On the Record with SAMHSA's Frances Harding - Page 2

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

(page 2)

You serve as the lead for SAMHSA's Strategic Initiative on Prevention of Substance Abuse and Mental Illness. The goal of this initiative is to create communities where individuals, families, schools, faith-based organizations, and workplaces take action to promote emotional health. Would you describe this initiative as a national wellness program like the corporate wellness programs that have become so popular across the country?

I actually would say that the wellness programs across the country are using our model of including all of the important pieces of prevention. What has changed greatly in prevention for SAMHSA are two things moving forward. Our efforts to bring the behavioral health practices in substance abuse and mental health services into the overall health of the country. The strategic initiative is a perfect picture of those efforts. We maximize opportunities to create environments where adults, families, communities and systems are motivated for overall behavioral change and physical health. 

It’s an evidence-based practice that we have learned over time. When you bring communities together, you need to bring anyone to the table that is connected to an issue. With a child-focused issue, you would have parents, schools, community health centers, criminal justice, medical professionals, mental health providers, youth directors, parks and recreational area managers come together. Anyone that intercedes with a child should be at your community table to help prevent substance abuse and to identify mental health disorders early. 

It’s important to note that this strategic initiative includes a focus on populations at high risk, including college students and transitional age youth; American Indians and Alaskan natives; ethnic minorities experiencing behavioral and mental health disparities; service members, veterans and their families; lesbian, gay, bisexual and transgender individuals; and more. With the little money that we have, we try to focus our efforts across the country at populations with the most risk. 

We are defined by four goals to address: first, emerging issues or anything that comes across that becomes important. For example, we never expected the marijuana problem in this country, and we did not predict the sudden rise in heroin use. We are learning more and more and more about the early identification of childhood psychosis and how we can intervene with evidence-based programs. 

The second goal is a focus on underage drinking. Underage drinking continues to be our number one problem in this country. A recent notable change is a renewed focus on higher education. For the last couple of decades, we focused on the age range of 12 to 17, and we’re doing fairly well with those efforts. But we have not done such a great job in the 18 to 25 year old population, mostly because the population is now increasing. We have a focus on college students, and college is a very unique environment, and on the young adults as well in that age range that are not in college and, most likely, in the workforce, hopefully.

The third goal continues to be suicide prevention, and it’s a core component of our healthcare system. For the last four years, we have been focusing very heavily on young people in terms of the youth at the most risk. That would be LGBT youth and the high-risk populations that I catalogued before. We are tweaking this focus in 2015. For the next four years, we are going to be focusing on working age adults between the ages of 25 and 64, particularly men in mid-life between the ages of 35 and 64. 

As you can see, we are following our own science. We are looking at the areas where there is the most risk. Although we have a good budget, we don’t have the kind of money that we would hope to have in order to have the kind of impact that our programs could have if such funding was made available to us. If the world was different, we obviously would not have to make these hard choices. But we are making the choices so our money counts. We are losing too many young men in mid-life crisis and middle-age adults as well. We need to do more to identify the risks so we can intervene and bring these numbers down.

Last but not least, the prescription drug issue is our fourth goal, and it seems to just keep growing into different areas. Our intentions in goal number four is to reduce opiate overdose incidents and death. We have narrowed our efforts to focus more on the prescription opiates in order to reduce the deaths that have become such a problem across the country as you mentioned earlier. Some would say that’s a different type of prevention. The fact is that when you look at the medical model of universal, selected and indicated, it 100% falls within the indicated population of prevention interventions. 

Beyond traditional substance misuse, SAMHSA's Strategic Initiative on Prevention of Substance Abuse and Mental Illness also targets tobacco misuse. Does this targeting cause problems with the well-known tobacco lobby? Are you targeting underage use of tobacco or the use of tobacco across the board?

SAMHSA’s focus on tobacco use is to provide support and leadership to help prevent and reduce tobacco among youth and people with mental and substance abuse disorders. First, we want to prevent young people using. I have been overseas to American territories and on the islands from Guam to Puerto Rico, the amount of young people smoking was astonishing. We are losing the fight over there so we are coming back in full force and focusing on youth and tobacco. 

