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On the Record with SAMHSA's Frances Harding
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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.
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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?
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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.
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.
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.
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.
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.