Embargoed ISSUE REPORT Reducing Teen until Thursday November 19 at 10:00 am EST Substance Misuse: WHAT REALLY WORKS 2015 NOVEMBER 2015 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. TFAH would like to thank the Conrad N. Hilton Foundation for their generous support of this report. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN Robert T. Harris, MD Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA President of the Board, TFAH Treasurer of the Board, TFAH Executive Director Vice President for Policy and Medical Director Hogg Foundation for Mental Health at the Senior Advisor North Carolina Medicaid Support Services CSC, Inc. University of Texas at Austin WK Kellogg Foundation David Fleming, MD C. Kent McGuire, PhD Cynthia M. Harris, PhD, DABT Vice President President and CEO Vice President of the Board, TFAH PATH Southern Education Foundation Director and Professor Arthur Garson, Jr., MD, MPH Eduardo Sanchez, MD, MPH Institute of Public Health, Florida A&M University Director, Health Policy Institute Chief Medical Officer for Prevention Theodore Spencer Texas Medical Center American Heart Association Secretary of the Board, TFAH John Gates, JD Senior Advocate, Climate Center Founder, Operator and Manager Natural Resources Defense Council Nashoba Brook Bakery REPORT AUTHORS Jeffrey Levi, PhD Laura M. Segal, MA Alejandra Martín, MPH Executive Director Director of Public Affairs Health Policy Research Manager Trust for America’s Health Trust for America’s Health Trust for America’s Health and Professor of Health Policy Anne De Biasi, MHA Kendra May, MPH Milken Institute School of Public Health at the Director of Policy Development Consultant George Washington University Trust for America’s Health PEER REVIEWERS TFAH thanks the following individuals and organizations for their time, expertise and insights in reviewing all or portions of the report. The opinions expressed in the report do not necessarily represent the views of these individuals or their organizations. Alice Dembner Kevin Haggerty, MSW, PhD Melissa Ough, MSW Project Director, Substance Use Disorders Associate Professor Policy Analyst, Substance Use Disorders Community Catalyst University of Washington and Community Catalyst Director Centers for Communities that Care 2 TFAH • healthyamericans.org Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1. Youth and Increased Risk for Substance Misuse . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2. Drug Overdose Deaths – Teens and Young Adults . . . . . . . . . . . . . . . . . . . . . . . . . 23 SECTION 1: Building a Public Health Approach to Substance Misuse Prevention and Positive Youth Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 10 ndicators (Example Highlight Policies) for Teen Well-being and Substance Misuse I Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 States: Indicators Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 States: Indicators Score Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 A. cademic Achievement: chronic absenteeism: warning sign – missing significant A numbers of school days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Indicator 1: Supporting Academic Achievement . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 B. School Environment: positive, supportive school climates . . . . . . . . . . . . . . . . . . . 33 Indicator 2: Preventing Bulling Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 C. Tobacco Use: electronic cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Indicator 3: Preventing Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 D. lcohol Use: alcohol taxes, palcohol, curbing underage alcohol misuse . . . . . . . . . 39 A Indicator 4: Preventing Underage Alcohol Sales . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 E. creening, Intervention and Treatment for Substance Use . . . . . . . . . . . . . . . . . . . 43 S Indicator 5: Coverage and Screening, Brief Intervention and Referral to Treatment . . 43 F. Mental Health: adverse childhood experiences (ACEs) . . . . . . . . . . . . . . . . . . . . . . 46 Indicator 6: Mental Health Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 G. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Indicator 7: Depression Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 H. Drug Use and Drug Misuse: preventing prescription drug misuse and the rising heroin epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Indicator 8: Good Samaritan Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 I. Prescription Drug Misuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Indicator 9: Treatment and Recovery Support for Prescription Drug Misuse . . . . . . . 54 J. Sentencing Reform: example efforts and approaches . . . . . . . . . . . . . . . . . . . . . . 57 Indicator 10: Sentencing Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 SECTION 2: Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 A. utting Prevention First: NIDA’s preventing drug use among children and adolescents: P a research-based guide for parents, educators and community leaders; public- private network models; community programs; schools: expanding the adoption and implementation of evidence-based programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 B. Making Screening, Early Intervention, Treatment and Connection to Services Routine Practice: school-based SBIRT; childhood screenings . . . . . . . . . . . . . . . . 79 C. Comprehensive and Sustained Treatment and Recovery Support: recovery high schools; NIDA’s principles of adolescent substance use disorder treatment: a research-based guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 TFAH • healthyamericans.org 3 I NT RO D UC TION Reducing Teen INTRODUCTION Reducing Teen Substance Misuse: Substance WHAT REALLY WORKS Misuse: Teen substance misuse continues to be a major public health Health Policy problem in the United States. series A significant number of students try alcohol, tobacco or other drugs as some point before entering or while in high school.1, 2, 3 While the number of teenagers. More than 65 percent of teens who regularly misuse or develop students have used alcohol, more substance use disorders has been than 40 percent used illegal drugs and decreasing over time, overall levels are around one-quarter used cigarettes at still too high. LAST TWO DECADES OF ALCOHOL, CIGARETTE, AND ILLICIT DRUG USE* *Past 30 day use. 60% 1994 50% 2014 40% 1994 30% 2014 NOVEMBER 2015 1994 20% 2014 10% Alcohol Cigarettes Illicit drugs 37.4% OF 12TH GRADERS 13.6% OF 12TH GRADERS 23.7% OF 12TH GRADERS 2014 23.5% OF 10TH GRADERS 7.2% OF 10TH GRADERS 18.5% OF 10TH GRADERS 9.0% OF 8TH GRADERS 4.0% OF 8TH GRADERS 8.3% OF 8TH GRADERS Source: NIH, Monitoring the Future, 2014. CIGARETTES E-CIGARETTES WHICH IS LESS THAN 5 STUDENTS IN THE AVERAGE CLASS. PRESCRIPTION /OVER-THE-COUNTER VS. ILLICIT DRUGS* *The percentage of 12th graders who have Adderall 6.8% used these drugs in the past year. Vicodin 4.8% Tranquilizers 4.7% Cold Medicines 4.1% After marijuana, OxyContin 3.3% prescription and over-the-counter Ritalin 1.8% medications Marijuana 35.1% account for most K2/Spice of the top drugs (“synthetic marijuana”) 5.8% abused by 12th graders in the MDMA/Ecstasy 3.6% past year. Cocaine 2.6% LSD 2.5% PRESCRIPTION ILLICIT DRUGS Source: NIH, Monitoring the Future, 2014. More than 90 percent of adults who More than 40 years of research exists develop a substance use disorder began from the National Institutes of Health using before they were 18-years-old.4 (NIH) and other experts that supports this approach, but there has been Substance misuse can have long-term a disconnect in implementing the adverse effects on physical and mental science into real-world practice.5, 6 health, academic and career attainment, relationships with family and friends A prevention-oriented approach — and establishing and being a connected building positive protective factors part of a community. and reducing risk factors — can decrease the chances of tweens and For decades, substance misuse strategies teens initiating, regularly using or focused on individual willpower to “just developing an addiction to alcohol say no” or intervening once a person and/or drugs. This approach not already has a serious problem. only lowers the chances for substance But, the evidence shows that if the misuse, but also has a bigger impact, country is going to maintain a continued since similar underlying root causes downward trend in substance use — it have also been shown to contribute to will require a greater emphasis on: 1) increased likelihood of poor academic preventing use in the first place; 2) performance, bullying, depression, intervening and providing support violence, suicide, unsafe sexual earlier after use has started; and 3) behaviors and other problems that can viewing treatment and recovery as a emerge during teenage years. sustained and long-term commitment. Risk Factors Protective Factors Aggressive behavior in childhood Good self-control Lack of parental supervision Parental monitoring and support Poor social skills Positive relationships Drug experimentation Academic competence Availability of drugs at school School anti-drug policies Community poverty Neighborhood pride TFAH • healthyamericans.org 5 In this report, the Trust for America’s Health (TFAH) examines how to help move towards a strong prevention-oriented, continuum-of-care approach to substance misuse — looking at policies and programs that have a high impact for improving the well-being of America’s youth. Section 1 reviews 10 examples of tween, teen and young adult years, important policy indicators or programs particularly during transition times that states may have in place that can such as starting middle and high have an impact on the well-being of school or college, leaving home for the children and youth and/or have been first time or starting in the workforce. connected with preventing and reducing l B uilding community-wide efforts — youth substance misuse. The indicators where school-based and community reflect a range of types of policies that programs are part of a coalition to support a prevention-intervention- implement comprehensive prevention treatment approach — from supporting services that employ a range of healthier schools and communities to interrelated