The reason why we focus on the use of tobacco in people with mental and substance abuse disorders is because a huge percentage of our populations, between 80% and 95%, of populations in both these groups are dying from tobacco complications before they die from complications from addiction of their mental illness. We have to stop this. There should not be the added burden of dealing with an addiction like tobacco and the resulting negative consequences for these people. In addition to our focus on the youth, this is why we are focusing on these populations as well. This is the one time that SAMHSA really looks within our population, and we really want to help the individuals in recovery and struggling with mental illness. We want to help the populations in treatment and in recovery for substance abuse and mental illness. 

For the young people, our major activity is our SYNAR Program and legislation. We oversee implementation of the SYNAR Amendment that enacted in July of 1992. This Congressional Amendment requires states to have laws in place prohibiting the sale and distribution of tobacco products to persons under the age of 18 and to enforce those laws effectively. It’s all about the illegal sales to minors. Across the United States, we have made great strides in reducing retailer violations of the law as required by the SYNAR Amendment. A major success was helping to do away with cigarette vending machines. In most states, the vending machines are gone. 

Luckily, the legislation has a lot of teeth to it. Not only did the legislation say there were targets the states had to reach of sales of less than 20%, there were consequences for going over that 20% cap. If states go over 20% in terms of your sales to minor, they begin to lose the block grant dollars. The 20% cap is measured by state statistics so we do trust them. For the states, the block grants are one of the major sources of their treatment and prevention dollars. That hits home and the result has been an incredible success. 

Back in 1992, the youth rates for tobacco had skyrocketed. There were some numbers that were astonishing; above 60% and even 70% of the tobacco sales in certain states being to minors. When this law was passed that promised to hit the states in the pocket if they failed to bring those rates down, the rates immediately began to fall. When prohibiting the sales of tobacco became a priority for the states, not only did positive results come quickly, but they have lasted as well. I am happy to say almost every state in the country remains in compliance with over 70% of the states holding steadfast at a 10% rate of tobacco sales to minors. That’s a remarkable improvement in a relatively short period of time. 

Is SAMHSA's Strategic Initiative on Prevention of Substance Abuse and Mental Illness focused on tobacco specifically or nicotine in general? Does the initiative cover e-cigarettes as well? Do you see e-cigarettes as the latest gateway drug for children?

The remarkable improvement I mentioned in the previous answer has been affected negatively in some states by e-cigarettes and the new vapor technology. We need to give training and technical assistance to the state programs so they can keep up with these changes. E-cigarettes definitely are one of the key emerging issues for us. E-cigarettes have been included in our focus since they first emerged because we focus on everything tobacco. Whether people are chewing it, vaping it or just smoking it in cigarettes, cigars or pipes, it doesn’t matter to us. SAMHSA does not separate it into nicotine use versus smoking. We are talking about any form that tobacco products can take. 

We are learning more and more about e-cigarettes from our friends over at the FDA. As states regulate the use of e-cigarettes, both in terms of regulation and banning their use in certain contexts, we keep track of all of these developments. In the future, we hope to make e-cigarettes part of the SYNAR legislation. That’s the direction where we are heading. After all, the e-cigarettes are increasingly popular among our adolescents. NIDA and the FDA are doing a lot of work on this issue, and you can find that information on their respective websites. We are learning from them. 

E-cigarettes could be a gateway, but we don’t have any definitive evidence for that supposition. I think that’s coming more from anecdotal reports that we are receiving from the states. Our data people are probing that question, but that will take time. As a prevention person coordinating policy for SAMHSA, I don’t think it matters that much to me. We try to support the states with the SPF, but each state needs to look at their own data as well. The states have to decide to target that issue as one of their high-risk areas, but we can’t tell them to do that based on anecdotal evidence. That’s not what we do. That’s the genius behind the Strategic Prevention Framework. It addresses all these emerging issues because it’s all about data collection, understanding that data, looking at the populations and being able to implement an evidence-based prevention program in the individual jurisdictions. SPF is based in science and it’s proven to be effective.

