now we can identify areas of the most risk that before could not be identified because they were so isolated. It suddenly allows these communities to have more of our treatment programs available to them. It also allows for improved prescription drug monitoring programs in these areas to avoid the rising problem of doctor shopping. 

Many of the new advances being made by SAMHSA are possible because we are able to take advantage of the media and electronic capabilities to help us with our programs.

In Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015–2018, you make a big emphasis on the fact that prevention works better than treatment in the fight to address drug abuse. What prevention methodology is SAMHSA currently promoting, and what methods would you like to promote in the future?

First, it bothered me that we are quoted as saying that prevention works better than treatment. Every time I read that question I had to remind myself to make a note to have that revised. I don’t think prevention works better than treatment, although I do think that it’s more cost-effective when you do prevention programming because obviously you reduce the need for treatment. However, tackling the drug and alcohol abuse issues requires a comprehensive approach. Not just prevention, intervention, or treatment; we have to have it all. That’s why SAMHSA talks about behavioral health from the perspective of prevention, treatment, and recovery services. It’s a hard message to give, and it’s delivered mostly by the prevention folks that are out there helping people to understand the need for all three. A big part of our role is centered around education. 

Since the 1990s, we have had a shared mission with mental health, primary care, and substance abuse treatment professionals to improve the well being of communities, families, schools, businesses and entire states. Substance abuse prevention and education complements treatment by reducing risk factors and enhancing protective factors or some people prefer to refer to the latter as identifying the strengths of a person, program, community, school or state. As a result, prevention activities have common ground with recovery support services. We want to help people develop the skills and resources that will assist them in maintaining a healthy lifestyle. 

We try to prevent a problem from occurring, we treat it if the problem does occur, then continue to assist after treatment to help a person stay in a life of healthy recovery. Our prevention strategies are centered around learning, including life skills training, substance abuse education and mentoring. We follow the Strategic Prevention Framework, otherwise known in the prevention community as the SPF. The framework is based around a five-step planning process to guide states, jurisdictions, tribes and communities in the selection, implementation, and evaluation of effective culturally-appropriate and sustainable prevention activities. I know it’s a mouthful, but it is the very heart of what we do. It helps these groups to collect data, understand how to analyze it, identify high-risk areas, select an evidence-based program to fit a high-risk area to mitigate or, at least, reduce the problem, and to build capacity so it can be done all over again. 

That’s basically what the SPF is all about. It promotes youth development, reduces risk-taking behaviors, builds assets and resilience, and prevents problem behaviors across the lifespan of the program. Since we have been working with the Strategic Prevention Framework, we have learned quite a bit. Sustainability in prevention programs is the most difficult task for both our grantees in specific and SAMHSA in general. The object of this process is to have a community own the prevention program and make it an ongoing part of their approach. We ultimately want them not only to use it, but to fund it as well. Federal dollars, state dollars, even private money will one-day leave. The key to sustainability is motivating community-based funding of prevention programs. While we institute the programs over a five to ten year period, they need to learn that the programs are needed if they are going to maintain a healthy environment. 

Reading the data, identifying their capacity, choosing the right prevention program for a specific community, and ultimately strengthening the protective factors and reducing the risk factors that are being faced is the most important part of the SPF. Prevention science over the years has really become that specific with the evidence-based programs. We know when a problem comes up that we can select an evidence-based practice from our list to address that specific problem. Such evidence-based practices have been designed for the demographics of a specific community in order to address the specific need of that community. That specificity has allowed us to provide services that have resulted in many of our success stories and reductions of some of the abuse in these communities. 

We develop a strategic plan with a community once a program is chosen. What are the steps that are going to be taken over the next five years to implement the effective prevention programs and services in the community. We need to see that they are actually doing the work. We call it boots on the ground so we can evaluate a community’s efforts for outcomes. Everything that we do must produce outcomes. We have to show impact. 

We also work within the Institute of Medicine’s model that has three categories of prevention: universal prevention/intervention, selective prevention/intervention, and indicated prevention/intervention. Rather than go into each category, anyone who is interested can look it up for more details. This model did help us extend our reach by becoming more understandable to the medical profession. 

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Growing up in Manhattan as a stutterer, John Lavitt discovered that writing was the best way to express himself when the words would not come. After graduating with honors from Brown University, he lived on the Greek island of Patmos, studying with his mentor, the late American poet Robert Lax. As a writer, John’s published work includes three articles in Chicken Soup For The Soul volumes and poems in multiple poetry journals and compilations. Active in recovery, John has been the Treatment Professional News Editor for The Fix. Since 2015, he has published over 500 articles on the addiction and recovery news website. Today, he lives in Los Angeles, trying his best to be happy and creative. Find John on Facebook, Twitter, and LinkedIn.