strategies matched to limiting access to substances to providing a particular community’s needs. positive support and treatment. While it Optimal efforts reinforce each other is not a comprehensive evaluation, taken — and work together to leverage all collectively, the indicators help show available resources, expertise and trends of progress and gaps in youth support across multiple sectors — and policy development. can build on existing strengths in a Section 2 features recommendations for community rather than reinventing or modernizing the nation’s strategy for competing with them. This includes: addressing youth substance misuse by • aining an understanding of the G implementing a research-based public needs, trends and existing resources health approach. Some key elements within a community — and matching include: the best evidence-based approaches l T he most effective approach to reducing with a community’s priorities; substance misuse is by preventing it • aving access to an expert H before it starts. To fill the gap between “backbone” organization that can research on evidence-based programs provide end-to-end support from and their implementation there needs selection to implementation to to be increased focus on: evaluation to continuous quality l S tarting programs when children improvement of programs; are younger — including programs • nsuring sufficient and sustained E focused on early childhood cross-sector funding; and development — which yields a bigger payoff for later prevention. Programs • ngaging youth, youth advocates E often start too late to have the desired and parents in the planning, impact. Continuing support must implementation and evaluation of also be sustained throughout the programs and practices. 6 TFAH • healthyamericans.org l A renewed energy is needed to to treat substance use and mental continuum of childhood screenings gain support for the adoption health disorders, and improving the that start at birth and help track a and implementation of evidence- integration and interactive support child’s milestones and development at based and sustained school-based between healthcare and education — particular stages — and identify when programs — moving beyond decades two sectors that routinely help chil- extra support is needed. of ineffective approaches. It also dren and teens but are often silo-ed. l T here is a major treatment gap for involves making substance misuse l R outine screening and brief substance misuse and dependence prevention one part of an integrated intervention are essential as children in the country — where only an set of positive youth development enter the tween and teen years — to estimated one in 10 individuals goals — including supporting help identify risks and problems who need treatment receive it.10 It broader academic achievement and quickly connect individuals is time to leverage resources and goals. Effective approaches also to services and support. Evidence opportunities from the Affordable require acknowledging that substance supports that earlier intervention Care Act (ACA), mental health parity misuse is a problem that impacts is constructive versus denial or laws (requiring health insurance all communities and that adopting waiting until a problem becomes too plans to cover mental health and programs should not come with a serious to ignore. This approach substance use disorder services at stigma. By focusing on prevention, it is recommended by the American least to the extent that the plans cover helps reinforce that these programs Academy of Pediatrics (AAP) and the other medical services) and federal, are to the benefit of all students. National Institute on Alcohol Abuse state and local support to ensure that Advancing these goals must include: and Addiction (NIAAA).7, 8, 9 all individuals who need treatment • roviding education and P Screening — via age-appropriate receive it — and that treatment reaching out to engage parents, questionnaires developed by health standards are brought up-to-date with educators, the larger community and social service professionals — the latest evidence-based approaches. and policymakers to understand can help identify teens and youth Success will require cooperative efforts the advances in the most recent at risk for substance misuse. Brief from a wide range of partners, including research about what works and why; interventions — even a few minutes parents, families, youth advocates, youth of counseling — have been shown to • ntegrating school-based and I groups, mental health professionals, help reduce alcohol and drug misuse community-based programs — pediatricians and a range of other in youth. And these efforts can help schools cannot and should not be healthcare providers, hospitals, insurers, identify needs and connect youth expected to solve the problem on social service providers, schools, and their families with services and their own — and to have the end-to- colleges, the foster care system, juvenile support. Early brief interventions end support of expert networks; and justice settings, community- and faith- that prevent and reduce substance based groups — as well as effective • mproving school climate — through I misuse also reduce the number of government policies and programs. positive behavior initiatives, increas- individuals later needing treatment. ing the number of specialists trained This should be part of a regular This report provides the public, policymakers and a broad and diverse set of partners with an objective, nonpartisan, independent analysis of the status of youth development policies; encourages greater transparency and accountability; and recommends ways to ensure the public health system and partners can work together across boundaries to accomplish the shared objective of preventing and reducing teen substance misuse. TFAH • healthyamericans.org 7 YOUTH AND INCREASED RISK FOR SUBSTANCE MISUSE There are a variety of reasons why teens difficulties in girls are the primary causes of may experiment with tobacco, alcohol problematic peer relationships. Individuals or other drugs. However, a number of exhibiting academic or behavior problems circumstances and influences put some at ages 7 to 9 are more likely to misuse kids at greater risk for substance misuse substances by age 14 or 15.11 and addiction. The more risks a child or teen is exposed Research has shown that there are to, the more likely the child will misuse a number of major life transitions in drugs. Some risks — such as parents or tweens’ and teens’ lives, which can friends who use drugs, alcohol or tobacco be “risk periods” for potential alcohol, — may have a bigger influence than others. tobacco and other drug misuse — as In addition, community factors — such as well as other risky behaviors. Some the availability of drugs, drug trafficking potential “triggers” include physical patterns and beliefs that substance use is development (such as puberty) or social not harmful — can influence risk of use. changes (such as starting middle school, high school or college, moving away from Positive protective factors — such as home or entering the workforce). Pre-teen strong, stable, supportive relationships — and teen years present new influences can mitigate against the risks. — including less adult supervision, interaction with wider groups of peers, In addition, teens’ and young adults’ development of romantic relationships, brains are still maturing (until around age exposure to peers who may be misusing 24), specifically in the pre-frontal cortex, substances, increased academic which allows humans to make rational pressure, higher expectations for decisions. Continuing brain development responsibility and individual caretaking, means teens are more likely to be potential onset of depression and other impulsive and take risks. Introducing factors. Family changes, like moving or drugs to the developing brain may cause parents’ separation or divorce can also long-term harmful changes in the brain.12 be disruptive. According to NIDA, “the initial decision to According to the National Institute on take drugs is mostly voluntary. However, when Drug Use (NIDA), some signs of risk for drug addiction takes over, a person’s ability substance misuse can actually be seen to exert self-control can become seriously im- throughout childhood. For instance, some paired. Brain imaging studies from drug-ad- personality traits and temperaments are dicted individuals show physical changes in associated with higher likelihood of later areas of the brain that are critical to judg- substance use. Children who are withdrawn ment, decision making, learning and memory, or aggressive often exhibit problems with and behavior control. Scientists believe that interpersonal relationships and social these changes alter the way the brain works, interactions — which can then lead to and may help explain the compulsive and risk for academic performance problems, destructive behaviors of addiction.”13 Some peer rejection and other concerns that can researchers also postulate there may be a increase the chance of substance use. genetic predisposition in some individuals to Aggressive behavior in boys and learning substance dependency.14, 15 8 TFAH • healthyamericans.org REDUCING RISKS AND INCREASING PROTECTIVE FACTORS FOR WHETHER TEENS INITIATE, REGULARLY USE OR BECOME DEPENDENT ON ALCOHOL AND/OR DRUGS16 Some Key Risk Factors Some Key Protective Factors Family l L ack of mutual attachment and nurturing by parents or caregivers l A strong bond between children and their families l I neffective parenting l P arental involvement in a child’s life l A chaotic home environment l S upportive parenting that meets financial, emotional, cognitive l L ack of a significant relationship with a caring adult and social needs l A caregiver who misuses substances, suffers from mental l S etting clear limits and expectations for behavior illness or engages in criminal behavior Outside the l C lassroom behavior concerns, such as aggression and impulsivity l A ge-appropriate monitoring of social behavior, such as family l A cademic failure curfews, adult supervision, knowing a child’s friends, enforcing household rules l P oor social coping skills l S uccess in academics and involvement in extracurricular l A ssociation with peers with problem behaviors, including activities drug misuse l S trong bonds with pro-social institutions, such as schools l M isperceptions of the extent and acceptability of drug-abusing behaviors in school, peers and the community l A cceptance of norms against drug misuse RISK FACTORS Biology/Genes Environment Genetics Gender Chaotic home and abuse Mental disorders Parent’s use and attitudes Peer influences Route of administration DRUG Early use Effect of drug itself Availability Community attitudes Poor school achievement Brain Mechanisms Addiction Source: NIDA TFAH • healthyamericans.org 9 UNDERAGE DRINKING Past-Month Binge Alcohol Use Among Adolescents l A mong high school students, 35 percent re- Aged 12–17, by Gender (2008–2013) port drinking, 21 percent report binge drink- 12% ing, 10 percent report driving after drinking and 22 percent rode in a car with a driver 8.9% 8.9% who had been drinking in the past 30 days 10% Healthy People 2020 Target: 8.6 % or below (in 2013). 