Then again, you might be saying, “Yeah, but how could they already have one on e-cigarettes?” The truth is that we really don’t yet, but we do have several evidence-based programs on tobacco and smoking. States are using those programs effectively with e-cigarettes. We will continue to work with NIDA and the FDA to improve those offerings, but they do exist in this previous form and they are being applied in a manner that appears to be working. 

Before joining SAMHSA, you served as president of the National Prevention Network, an organization representing the alcohol and drug abuse prevention offices in all 50 states. You were the representative to that organization from New York. What are the drug prevention offices? Can you tell us more about the National Prevention Network? What have they been able to accomplish?

Of course, we don’t have enough time to talk about all of the things that they have been able to accomplish, but let me try to explain what NPN is and why it’s important. Every state has an office of substance abuse somewhere. Back in the day, we had drug offices and alcohol offices. Those evolved into substance abuse offices that today have evolved again into behavioral health offices, public health offices, just plain health offices and so forth and so on, but somewhere, if you look closely enough at each state's org chart, there will be a space for substance abuse. Whomever leads the prevention office in each state is invited to join the National Prevention Network.

National Association of State Alcohol and Drug Abuse Directors (NASADAD) is the parent company of the National Prevention Network, the National Treatment Network and the National Women’s Network. Although the National Prevention Network is part of this larger association, it still is pretty independent as well. When I was the president of NPN, we were the voice of prevention for the country that worked very closely with SAMHSA. As a result, when I moved from NPN into federal service with SAMHSA in 2008, it made a lot of sense to go from one to the other.

An NPN representative communicates prevention programs and updates across states and jurisdictions. We develop policies and guidelines to enhance the use of prevention resources. We help educate state legislators with a new focus on bringing this information to healthcare organizations in each state. We try to promote prevention in the workforce by educating company executive teams and leadership about prevention techniques and strategies. NPN really has increased awareness of the field of prevention science. 

The science of prevention is quite young, but it has made amazing strides in the past 20 years. This network of prevention-trained individuals have taken the science of prevention and spread it across the country. It has been a huge leap in terms of recognition and implementation to be able to connect prevention with science. When you back an idea with science, people tend to listen and pay attention to what is being said and offered. The NPNs are the foot soldiers of getting the messages about prevention and the policies of SAMHSA on prevention out there very quickly. There is a real luxury to having science-trained prevention specialists with evidence-based programs across the country for more than two decades, raising awareness about prevention science and the work of SAMHSA. SAMHSA views the NPN representatives as our first voice in each of the states. Whenever we do anything with a state, the first person we contact is the National Prevention Network representative. 

Another huge accomplishment of NPN has been to push the science of prevention research. They have improved our ability to implement programs like the SPF by raising awareness across the board about the validity and evidence-based results of the science of prevention research. They are the force that has really helped to bring prevention to the table. 

Prevention is a really difficult field for a number of reasons, and it takes very well-trained people who have been in this business for a number of years to understand all the complexities. The reason for that difficulty is very simple: You can’t follow a person through a prevention program and then have data of your success. You are working with populations and communities that are always changing. You need to be a leader first and a prevention expert second because you need to lead a whole group of people in changing the way they think about and their values structures around the use of alcohol which is a legal substance, the use of tobacco which is a legal substance, and the use of drugs which are substances that are either illegal or being used in an illegal manner. You have to spread messages that most people don’t want to hear because if they admit that it’s not good for a young person to drink or use tobacco, then what does that mean for them. It forces them to shine a light on their own behavior. 

NPN and NASADAD have a co-funded convention every year so every prevention worker can keep up on the new developments and improve their knowledge base. We pay for every NPN representative in the country to attend, one way or another, through grants and the like, so they can keep up to date. One of the most challenging and exciting parts about being in the field of prevention is that it’s ever changing and it’s never stagnant and it’s never stale. We are not doing the same programs over and over because our populations switch. The most challenging and difficult part about being a prevention person is it never stops changing and you always have to keep up to speed. 