17 By 12th grade, more than 65 percent of students have tried alcohol.18 8% l W hile current numbers are still high, Males 7.9% Total the number of high school students 6% 7.4% 7.2% Females reporting drinking has decreased sig- 6.2% nificantly over the past decade (from a 4% rate of 45 percent in 2003), and binge drinking has also lowered (from a rate 2% of 28 percent in 2003).19 l U nderage drinking contributes to more 0% than 4,300 deaths and 189,000 2008 2009 2010 2011 2012 2013 emergency room visits by persons Year under 21 years of age each year.20, 21 Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008 to 2013. l M ore than 60 percent of teens (12- to 17-year-olds) do not perceive that there is a significant risk to drinking five or more alcoholic drinks once or Past-Month Binge Alcohol Use Among Adolescents Aged 12–17, twice a week, and 37.5 percent do not by Race/Ethnicity (2013) perceive significant risk to drinking at 8% that level every day.22 7.3% 6.3% l Y outh who start drinking before the age of 15 are five times more likely to de- 6% 5.6% velop an alcohol addiction later in life 4.5% than those who begin drinking at or after 3.9% 4% the age of 21 years.23 2.8% l D rinking alcohol is related to other risky behaviors, for instance: 2% l N early one in four fatal car accidents among 15- to 20-year-olds were the re- sult of drinking and driving — of which 0% White Black American Native Asian Hispanic or almost three-quarters were also not Indian or Hawaiian or Latino wearing a seat belt.24 Alaska Native Other Pacific Islander l U nderage drinking plays a significant Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013. role in engaging in unprotected, un- wanted and unintended sexually ac- tivity and sex with multiple partners, increasing the risk of sexually trans- mitted infections, including HIV, and unplanned pregnancies.25, 26, 27, 28 10 TFAH • healthyamericans.org Past-Month Illicit Drug Use Among Adolescents ILLICIT DRUG USE Aged 12–17, by Race/Ethnicity (2009–2013) l O verall teen (12- to 17-year-olds) use of illicit drugs has decreased by 13 percent 12% 11.8% since 2009 — but rates remain high.29 11.4% More than 4 thousand teens and young 11.1% adults died from drug overdoses in 2013.30 11% 10.8% 10.8% l T eens reporting regular marijuana use 10.5% is one illicit drug with recent reported Black 10.2% increases in use — from 6.7 percent in 10.1% 10.1% 10.1% 10.3% 2008 to 7.1 percent in 2013.31 10% 9.7% l M ost youth report they do not think oc- 9.8% 9.6% 9.7% 9.7% casional marijuana smoking is harmful 9.5% 8.8% — neither once a month (75.8 percent) 9% ( , ) Total White or more frequently (one or twice a Hispanic week, 60.5 percent).32 8.7% or Latino l T wenty states and Washington, D.C. 8% have decriminalized or have taken 2009 2010 2011 2012 2013 action to soon decriminalize mari- Year juana possession for adults — and Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2009 to 2013. 23 states and Washington, D.C. have legalized medical marijuana.33 l E arly chronic marijuana use that extends into adulthood is linked to Past-Month Illicit Drug Use Among Adolescents Aged 12–17 (2013) declines in IQ of up to 8 points — and 8% 7.1% regular marijuana use during youth is associated with higher unemployment and lower income, academic attainment 6% and life satisfaction.34, 35, 36 l A mong other drugs: inhalant use among 4% 8th graders dropped from a peak of 12.8 percent in 1995 to 5.3 percent in 2014; 2.2% ecstasy use declined in 10th graders 2% from a peak of 6.2 in 2001 to 2.3 per- cent in 2014; synthetic cannabinoids 0.6% 0.5% 0.2% (K2/Spice) among 12th graders declined 0.1% 0% from 11.3 percent in 2012 to 5.8 per- Marijuana Nonmedical use of Hallucinogens Inhalants Cocaine Heroin cent in 2014; hallucinogen salvia use psychotherapeutics among 12th graders declined from 3.2 Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013. percent in 2013 to 1.8 percent in 2014; and synthetic stimulant (bath salts) use by 8th graders dropped from 1 percent in 2012 to 0.5 percent in 2014.37 TFAH • healthyamericans.org 11 W hile heroin rates have remained steady l Past-Month Marijuana Use Among Adolescents Aged 12–17 for teens, rates have doubled in the past (2008–2013) decade among young adults as they tran- 10% sition from prescription drugs and other illegal drugs as they age.38, 39 7.9% 8% 7.4% 7.4% 7.2% 7.1% l mong high school students (as of 2013), A 6.7% around 40 percent report having tried mar- 6% ijuana, 5.5 percent tried cocaine, 7.1 per- Healthy People 2020 Target: 6.0 % or below cent tried hallucinogenics (LSD, acid, PCP , 4% angel dust, mescaline or mushrooms), 8.9 percent tried inhalants, 6.6 percent tried ecstasy, 2.2 percent tried heroin, 3.2 2% percent tried methamphetamines and 3.2 percent tried illegal steroids.40 0% 2008 2009 2010 2011 2012 2013 l round 20 percent of 8th graders report A Year having tried illegal drugs — that number Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use vand Health, 2008 to 2013. increases to 49 0percent by 12th grade.41 l A round 3.5 percent of teens (12- to 17-year-olds) and 7.4 percent of young adults (18- to 25-year-olds) are dependent on or misuse illegal drugs.42 Past-Month Marijuana Use Among Adolescents, by National Survey (2002–2013) 25% 23.1% 23.4% 9th–12th Grades 22.4% (Youth Risk Behavior 20.2% 20.8% Survey) 19.7% 22.6% 22.9% 22.7% 20% 21.5% 21.2% 21.4% 12th Grade 20.6% (Monitoring the Future) 19.9% 19.8% 19.4% 18.3% 18.8% 15% 13.1% 12.3% 12.4% 12.4% 12.5% 11.2% 11.2% 11.8% 10.9% 10.4% 8th and 10th Grades 10.0% 9.8% Combined (Monitoring 10% the Future) Aged 12–17 8.2% 7.9% 7.6% 7.9% 7.4% 7.4% 7.2% 7.1% (National Survey 5% 6.8% 6.7% 6.7% 6.7% on Drug Use and Health) 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002 to 2013; National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002 to 2013; Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2003, 2005, 2007, 2009, 2011, and 2013. 12 TFAH • healthyamericans.org Past-Year Nonmedical Pain Reliever Use Among Adolescents, by National Survey and Gender (2002–2013) 12% 11.6% 10.7% 10.9% 10.7% 10.9% 10.7% 10.6% 10.3% 9.9% 10% 9.6% 9.3% 8.3% 8.4% 7.9% 8.1% 7.9% 7.9% 12th Grade Males 7.8% 7.6% 7.8% 8% 7.4% 7.4% (Monitoring the Future) 7.4% 7.8% 8.1% 7.5% 6.5% 7.4% 6.5% 12th Grade Females 7.2% 7.3% 7.0% 7.2% 7.2% 7.0% 6.8% 5.6% (Monitoring the Future) 6% 6.5% 6.4% 5.6% 6.3% 6.0% 4.8% Aged 12–17, Females 5.7% 5.5% 5.4% (National Survey on 5.1% Drug Use and Health) 4% 4.5% Aged 12–17, Males (National Survey on Drug Use and Health) 2% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002 to 2013; National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002 to 2013. PRESCRIPTION DRUG MISUSE l round 4.7 percent of teens (12- to 17-year-olds) A report misusing prescription drugs. While this represents a decrease of 36 percent in the past decade (7.3 percent in 2002), rates remain high.43 Most teens taking these drugs are misusing medi- cines prescribed to family or friends. Since 1999, the amount of prescription painkillers prescribed and sold in the United States has nearly quadru- pled. l P rescription drug overdoses were responsible for more than half of all drug overdose deaths in 2013 — accounting for 22,700 fatalities.44 l H igh school students report misusing different types of prescription drugs including: 6.8 percent using stimulants (frequently used for Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)); 4.8 percent using Vicodin and 3.3 percent using OxyContin (narcotics/ opioids used for pain relief); and 4.7 percent using depressants, such as tranquilizers.45 TFAH • healthyamericans.org 13 TOBACCO AND ELECTRONIC Past-Month Cigarette Use Among Adolescents CIGARETTE (E-CIGARETTE) USE Aged 12–17, by Race/Ethnicity (2009–2013) l A round 24.6 percent of high school 12% students report using any tobacco 10.7% product — including 9.2 percent 9.8% smoking cigarettes, 9.4 percent smoking 10% 9.0% 9.3% hookahs, 8.2 percent smoking cigars 8.4% 8.2% 7.8% and 13.4 percent using e-cigarettes.46 8% 7.2% 7.9% 6.6% White l E -cigarette use among high school 7.6% 6.1% 5.6% students increased exponentially from 6% 4.8% Total 1.5 percent in 2011 to 13.4 percent 5.3% 3.7% Hispanic in 2014. Nearly 4 percent of middle 4% 4.9% 4.4% or Latino 4.1% schoolers reported using e-cigarettes 3.2% Black in 2014. 2% l I f smoking current rates continue at current levels, 5.6 million of current 0% 2009 2010 2011 2012 2013 12- to 24-year-olds will die early from Year smoking-related illnesses as they age Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use into tobacco-use related illnesses.47, 48 and Health, 2009 to 2013. l M ore than one-third (35.7 percent) of teens do not perceive smoking one or more packs of cigarettes per day as Past-Month Cigarette Use Among Adolescents Aged 12–17, risky. 49 Teens perceive e-cigarettes as by Race/Ethnicity (2013) having lower risk for regular use than 8% any other drug, including alcohol.50 7.2% 6% 4% 3.6% 3.7% 3.2% 2.5% 2% 0% White Black Native Asian Hispanic or Hawaiian or Latino Other Pacific Islander Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013. 14 TFAH • healthyamericans.org Past-Year Initiation of Selected Substances Among Adolescents SOCIOECONOMIC STATUS AND Aged 12–17 (2009–2013) SUBSTANCE USE l Y outh from affluent families and/or 12% neighborhoods report more frequent 10.8% 10.5% 10.2% substance and alcohol use than lower-in- 9.8% 9.7% Used Alcohol come teens — often related to having for the First Time more resources available to them to ac- 8% cess alcohol and drugs.51, 52, 53 l S moking is higher among teens of par- 5.5% 5.5% 5.2% 5.0% Used Marijuana ents with lower levels of incomes and ed- 4.8% for the First Time ucation while alcohol use, binge drinking 5.2% 4% 4.9% 4.7% Used Cigarettes and marijuana use are higher for teens 4.1% for the First Time 3.7% of parents with higher levels of income 3.5% 3.2% 3.0% Nonmedical Use of and education.54, 55, 56 Teens from affluent 2.9% 2.4% Psych otherapeutics families are more likely to initiate and for the First Time regularly use alcohol or drugs starting at 0% 2009 2010 2011 2012 2013 a younger age. Year l H igher parental education or income Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2009 to 2013. during childhood is associated with higher rates (1.3 to 1.6 times higher) of binge drinking, marijuana use and cocaine use among college students Past-Year Initiation of Selected Substances Among Adolescents compared with lower parental education Aged 12–17, by Race/Ethnicity (2013) or income during childhood.57 12% 10.5% White 9.1% 9.1% Black 8% Hispanic or Latino 4.1% 3.6% 4% 3.0% 2.6% 2.4% 1.9% 0% Alcohol Cigarettes Nonmedical Use of Prescription Drugs Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013. TFAH • healthyamericans.org 15 TEEN AND YOUTH PREGNANCY AND SUBSTANCE USE l T here are around 305,000 births to nomic costs of $53,000 per baby for 15- to 19-year-olds annually — and by immediate medical costs for treating a age 25, nearly half of all U.S. women baby diagnosed with opioid withdrawal give birth. 58, 59 Nearly 60 percent of syndrome (neonatal abstinence syn- pregnant teens report using one or drome (NAS)).62, 63, 64, 65 Babies exposed more substances in the past year, and to drug use in utero are at higher risk one-third of pregnant 12- to 14-year-olds for prematurity, birth defects, learning report using one or more substances in disabilities, behavioral disorders and a the past month.60 Pregnant teens were range of other health problems. most likely to use alcohol (16 percent), l A pproximately 11 percent of pregnant followed by marijuana (14 percent) and teens (15- to 19-years-old) and more other illicit drugs (5 percent). than 13 percent of pregnant 20- to l A round 400,000 babies in the United 24-year-olds reported smoking while States are diagnosed with Fetal Alcohol pregnant.66 Smoking during pregnancy Syndrome Disorder — which is the results in around 1,015 deaths annually leading risk of mental retardation and as well as increased risk for low birth preventable cause of birth defects, and weight, ADHD and other health risks.67, 68 can contribute to low birth weight, pre- maturity and related lifelong physical l A lcohol and other drug use can contribute and behavioral health complications.61 to risky sexual behaviors, which can lead to increased chance of pregnancy or sex- l A round one in 20 women use illegal ually transmitted infections.69, 70 Teens drugs during pregnancy and 13,500 who regularly smoke or have parents with babies were born with opioid drug with- a substance use disorder are also asso- drawal syndrome in 2009 (including ciated with higher risk of teen pregnancy. prescription painkillers) — with eco- Percentage of Births Which Were to Mothers Who Smoked During Pregnancy, by Age, 2013* 25 20 15 13.3 10.6 Percent 10 8.9 5.7 4.4 5 4.0 2.5 0 Under 15 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-54 years years *Data are based on the 41 States using the 2003 revision of the standard birth certificate, representing 87 percent of all births Source: National Center for Health Statistics, CDC WONDER online tool. http://wonder.cdc.gov/natality-current.html 16 TFAH • healthyamericans.org Adolescents Aged 12–17 Who Perceived No Great Risk From the Use of Selected Substances (2009–2013) 80% 75.8% Smoke Marijuana 73.5% 72.4% Once a Month 69.7% 70.4% 70% Have Five or More Drinks Once or 60.4% 60.3% 61.0% 59.6% 59.3% Twice a Week 60% 60.5% Smoke Marijuana Once or Twice a 56.4% Week 55.2% 50% 52.8% 51.0% Have Four or Five Drinks Nearly 40% 37.5% Every Day 35.9% 35.3% 36.1% 35.2% Smoke One or 35.7% More Packs of 34.5% 34.7% 34.3% Cigarettes Per Day 33.8% 30% 2009 2010 2011 2012 2013 Year Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2009 to 2013. Sexual Identity and Substance Misuse Health Risks:72 SEXUAL MINORITIES AND Analysis of the Youth Risk Behavior Surveillance (YRBS) Data from 2001-2009 SUBSTANCE USE (Note: Mean findings from across 12 states or large cities) l L esbian, Gay and Bisexual (LGB) Heterosexual Gay or Lesbian Bisexual adolescents have higher rates of smoking, Current Cigarette Use* 13.6% 30.5% 30.8% alcohol use and other drug use compared Cigarettes – Tried before age 13 10% 25.7% 24% with heterosexual teens, and they are Current Alcohol Use* 37.6% 47.5% 55.6% more likely to begin drinking earlier and Alcohol – Drank before age 13 21.3% 34.6% 27.1% have higher levels of risky drinking.71 Current Marijuana Use* 21.8% 34.5% 36.8% l L GB youth are more than three times as Marijuana – Tried before age 13 8.2% 21.4% 21.5% Current Cocaine Use* 1.8% 16.6% 11% likely to report substance use than their Ever Used Heroin 1.8% 17.7% 9.6% heterosexual peers. Ever Used Methamphetamines 3.4% 21.5% 14.9% Used Steroids Without Prescription 2.4% 17.1% 10.6% Note: *Current is defined as within the 30 days before the survey. TFAH • healthyamericans.org 17 COLLEGE TRENDS 18 TFAH • healthyamericans.org TFAH • healthyamericans.org 19 HEROIN USE: RISE IN YOUNG ADULTS Heroin use has more than doubled among 18- to 25-year-olds in the past decade.73, 74 The rise in prescription painkiller misuse has been a major contributing factor to the increase. A rising number of individuals who have become addicted to prescription painkillers have turned to heroin as an al- ternative — it is relatively cheap and often easier to access.75, 76, 77, 78, 79, 80 More than nine in 10 people who use heroin also use at least one other drug. Forty-five percent of people who use heroin are also ad- dicted to prescription painkillers. l T he cost of heroin can often be one-sixth to one-tenth the price in different loca- tions (often around $5 a “bag”) compared to prescription painkillers and can be more easily available in some locations. Individuals who inject heroin via needles are also at increased risk for HIV/AIDS and hepatitis B and C.81 New acute hep- atitis C infections increased by 151.5 percent from 2006-2010 to 2010-2013.82 According to the U.S. Centers for Disease Control and Prevention (CDC), the increase has predominantly been among young adults (under 30-years-old) who are white, live in non-urban areas, particularly in the East and Midwest, and have a history of injection drug use and have previously used prescription painkillers.83, 84 20 TFAH • healthyamericans.org Sources: SAMHSA, Los Angeles Times, Frost & Sullivan TFAH • healthyamericans.org 21 YOUTH SUBSTANCE MISUSE DATA There are three major national surveys The Youth Risk Behavior Surveillance that examine alcohol and/or drug use System (YRBSS) is a national (public trends among teens and/or youth. and private) school-based survey con- They study different segments of ducted by CDC every two years of 9th the population and are conducted at through 12th grade students. YRBSS is different times, but all help examine used to monitor priority health risk be- different patterns of risk, use and havior among youth relating to injuries perceptions to help inform policies and and violence, sexual behaviors, tobacco resource allocations. use, alcohol and other drug use, diet, physical activity, obesity and asthma. The National Survey on Drug Use and The data from YRBSS are available at a Health (NSDUH) is an annual nationwide state level for participating states. survey that interviews approximately 70,000 randomly selected individuals (a The Monitoring the Future (MTF) is a household survey), ages 12 and older, national survey conducted every year and is sponsored by the Substance in the 8th, 10th and 12th grade, and Abuse and Mental Health Services follow-up questionnaires are given to a Administration (SAMHSA). NSDUH sample of each graduating cohort for provides national and state-level data several years. MTF is conducted by on use of tobacco products, alcohol, the Institute for Social Research at the illicit drugs (including non-medical use University of Michigan, and supported of prescription drugs) and mental health by NIH grants.85 MTF tracks trends in the United States. NSDUH tracks over time of youth use, attitudes and trends and assesses consequences of values relating to tobacco products (in- substance use and identifies high risk cluding e-cigarettes and hookah), and groups for substance use and misuse. alcohol and illicit drug misuse (including The age range commonly used for teens non-medical use of prescription drugs). is 12- to 19-year-olds, which captures The survey is designed to examine the age span for initiation and use, but changes that may occur across all age since it averages the age span, it does groups and within cohorts and changes not capture how drug and alcohol use in environment or life role. The survey increases significantly at a population is given to 50,000 students in 420 pub- level as teens age. lic and private middle and high schools. 22 TFAH • healthyamericans.org DRUG OVERDOSE DEATHS — TEENS AND YOUNG ADULTS The number of youth drug overdose Drug Overdose Deaths for Teens and Young Adults, 3-Year Average Mortality deaths has grown dramatically over the Rates, between 1999-2001, 2005-2007 and 2011-2013, in Four States: Arizona, Missouri, New York and Ohio last 15 years. In 1999-2001, no states 14 had a drug overdose death rate above 12 6.1 per 100,000 teens and young adults 10.2 (12- to 25-year olds). By 2005-2007, 40 10 9.5 states had an increase in drug overdose 8 7.5 9.1 7.4 death rates (compared to 1999-2001), of 6.9 6.9 6 which 28 states had rates above 6.1 per 100,000 teens and young adults. In 2011- 4 4 3.1 3.5 2013 (compared to 2005-2007), rates 2 2.2 1.8 dropped in five states, but significantly 0 increased in 13 states of which 11 had 1999-2001 2005-2007 2011-2013 Arizona Missouri New York Ohio rates above 6.1 per 100,000 teens and young adults (compared to 2005-2007). Drug Overdose Deaths for Teens and Young Adults, 3-Year Average Mortality By 2011-2013, a total of 33 states had Rates, between 1999-2001, 2005-2007 and 2011-2013, in Four States: drug overdose death rates above 6.1 per Florida, Louisiana, Mississippi and Tennessee 14 13.4 100,000 teens and young adults. Rates were highest in West Virginia (12.6 per 12 100,000) and lowest in North Dakota (2.2 10.7 10 per 100,000). 