I always give my staff and the great people that I have the pleasure the work with the opportunity to keep up with the changes in environmental science or environmental prevention, which is basically the methodology of bringing all the disparate elements of a community together and helping them learn their piece in solving the puzzle of whatever issue is on the table as a risk factor for a particular population or at least reducing the problem that they are working on as much as possible.

In 2004, you became the first non-researcher to receive the prestigious Science to Practice Award from the Society for Prevention Research. What is this award and why is the society important? Why do you believe you were chosen to receive it?

Biggest surprise of my life! Let’s start with that. I had known about the Society for Prevention Research for quite some time. The reason why they are so important is that nothing about what I have talked about today—this is just me speaking and I’m sure this is not a thought shared by everybody— would be as effective without this organization. The modern field of prevention and the science of prevention that we use today wouldn't be as complete or as professionally well done without the Society for Prevention Research. 

The Society for Prevention Research is a group of scientists and researchers who have devoted their careers to prevention research. The very fact that they have do so was amazing to me when I learned about them several decades ago. They continue to work to focus on what strategies we can bring to bear that will help this country reduce the problem of substance abuse and, now, substance abuse and mental health disorders. They are the ones that primarily have developed that list of evidence-based programs that SAMHSA uses. I can say with the utmost certainty, depending on the problems that you have in your neighborhood, or your community, or your state, once you do the data and find the areas of greatest risk, we can match up an evidence-based program that will almost perfectly meet your requirements if the population, demographics and outcome desired meet the program’s criteria. 

We even have programs through the Society for Prevention Research that focus on higher education programs. We have programs for the higher education population. We are working on the Society for Prevention Research to expand their reach into indigenous populations, tribes, and the Asian-Pacific populations as well. The Society for Prevention Research is really the heart of prevention as we continue to move forward. 

Why did they choose me? I ask myself that question. I think it’s because I totally embraced the work that they were doing. It helped me in my job; first, in New York State, then as president of the National Prevention Network, They helped me bring the latest prevention science to the table. They gave me the ability to show how evidence-based programs really are better as opposed to programs that just look good, feel good, and the number one argument being that they had a little success here so let’s apply it everywhere else. That’s where prevention came from and the Society for Prevention Research helped us to evolve beyond gut instinct and into actual science. It was not enough to do things just because they felt right. 

Let me give you an example: We would take a car that had been banged up in an underaged drinking and driving accident. We would put that car in front of a high school, thinking that seeing the negative consequences of that behavior would deter young people from drinking and driving during their prom season. We now know and we have evidence to prove that that’s not so because of the young person’s brain. But it looked good at the time. Back in the day, we never even thought about brains, and how alcohol and drugs affect the brain and their thinking. 

Technically, if you were to follow that science, although it’s not done this way in our country, the young person’s brain in the area of judgment is not fully developed until age 24 or even 25. Technically, we shouldn’t be driving before age 24. Technically, we shouldn’t be drinking before age 24. Of course, we would never do this, but it’s that kind of learning and thinking that the Society for Prevention Research does. They really provided a whole new perspective.

I was the first person to be outspoken about the use of the science. For whatever reason, it made a lot of sense to me and it just clicked. I think that’s why they gave me the award because I was helping to promote their work. To this day, I meet with them every year, and I always come with an agenda so I’m surprised sometimes that they’re still willing to meet with me. I will point out the populations and the issues that we need help with. We need help with e-cigarettes. We need help understanding the usage rates of marijuana and why people continuously do not listen to the statistics of why the marijuana of today is so much worse and so much more dangerous than ever before. 

I reach out to my friends at the Society for Prevention Research. These are hardcore, long-term researchers that have developed programs and brought them through the rigorous testing necessary to become evidence-based. They have implemented them in many different communities to show that they work and can be part of the list of our resources. I am more successful at what I do because of my association with this organization. I can’t say enough about the important work that they have done and continue to do.

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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.