9.1 8 Between 1999-2001 and 2011-2013, the 7 youth (12- to 25-year olds) drug overdose 6 6.2 5.8 5.6 death rates more than doubled in 18 states 5.7 (Alabama, Arizona, California, Colorado, 4 3.5 3.7 3.4 Connecticut, Georgia, Hawaii, Idaho, Illinois, 2 2.1 Kentucky, Nebraska, Nevada, New Jersey, New Mexico, North Carolina, Oregon, South 0 1999-2001 2005-2007 2011-2013 Carolina and Tennessee), more than tripled Florida Louisiana Mississippi Tennessee in 12 states (Arkansas, Delaware, Indiana, Iowa, Michigan, Minnesota, Missouri, New adults (19 to 25 year olds), death rates Hampshire, New York, Oklahoma, Utah and exceeded 20 per 100,000 in five states: West Virginia) and more than quadrupled in West Virginia (23.0 per 100,000), New five states (Kansas, Montana, Ohio, Wiscon- Mexico (22.3 per 100,000), Utah (22.1 sin and Wyoming). per 100,000), Pennsylvania (21.0 per Overdose deaths increase dramatically from 100,000) and Nevada (20.1 per 100,000). teen to young adult years. In 2011-2013, Fourteen states had young adult death the national young adult (19- to 25-year-olds) rates between 15 and 20 per 100,000; overdose death rate (12.7 per 100,000) 19 states had young adult death rates is more than eight times greater than the between 10 and 15 per 100,000; and 11 national teen (12- to 18-year olds) drug states had rates below 10 per 100,000. overdose death rate (1.5 per 100,000). Data is based on a TFAH analysis from No state had a teen (12- to 18-year olds) CDC’s Web-based Injury Statistics and Query drug overdose death rate above 3.1 and Reporting (WISQARS) system.86 For per 100,000 (2011-2013). For young more on the methodology, see Appendix B. TFAH • healthyamericans.org 23 DRUG OVERDOSE DEATHS, DRUG OVERDOSE DEATHS, DRUG OVERDOSE DEATHS, 2011-2013, 1999-2001, AGES 12-25 2005-2007, AGES 12-25 AGES 12-25, CRUDE RATES Total Rates Total Rates Total Rates State Male Rates Female Rates Male Rates Female Rates Ranking Male Rates Female Rates (95% C.I.) (95% C.I.) (95% C.I.) Alabama 2.3 (+/-0.6) 3.2 1.5* 6.9 (+/-1.0)¥ 11.1 2.7 6.2 (+/-0.9) 32 8.9 3.4 Alaska 3.8* (+/-1.9) 1.4* 6.3* 7.7 (+/-2.6) 11.2 3.8* 7.2 (+/-2.5) 24 8.5 5.7* Arizona 4.0 (+/-0.7) 6.1 1.8 7.4 (+/-0.9)¥ 10.8 3.8 10.2 (+/-1.0)§ 8 14.9 5.2 Arkansas 2.4 (+/-0.8) 2.9 1.9* 7.9 (+/-1.4)¥ 12.1 3.6 8.4 (+/-1.4) 19 11.6 5.1 California 1.7 (+/-0.2) 2.4 0.9 3.2 (+/-0.2)¥ 4.5 1.8 4.9 (+/-0.3)§ 43 7.0 2.6 Colorado 3.5 (+/-0.7) 4.8 2.0 7.3 (+/-1.0)¥ 10.2 4.2 10.2 (+/-1.2)§ 8 13.6 6.6 Connecticut 4.1 (+/-1.0) 6.7 1.3* 8.3 (+/-1.3)¥ 12.5 3.8 8.3 (+/-1.3) 20 12.8 3.6 Delaware 2.7* (+/-1.5) 4.0* 1.3* 5.1 (+/-2.0) 7.4* 2.8* 10.2 (+/-2.7)§ 8 12.2 8.1 D.C. 0.9* (+/-1.0) 1.9* 0.0* 1.3* (+/-1.1) 2.3* 0.5* --- --- --- Florida 5.8 (+/-0.5) 8.5 2.9 10.7 (+/-0.6)¥ 15.4 5.6 5.7 (+/-0.5)€ 40 7.8 3.5 Georgia 2.3 (+/-0.4) 3.4 1.0 5.5 (+/-0.6)¥ 8.5 2.4 5.2 (+/-0.6) 42 6.8 3.5 Hawaii 1.6* (+/-0.9) 1.9* 1.2* 2.9 (+/-1.2) 4.9* 0.6* 4.6 (+/-1.5) 45 6.4 --- Idaho 2.5 (+/-1.1) 3.6* 1.2* 3.3 (+/-1.2) 5.2 1.3* 5.8 (+/-1.5) 38 7.2 4.3* Illinois 3.9 (+/-0.5) 6.0 1.6 6.2 (+/-0.6)¥ 9.1 3.2 8.2 (+/-0.6)§ 21 12.2 4.1 Indiana 2.4 (+/-0.5) 3.7* 1.1* 9.7 (+/-1.0)¥ 14.3 5.0 9.6 (+/-1.0) 12 14.7 4.3 Iowa 1.4 (+/-0.5) 2.0* 0.8* 3.5 (+/-0.9)¥ 5.0 1.9* 4.3 (+/-1.0) 46 6.4 2.1* Kansas 1.3 (+/-0.5) 1.6* 1.0* 4.1 (+/-1.0)¥ 6.1 2.0* 5.9 (+/-1.2) 36 8.5 3.0 Kentucky 4.0 (+/-0.8) 5.7 2.1 11.5 (+/-1.3)¥ 16.9 5.8 10.5 (+/-1.3) 7 14.6 6.3 Louisiana 3.5 (+/-0.7) 5.1 1.8 13.4 (+/-1.4)¥ 21.8 4.8 6.2 (+/-0.9)€ 32 8.1 4.2 Maine 3.6 (+/-1.4) 6.3 0.9* 10.2 (+/-2.3)¥ 14.8 5.3* 4.7 (+/-1.6)€ 44 6.6 --- Maryland 5.2 (+/-0.8) 7.8 2.5 7.3 (+/-0.9)¥ 11.2 3.3 8.5 (+/-1.0) 18 12.0 5.0 Massachusetts 5.2 (+/-0.8) 7.0 3.4 6.8 (+/-0.8)¥ 10.1 3.4 7.8 (+/-0.9) 23 11.2 4.3 Michigan 2.1 (+/-0.4) 2.5 1.6 6.6 (+/-0.7)¥ 9.5 3.5 8.1 (+/-0.7)§ 22 11.0 5.1 Minnesota 1.6 (+/-0.5) 1.9 1.4* 3.0 (+/-0.6)¥ 4.4 1.6 5.7 (+/-0.9)§ 40 8.5 2.7 Mississippi 2.1 (+/-0.7) 2.6 1.5* 5.6 (+/-1.1)¥ 8.2 2.9 3.7 (+/-0.9)€ 47 4.8 2.6 Missouri 3.1 (+/-0.6) 4.7 1.4 7.5 (+/-0.9)¥ 11.0 3.9 9.5 (+/-1.0)§ 13 13.5 5.4 Montana 1.6 (+/-1.0) 1.8* 1.5* 7.5 (+/-2.2)¥ 9.0 5.8* 7.0 (+/-2.2) 26 8.3 5.6* Nebraska 1.4* (+/-0.7) 2.2* 0.6* 2.5 (+/-0.9) 3.0* 1.9* 3.7 (+/-1.1) 47 5.4 1.9* Nevada 4.4 (+/-1.2) 5.6 3.2* 11.8 (+/-1.8)¥ 15.2 8.0 11.6 (+/-1.7) 5 16.5 6.6 New Hampshire 3.0* (+/-1.3) 4.7* 1.2* 10.5 (+/-2.3)¥ 15.4 5.4* 9.3 (+/-2.2) 15 12.8 5.6* New Jersey 4.8 (+/-0.7) 7.2 2.2 6.3 (+/-0.7)¥ 9.4 3.0 10.7 (+/-0.9)§ 6 15.3 5.7 New Mexico 6.1 (+/-1.4) 9.6 2.5* 9.8 (+/-1.8)¥ 13.9 5.4 12.5 (+/-2.0) 2 17.3 7.4 New York 1.8 (+/-0.3) 2.4 1.0 3.5 (+/-0.3)¥ 5.3 1.7 6.9 (+/-0.5)§ 29 10.4 3.3 North Carolina 3.0 (+/-0.5) 3.8 2.2 8.0 (+/-0.8)¥ 11.6 4.3 7.1 (+/-0.7) 25 10.4 3.5 North Dakota 1.2* (+/-1.1) 1.8* 0.5* 3.0* (+/-1.6) 3.9* 1.9* 2.2* (+/-1.4) 50 --- --- Ohio 2.2 (+/-0.4) 3.3 1.1 6.9 (+/-0.6)¥ 10.1 3.7 9.1 (+/-0.7)§ 16 12.3 5.7 Oklahoma 2.6 (+/-0.7) 4.0 1.2* 9.6 (+/-1.3)¥ 14.8 4.1 9.4 (+/-1.3) 14 14.0 4.4 Oregon 2.5 (+/-0.7) 3.6 1.3* 5.3 (+/-1.0)¥ 7.7 2.8 6.5 (+/-1.1) 31 9.7 3.3 Pennsylvania 6.1 (+/-0.6) 9.2 2.9 10.5 (+/-0.7)¥ 15.6 5.1 11.8 (+/-0.8) 4 17.1 6.3 Rhode Island 3.6 (+/-1.5) 4.6* 2.7* 5.2 (+/-1.7) 8.5 1.9* 6 (+/-1.9) 34 9.4 --- South Carolina 2.7 (+/-0.7) 4.3 1.1 5.3 (+/-0.9)¥ 8.2 2.3 5.8 (+/-0.9) 38 8.1 3.5 South Dakota 1.9* (+/-1.2) 2.4* 1.3* 2.2* (+/-1.3) 3.2* 1.3* 3.3* (+/-1.6) 49 5.2 --- Tennessee 3.4 (+/-0.6) 4.9 1.8 9.1 (+/-1.0)¥ 12.5 5.6 7.0 (+/-0.9)€ 26 10.0 3.9 Texas 3.1 (+/-0.3) 4.5 1.5 5.9 (+/-0.4)¥ 8.9 2.8 6.0 (+/-0.4) 34 8.6 3.2 Utah 3.5 (+/-0.9) 5.1 1.8* 12.5 (+/-1.6)¥ 17.9 6.9 12.1 (+/-1.5) 3 16.3 7.8 Vermont 4.8* (+/-2.3) 5.5* 4.1* 6.9 (+/-2.7) 9.8* 3.8* 7.0 (+/-2.7) 26 8.1* 5.8* Virginia 3.4 (+/-0.6) 4.4 2.3 5.3 (+/-0.7)¥ 7.4 3.0 5.9 (+/-0.7) 36 7.9 3.8 Washington 3.6 (+/-0.6) 4.6 2.5 6.5 (+/-0.8)¥ 9.1 3.7 6.9 (+/-0.8) 29 10.1 3.5 West Virginia 3.8 (+/-1.2) 5.2 2.4* 13.8 (+/-2.3)¥ 17.5 9.9 12.6 (+/-2.2) 1 14.6 10.5 Wisconsin 2.0 (+/-0.5) 2.4 1.5 5.8 (+/-0.8)¥ 8.6 2.9 8.8 (+/-1.0)§ 17 12.7 4.7 Wyoming 1.6* (+/-1.4) 1.2* 2.0* 3.7* (+/-2.1) 5.8* 1.3* 9.8 (+/-3.4)§ 11 14.0 --- U.S. Total Rates 3.1 4.4 1.7 6.6 9.7 3.4 7.3 10.4 4.1 NOTE: * Indicates crude rate based on 20 or fewer NOTE: * Indicates crude rate based on 20 or fewer NOTE: For rankings, 1 = Highest mortality rate and 50 = Lowest mortal- deaths and may be unstable. --- indicates state-level deaths and may be unstable. --- indicates state-level ity rate. * Indicates crude rate based on 20 or fewer deaths and may counts and rates based on fewer than 10 deaths counts and rates based on fewer than 10 deaths have be unstable. --- indicates state-level counts and rates based on fewer have been suppressed. Confidence intervals (C.I.) been suppressed. Confidence intervals (C.I.) have been than 10 deaths have been suppressed. Confidence intervals (C.I.) have have been rounded to one decimal point. All data rounded to one decimal point. Red and ¥ indicates a been rounded to one decimal point. Red and § indicates a statistical are 3-year average rates from CDC’s Web-based Injury statistical increase in rates between years 1999-2001 increase in rates between years 2005-2007 and 2011-2013. Green Statisitics Query and Reporting System (WISQARS). and 2005-2007. All data are 3-year average rates from and € indicates a statistical decrease in rates between years 2005- CDC’s Web-based Injury Statisitics Query and Reporting 2007 and 2011-2013. All data are 3-year average rates from CDC’s System (WISQARS). Web-based Injury Statisitics Query and Reporting System (WISQARS). 24 TFAH • healthyamericans.org Drug Overdose Deaths, 12- to 25-Year-Olds, 3-Year Average Mortality Rates, 1999 – 2001 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY <5.0% NC TN 5.0% to 7.9% AZ OK NM AR SC 8.0% to 10.9% GA 11.0% to 13.9% MS AL 14.0% to 16.9% TX LA ≥17.0% Rate has been FL suppressed, AK state had less HI than 10 deaths reported Drug Overdose Deaths, 12- to 25-Year-Olds, 3-Year Average Mortality Rates, 2005 – 2007 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY <5.0% NC TN 5.0% to 7.9% AZ OK NM AR SC 8.0% to 10.9% GA 11.0% to 13.9% MS AL 14.0% to 16.9% TX LA ≥17.0% Rate has been FL suppressed, AK state had less HI than 10 deaths reported Drug Overdose Deaths, 12- to 25-Year-Olds, 3-Year Average Mortality Rates, 2011 – 2013 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY <5.0% NC TN 5.0% to 7.9% AZ OK NM AR SC 8.0% to 10.9% GA 11.0% to 13.9% MS AL 14.0% to 16.9% TX LA ≥17.0% Rate has been FL suppressed, AK state had less HI than 10 deaths reported TFAH • healthyamericans.org 25 DRUG OVERDOSEE DEATHS, DRUG OVERDOSE DEATHS, 2011-2013, AGES 12-18 2011-2013, AGES 19-25 State Total Rates Male Rates Female Rates Total Rates Ranking Male Rates Ranking Female Rates Ranking Alabama 1.1* 1.5* --- 10.9 32 16.0 29 5.8 31 Alaska --- --- --- 11.4 29 14.6* 33 --- Arizona 2.9 4.6 1.1* 17.3 9 24.7 10 9.3 13 Arkansas 2.3* 2.8* --- 14.2 22 20.1 20 8.2 18 California 1.2 1.6 0.8 8.3 44 11.9 44 4.3 41 Colorado 2.7 3.2 2.2* 17.1 10 22.9 15 10.7 9 Connecticut 1.2* 1.9* --- 15.8 17 24.0 11 6.9 22 Delaware --- --- --- 16.0 15 19.6 22 12.4* 4 D.C. --- --- --- --- --- --- Florida 1.4 1.9 1.0 9.6 41 13.2 41 5.7 34 Georgia 1.1 1.3* 0.8* 9.2 42 12.2 43 6.1 29 Hawaii --- --- --- 7.4 45 9.9 46 --- Idaho --- --- --- 10.4 34 13.6 39 7.0* 21 Illinois 1.9 2.4 1.3 14.5 21 22.0 17 6.9 22 Indiana 2.2 2.8 1.6* 16.7 11 26.3 7 6.9 22 Iowa 1.4* --- --- 7.0 46 10.7 45 3.1* 42 Kansas 1.7* --- --- 9.8 40 14.5 36 4.7* 38 Kentucky 1.9 2.4* --- 18.7 7 26.1 8 10.9 7 Louisiana 1.3* --- 1.6* 10.5 33 14.6 33 6.4 26 Maine --- --- --- 9.2 42 12.8 42 --- Maryland 1.6 2.2* --- 15.2 19 21.4 19 8.8 16 Massachusetts 1.2 1.8* --- 13.5 23 19.6 23 7.4 20 Michigan 1.4 2.0 0.8* 14.7 20 20.0 21 9.2 14 Minnesota 1.3 1.7* --- 9.9 39 15.2 31 4.5 39 Mississippi --- --- --- 6.4 48 8.4 48 4.4* 40 Missouri 2.0 2.7 1.2* 16.6 13 23.8 12 9.2 14 Montana --- --- --- 11.2 31 13.6 39 8.5* 17 Nebraska --- --- --- 6.5 47 9.4 47 --- Nevada 3.1 4.8* --- 20.1 5 28.0 5 11.7 5 New Hampshire --- --- --- 17.8 8 25.2 9 10* 12 New Jersey 1.9 2.4 1.5* 20.0 6 29.1 4 10.2 11 New Mexico 2.2* 3.6* --- 22.3 2 30.1 3 13.9 2 New York 1.0 1.5 0.4* 12.0 25 18.2 24 5.7 34 North Carolina 2.0 2.9 1.1* 11.8 27 17.4 26 5.8 31 North Dakota --- --- --- --- --- --- Ohio 1.3 1.9 .8* 16.7 11 22.9 15 10.5 10 Oklahoma 2.8 3.6* 1.9* 15.4 18 23.6 13 6.7 25 Oregon 1.4* 1.9* --- 11.4 29 17.0 27 5.5 37 Pennsylvania 1.8 2.8 .8* 21.0 4 30.4 1 11.4 6 Rhode Island --- --- --- 10.0 38 16.0 29 --- South Carolina 0.8* --- --- 10.3 36 14.6 35 5.8 31 South Dakota --- --- --- 5.2* 49 7.7* 49 --- Tennessee 1.9 2.2* 1.5* 11.9 26 17.6 25 6.1 29 Texas 1.5 2.2 0.8 10.4 34 15.0 32 5.6 36 Utah 2.0* 2.4 --- 22.1 3 30.2 2 13.8 3 Vermont --- --- --- 12.6 24 14.2* 37 10.9* 7 Virginia 1.1 1.2* 1.0* 10.1 37 13.8 38 6.2 27 Washington 1.6 2.4 --- 11.8 27 17.0 27 6.2 27 West Virginia --- --- --- 23.0 1 26.5 6 19.3 1 Wisconsin 1.4 1.5* 1.3* 16.0 15 23.6 13 8.1 19 Wyoming --- --- --- 16.1 14 21.7* 18 --- U.S. Total Rates 1.6 2.1 1.0 12.7 18.2 7.0 NOTE: For rankings, 1 = Highest mortality rate. * Indicates crude rate based on 20 or fewer deaths and may be unstable. --- indicates state-level counts and rates based on fewer than 10 deaths have been suppressed. All data are 3-year average rates from CDC’s Web-based Injury Statisitics Query and Reporting System (WISQARS). 26 TFAH • healthyamericans.org Drug Overdose Deaths, 12- to 18-Year-Olds, 3-Year Average Mortality Rates, 2011 – 2013 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA TX LA FL AK HI <5.0% 5.0% to 7.9% 8.0% to 10.9% 11.0% to 13.9% 14.0% to 16.9% ≥17.0% Rate has been suppressed, state had less than 10 deaths reported Drug Overdose Deaths, 19- to 25-Year-Olds, 3-Year Average Mortality Rates, 2011 – 2013 WA MT ME ND VT OR MN ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC MS AL GA TX LA FL AK HI <5.0% 5.0% to 7.9% 8.0% to 10.9% 11.0% to 13.9% 14.0% to 16.9% ≥17.0% Rate has been suppressed, state had less than 10 deaths reported TFAH • healthyamericans.org 27 S EC T I ON 1 : Building a SECTION I: BUILDING A PUBLIC HEALTH APPROACH TO SUBSTANCE MISUSE PREVENTION Building a Public Health Approach Public Health to Substance Misuse Prevention Approach and Positive Youth Development to Substance A public health approach to substance misuse focuses on a Misuse continuum-of-care: 1) putting prevention first — focusing on Prevention and the health and well-being of childrensupporting reducing risks and promoting protective factors; 2) and teens, screening Positive Youth for risk-factors and early intervention; and 3) providing Development comprehensive, effective treatment andchildren, teens and This approach stresses strategies to support recovery support. families in their daily lives — where they live, learn and play — including by connecting children and their families to systems and programs that can help provide additional help as needed. In this section, TFAH examines a series and youth — but these 10 specific policy of 10 indicators of policies and/or areas help highlight the status of some programs that states may have in place specific strategies that help prevent and that have been recommended by experts reduce youth substance misuse. Taken to help advance one or more of these collectively, they provide a snapshot of key areas. Nearly every policy area has areas of progress and ongoing gaps in an impact on the well-being of children youth development policies. NOVEMBER 2015 10 Indicators (Example Highlight Policies) for Teen Well-being and Substance Misuse Prevention Indicator 1: Supporting Academic Achievement 35 states have at least an 80 percent high school graduation rate (2013-2014). Indicator 2: Preventing Bullying 21 states have comprehensive bullying prevention laws. Indicator 3: Preventing Smoking 30 states and Washington, D.C. have smoke-free laws prohibiting smoking in public places, including restaurants and bars. Indicator 4: Preventing Underage Alcohol Sales 37 states and Washington, D.C. have liability laws (dram shop) holding establishments accountable for selling alcohol to underage or obviously intoxicated individuals. Indicator 5: Screening, Intervention and 32 states and Washington, D.C. have billing codes for Screening, Brief Intervention Referral to Treatment Support and Referral to Treatment (SBIRT) in their medical health (Medicaid or private insurance) programs. Indicator 6: Mental Health Funding 29 states and Washington, D.C. increased funding for mental health services in Fiscal Year (FY) 2015. Indicator 7: Depression Treatment 30 states have rates of treatment for teens with major depressive episodes above 38.1 percent. Indicator 8: Good Samaritan Laws 31 states and Washington, D.C. have laws in place to provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose. Indicator 9: Treatment and Recovery Support 30 states and Washington, D.C. provide Medicaid coverage for all three for Prescription Drug Misuse FDA-approved medications for the treatment of painkiller addiction. Indicator 10: Sentencing Reform 31 states and Washington, D.C. have taken action to roll back “one-size-fits-all” sentences for nonviolent drug offenses. Youth Substance Misuse Prevention Indicator Map STATE INDICATORS Each state received a score based on these WA ME 10 indicators. States received one point MT ND OR MN VT for achieving an indicator or zero points if NH ID SD WI NY MA they did not. Zero is the lowest possible WY MI CT RI overall score (no policies in place), and 10 NE IA PA NJ NV OH is the highest (all the policies in place). IL IN DE CA UT MD CO WV KS MO KY VA DC It is important to note the indicators NC measure whether a law, regulation or AZ TN Scores Color OK NM AR SC 3 policy is in place but does not assess how MS AL GA 4 the measures are enforced or if there is 5 TX LA sufficient funding to carry them out. 6 AK FL 7 8 HI 9 10 SCORES BY STATE 10 9 8 7 6 5 4 3 (2 states) (7 states) (8 states & D.C.) (4 states) (5 states) (9 states) (11 states) (4 states) Minnesota California D.C. Colorado Alabama Arkansas Alaska Idaho New Jersey Connecticut Delaware Iowa Illinois Florida Arizona Louisiana Maine Massachusetts North Carolina Missouri Hawaii Georgia Mississippi Maryland New Hampshire Pennsylvania Rhode Island Kansas Indiana Wyoming New Mexico Ohio Utah Kentucky Nebraska New York Oregon Michigan Nevada Vermont Virginia Montana South Carolina Washington North Dakota South Dakota Wisconsin Oklahoma Tennessee Texas West Virginia TFAH • healthyamericans.org 29 STATE INDICATORS (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Support Preventing Preventing Preventing SBIRT: Mental Depression Good Treatment Sentencing Academic Bullying: Smoking: Underage State has Health Treatment: Samaritan and Recovery Reform: Achievement: State has State has Alcohol Sales: billing codes for Funding: State have rates Laws: Support for States has State has comprehensive smoke-free State has liability Screening, Brief State of treatment State has laws Prescription taken action to at least an bullying laws that (dram shop) Intervention increased for teens with in place to Drug Misuse: roll back “one- 80 percent prevention prohibit laws holding and Referral for funding for major depressive provide some State provides size-fits-all” Total State chi school laws. smoking in establishments Treatment in mental health episodes immunity from Medicaid coverage sentences for Score graduation rate public places, accountable for their medical services for at or above criminal charges for all three nonviolent drug (2012-2013). including selling alcohol health programs Fiscal Year the National or mitigation of FDA-approved offenses. restaurants and to underage (Medicaid 2015. percentage of sentencing of medications for bars. or obviously or private 38.1 percent seeking help for the treatment intoxicated insurance). (2009-2013). an overdose. of painkiller individuals. addiction. Alabama 3 3 3 3 3 3 6 Alaska 3 3 3 3 4 Arizona 3 3 3 3 4 Arkansas 3 3 3 3 3 5 California 3 3 3 3 3 3 3 3 3 9 Colorado 3 3 3 3 3 3 3 7 Connecticut 3 3 3 3 3 3 3 3 3 9 Delaware 3 3 3 3 3 3 3 3 8 D.C. 3 3 3 3 3 3 3 3 8 Florida 3 3 3 3 3 5 Georgia 3 3 3 3 4 Hawaii 3 3 3 3 3 5 Idaho 3 3 3 3 Illinois 3 3 3 3 3 3 6 Indiana 3 3 3 3 4 Iowa 3 3 3 3 3 3 3 7 Kansas 3 3 3 3 3 5 Kentucky 3 3 3 3 3 5 Louisiana 3 3 3 3 Maine 3 3 3 3 3 3 3 3 3 9 Maryland 3 3 3 3 3 3 3 3 3 9 Massachusetts 3 3 3 3 3 3 3 3 8 Michigan 3 3 3 3 3 5 Minnesota 3 3 3 3 3 3 3 3 3 3 10 Mississippi 3 3 3 3 Missouri 3 3 3 3 3 3 6 Montana 3 3 3 3 3 5 Nebraska 3 3 3 3 4 Nevada 3 3 3 3 4 New Hampshire 3 3 3 3 3 3 3 3 8 New Jersey 3 3 3 3 3 3 3 3 3 3 10 New Mexico 3 3 3 3 3 3 3 3 3 9 New York 3 3 3 3 3 3 3 3 3 9 North Carolina 3 3 3 3 3 3 3 7 North Dakota 3 3 3 3 3 5 Ohio 3 3 3 3 3 3 3 3 8 Oklahoma 3 3 3 3 3 5 Oregon 3 3 3 3 3 3 3 3 8 Pennsylvania 3 3 3 3 3 3 3 7 Rhode Island 3 3 3 3 3 3 6 South Carolina 3 3 3 3 4 South Dakota 3 3 3 3 4 Tennessee 3 3 3 3 4 Texas 3 3 3 3 4 Utah 3 3 3 3 3 3 6 Vermont 3 3 3 3 3 3 3 3 3 9 Virginia 3 3 3 3 3 3 3 3 8 Washington 3 3 3 3 3 3 3 3 8 West Virginia 3 3 3 3 4 Wisconsin 3 3 3 3 3 3 3 3 8 Wyoming 3 3 3 3 Total States 35 21 30 + D.C. 37 + D.C. 32 + D.C. 29 + D.C. 30 + D.C. 31 + D.C. 30 + D.C. 31 +DC 30 TFAH • healthyamericans.org 35 states have at least an 80 percent high school 15 states and D.C. have less than 80 percent high INDICATOR 1: graduation rate (2013-2014). (1 point) school graduation rate (2013-2014). (0 points) Alabama (86.3%) New Hampshire (88.1%) Alaska (71.1%) SUPPORTING ACADEMIC Arkansas (86.9%) New Jersey (88.6%) Arizona (75.7%) ACHIEVEMENT California (81.0%) North Carolina (83.9%) Colorado (77.3%) Connecticut (87.0%) North Dakota (87.2%) D.C. (61.4%) Delaware (87.0%) Ohio (81.8%) Florida (76.1%) Key Finding: 35 states have at Hawaii (81.8%) Oklahoma (82.7%) Georgia (72.5%) Illinois (86.0%) Pennsylvania (85.5%) Idaho (77.3%) least an 80 percent high school Indiana (87.9%) Rhode Island (80.8%) Louisiana (74.6%) graduation rate. Iowa (90.5%) South Carolina (80.1%) Michigan (78.6%) Kansas (85.7%) South Dakota (82.7%) Mississippi (77.6%) Kentucky (87.5%) Tennessee (87.2%) Nevada (70.0%) Maine (86.5%) Texas (88.3%) New Mexico (68.5%) Maryland (86.4%) Utah (83.9%) New York (77.8%) Massachusetts (86.1%) Vermont (87.8%) Oregon (72.0%) Minnesota (81.2%) Virginia (85.3%) Washington (78.2%) Missouri (87.3%) West Virginia (84.5%) Wyoming (78.6%) Montana (85.4%) Wisconsin (88.6%) Nebraska (89.7%) Source: U.S. Department of Education, ED Data Express, Regulatory Adjusted Cohort Graduation Rates, 2013-2014. Ongoing substance misuse has a high correlation with school dropout rates.87 In the United States, more than one million students per year dropout of high school, approximately 7,000 students per day.88, 89 This indicator examines high school (27.3 percent versus 15.3 percent) and use starts, it can lead to further decline. graduation rates by state. Thirty-five nonmedical prescription drugs (9.5 per- In other cases, substance use precedes states meet the national goal of at least cent versus 5.1 percent). Students who do academic problems, but they continue a 80 percent of students completing not complete high school also have higher cycle of increasing difficulties. high school.90 While a variety of factors rates of alcohol use and binge drinking.92 Substance use can impair cognitive contribute to higher likelihood of Graduation rates are often interrelated development — the working memory dropping out of schools (including to a teen’s well-being and academic and learning parts of the brain — family factors, socioeconomic status challenges. High rates of absenteeism, diminishing a child’s ability to pay and trends and types of supports within classroom behavior concerns and attention in school and decreasing a particular school or community), academic performance problems are school engagement, reducing academic addressing substance misuse is a key warning signs for increased risk for achievement and disrupting academic component in supporting youth well- future substance misuse. progress.95, 96, 97 Drug use among being and education attainment. adolescents leads to declines in academic According to research from NIDA, Nationally, around 20 percent of motivation, study habits and goal setting. children with academic problems at students do not graduate from high ages 7 to 9 are more likely to be involved Students with an average grade of ‘D’ school — with the rate being higher (30 with substance use by age 14 or 15.93 As or lower are more likely to be a person percent) among low-income students.91 children reach middle and high school, who uses substances compared to Twelfth graders who do not complete high the correlation between substance use students whose grade average is better school (ages 16 to 18) are almost twice as and school performance issues becomes than a ‘D.’ Persistent marijuana users likely to currently use cigarettes (56.8 per- bidirectional.94 For some children, show a significant drop in IQ between cent versus 22.4 percent), illicit drugs (31.4 academic difficulties may precede the childhood and midlife.98 percent versus 18.2 percent), marijuana initiation of drug use, but once drug TFAH • healthyamericans.org 31 Providing support to students with Reducing the use or frequency of substance Not having a high school diploma has academic performance concerns — and misuse can increase school attendance and both individual consequences (e.g. with irregular school attendance — and improve academic performance.100, 101 higher unemployment, lower work helping improve the overall school wages, poorer health outcomes) and Students who avoid substance use all climate, can help reduce substance societal implications (e.g. lower skilled together score higher on state reading misuse.99 Identifying schools and school work force, negative economic impact). and math tests, and have higher grades districts with low graduation rates can also than their peers who use alcohol or help identify where to target resources for other drugs.102, 103 support at a community level. CHRONIC ABSENTEEISM: WARNING SIGN — MISSING SIGNIFICANT NUMBERS OF SCHOOL DAYS Attending school regularly is essential to students gaining the academic and social skills they need to succeed. Students who miss a significant amount of school are likely to fall behind academically.104, 105 Starting as early as preschool and kindergarten, chronic absenteeism has an impact, including missing basic milestones for literacy, early math skills and social-emotional development. Regularly missing 10 percent of the academic year in early primary school years can leave students unable to read proficiently by third grade and off track for high school graduation. A key component of a safe, supportive school environment in- cludes encouraging and fostering regular school attendance. Source: Attendance Works Chronic absenteeism can be an important warning signal that a child is experiencing problems — due to physical health, behavior school systems and communities to match needs. A review of or mental health, struggling with academic performance, family schools in six states found chronic absenteeism rates ranged stability and financial security, fear of bullying and/or threats of from 6 percent to 23 percent — with high poverty urban schools violence. By tween and teen years, it can also be an early way to reporting up to one-third of students as chronically absent.106 identify substance use problems. High rates of chronic absenteeism are often concentrated For instance, a child with unmanaged asthma may miss a high in relatively few schools. In Florida, 15 percent of schools number of school days, putting him or her behind on early school accounted for at least half of all chronically absent students. achievement which then escalates to falling further behind over Currently, school systems around the country track student time and being at higher risk for substance misuse, other risk be- absences in different ways — with few having early warning haviors and/or not graduating. If the problem was identified early systems in place to monitor for chronic absenteeism throughout in the child’s school career — and appropriate healthcare and re- a school year and few providing follow up support or case lated services were provided — that child would have better odds management for students and families. for future academic and lifetime success. Educating parents and school systems about the importance of In the past, absenteeism has often been treated as a behavior regular school attendance — starting as early as preschool and or truancy issue — where it becomes an additional “problem” to kindergarten — and building systems that keep track of students’ be punished — instead of a way of identifying children, teens and attendance and providing follow up support when there are chronic families who may need additional help and support. absentee problems is an important component of improving the Tracking patterns of chronic absenteeism can also lead to a nation’s school system to provide children with a better education better understanding of where and how to target resources within and chance to thrive. 32 TFAH • healthyamericans.org 21 States have comprehensive bullying prevention 29 states and D.C. do not have comprehensive bullying INDICATOR 2: laws. (1 point) prevention laws. (0 points) Alabama Minnesota Alaska Nebraska PREVENTING BULLYING Arkansas New Hampshire Arizona Nevada LAWS California New Jersey Delaware North Dakota Colorado New Mexico D.C. Ohio Connecticut New York Georgia Oklahoma Key Finding: 21 states have Florida North Carolina Hawaii Pennsylvania Illinois Oregon Idaho Rhode Island comprehensive bullying Iowa Vermont Indiana South Carolina prevention laws. Maine Virginia Kansas South Dakota Maryland Washington Kentucky Tennessee Massachusetts Louisiana Texas Michigan Utah Mississippi West Virginia Missouri Wisconsin Montana Wyoming Source: American Academy of Pediatrics Bullying is a form of youth violence that can be inflicted physically, verbally, relationally or by damaging a young person’s property.107 CDC defines bullying as, “any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated.” 108 It can have a long-term negative psychological impact on victims. Being bullied can result in physical According to AAP, recommended state injury, social and emotional distress policy “clearly defines the role and the Percent of Students who Report Being Bullied and even death. Victimized youth are at authority of the school officials, teachers, on School Property vs. Electronic Bullying increased risk for depression, anxiety, and other school employees to address sleep difficulties, poor school adjustment, bullying and would require a zero suicide and thoughts of suicide — as well tolerance policy for bullying based on as substance misuse.109, 110 race, ethnicity, gender, sexual orientation, 20% 15% gender identity, disability, religious In addition, youth who bully others beliefs, and other personal attributes… are at increased risk for substance use, [and applies] to students in all schools, academic problems and violence later in On School Property Electronic Bullying both on or off campus, or through the adolescence and adulthood. use of technology (i.e., cyberbullying).”113 All 50 states, Washington, D.C., Guam, l A bout 20 percent of high school Puerto Rico and the U.S. Virgin Islands students report being bullied on school have bullying prevention laws or policies in property and 15 percent report being place, according to the federal government bullied electronically in the previous 12 website, StopBullying.gov.111 However, months, according to a 2013 national only 21 states have comprehensive survey by CDC.114 Reported rates are bullying prevention laws, according to the 22 percent among Whites, 18 percent American Academy of Pediatrics.112 TFAH • healthyamericans.org 33 among Latinos and 13 percent among anti-bullying policies, less than half There are efforts to align the “zero toler- Blacks.115 Females are more likely to of the districts mentioned protection ance” approaches to bullying with effective report being a victim of bullying (24 for students based on their actual or intervention strategies to address bullying percent versus 16 percent of males.) perceived sexual orientation, fewer — that avoid harsh discipline approaches district policies (14 percent) mentioned that often end up exacerbating the unde- l L esbian, gay, bi-sexual and transgender protection for students based on their sired behavior, and conflict resolution and (LGBT) youth are significantly more gender identity/expression and even peer mediation are often not appropriate likely to be bullied and abused in a less districts (3 percent) mentioned for bullying, which is characterized by range of ways, which may contribute actual LGBT language and staff victimization rather than conflict. In fact, to increased risk and subsequent high professional development in their anti- participating in bullying can actually often incidence of mental health problems, bullying policies.118 And, in states with be an early indicator of other problem substance misuse, risky sexual behavior anti-bullying laws, 60 percent of non- behaviors. Additional research and efforts and HIV.116, 117 A study conducted by conforming gender identity students and are needed to determine the best strate- the Gay, Lesbian & Straight Education about 40 percent of LGB students where gies for positively addressing and curtailing Network (GLSEN) found that of the not provided protection from bullying. bullying behavior.119 71 percent of U.S. school districts with POSITIVE, SUPPORTIVE SCHOOL CLIMATES Schools are primarily concerned with dent outcomes, including lower academic risk behaviors and tobacco, alcohol and promoting academic achievement, but it performance and engagement, higher drop- other drug misuse. According to CDC, while is also important to provide and foster out rates, failure to graduate on time and efforts to improve child and adolescent a culture that is safe and supportive for increased future disciplinary actions. health have typically addressed specific students to learn and thrive — which helps health risk behaviors, such as tobacco use CDC has also defined key strategies that them better reach their academic potential. or violence, results from a growing number help improve positive protective factors of studies suggest that greater health im- Traditionally, many school systems have through school connectedness and parent pact might be achieved by also enhancing relied on a punitive approach to address engagement, including promoting adult sup- protective factors that help children and student behavior — including detention, port (school staff can dedicate their time, adolescents avoid multiple behaviors that suspension and expulsions. More than interest, attention, and emotional support to place them at risk for adverse health and 3.3 million students are suspended or ex- students); belonging to a positive peer group educational outcomes.123 pelled from U.S. public schools annually.120 (a stable network of peers can improve stu- dent perceptions of school); commitment to A number of school districts have recently Recently, a number of initiatives have education (believing that school is important adopted the Positive Behavior Interventions emerged to help schools be more sup- to their future, and perceiving that the adults and Supports (PBIS) model, applying portive and provide services and help for in school are invested in their education can evidence-based practices for all students to children who are struggling. Proactive, get students engaged in their own learning increase academic performance, improve preventive approaches — both school-wide and involved in school activities); and school safety, decrease problem behavior and and individual focused — that address the environment (the physical environment and establish a positive school culture.124, 125, 126 underlying cause of negative behaviors psychosocial climate can set the stage for It emphasizes multiple strategies to have been associated with increases in positive student perceptions of school). 122 support social and behavioral improvement, academic engagement and achievement In addition, research shows that parent such as character education, asset and reductions in suspension and dropout engagement in schools is closely linked to building, social skills instruction, bullying rates.121 Conversely, punitive-centered better student behavior, higher academic prevention, developmental guidance, approaches, such as suspensions and ex- achievement, and enhanced social skills building consultation teams, restorative pulsions, have been shown not to improve — and makes it more likely that teens will justice practices, wrap-around services and student behavior or school climate. In avoid unhealthy behaviors, such as sexual behavioral intervention plans. fact, they are associated with negative stu- 34 TFAH • healthyamericans.org This approach can help benefit all students: provide students with alternative, appro- safety and reduce substance misuse, priate strategies and methods to cope and the School Climate Transformation l U niversal support: Infrastructure, pro- with situations; and small group inter- Grants, which provide support to states cesses and procedures to establish a ventions to teach students emotional and local school agencies to implement supportive and respectful school culture regulation, coping, stress management evidence-based, multi-tiered positive — for all students and staff in all school and problem-solving activities. behavioral frameworks.127 In 2014, settings (including classrooms, hallways, School Climate Transformation Grants libraries, cafeterias, recreation spaces l T ertiary/Intensive intervention: Ad- were awarded to 71 school districts in 23 and school buses). For instance, setting dresses problematic behavior of indi- states, Washington, D.C. and the U.S. Vir- standards where prompt intervention vidual high-need students — setting gin Islands totaling $35.8 million, and 12 is taken for behaviors (by students or expectations and developing team-based states totaling $7.3 million.128 The goal of adults) that are inconsistent with this approaches. For example, training in the program is to connect children, youth standard; behavior management strate- teacher/environmental interventions and families to appropriate services and gies are clear, consistent, proactive and that identify triggers and develop strate- support; improve conditions for learning predictable; modeling appropriate and gies to reduce and defuse situations; in- and behavior outcomes for school-aged caring behavior by adults; implementing dividual interventions to teach students youth; and increase awareness of and the comprehensive and supportive counsel- emotional regulation, coping, stress ability to respond to mental-health issues ing services. management and problem-solving; com- among school-aged youth. prehensive FBSs coupled with intensive l S econdary/Tiered support: Processes BIPs to each individual students alterna- Some local school districts have also and procedures to address behavioral tive, appropriate behavior patterns; wrap begun trauma-informed practices to challenges of groups of students with around services and interventions with encourage safe, supportive climates in similar behavior problems, such as at- multi-disciplinary teams from school, schools and to manage behavior concerns tention-seeking or avoidance. Examples mental health, the family and other — acknowledging and responding to the include building consultation teams that systems, such as child welfare and ju- role of trauma (ranging from having been support classroom teachers’ efforts to venile justice programs, as appropriate; physically abused to living in adverse cir- be more responsive to students affected intensive case management to closely cumstances contributing to a prolonged by trauma; screening students to deter- monitor the student’s response to inter- experience of “toxic stress”) in the devel- mine if other assessments or referrals ventions and coordinate involvement of opment of emotional, behavioral, educa- would be helpful; monitoring students’ multiple educators, other professionals tional and physical difficulties in the lives responses to interventions; referrals and the family; IEPs and 504 plans for of children and youth.129 to community services and programs; students with identified disabilities; and parent/caregiver education support and For instance, in Philadelphia, the United parent/caregiver training and support services; classroom support to help Way has helped fund courses for teach- programs and services. teachers differentiate instruction and ers on how to recognize when students behavior management; 504 plans and Two joint Department of Education and are experiencing trauma and, when there Individual Education Plans (IEPs) for Department of Justice (DOJ) initiatives are behavior incidents, how to help stu- students with identified disabilities; brief aimed at efforts to improve school climate dents calm down and recover sufficiently functional behavior assessment (FBAs) and supportive interventions include the to rejoin the school day. For instance, to understand why students may be re- Safe and Supportive School Grants, which sometimes a drink of water or having 20 sponding in particular ways (for example, help support statewide measurement of, minutes to “reset” — or an understanding fight, flight or freeze); and low-intensity and targeted programs to improve condi- of how not to retrigger a trauma in a child behavior intervention plans (BIPs) to tions for learning to help improve school — is all that is needed.130 TFAH • healthyamericans.org 35 INDICATOR 3: 30 states and D.C. have smoke-free laws prohibiting 20 states do not have smoke-free laws prohibiting smoking in public places, including restaurants and smoking in public places, including restaurants and PREVENTING SMOKING bars. (1 point) bars. (0 points) Arizona Nebraska Alabama Missouri California New Hampshire Alaska Nevada Key Finding: 30 states and Colorado New Jersey Arkansas Oklahoma Washington, D.C. have smoke- Connecticut New Mexico Florida Pennsylvania D.C. New York Georgia South Carolina free laws that prohibit smoking Delaware North Carolina Idaho Tennessee Hawaii North Dakota Indiana Texas in public places, including Illinois Ohio Kentucky Virginia restaurants and bars. Iowa Oregon Louisiana West Virginia Kansas Rhode Island Mississippi Wyoming Maine South Dakota Maryland Utah Massachusetts Vermont Michigan Washington Minnesota Wisconsin Montana Source: Campaign for Tobacco-Free Kids The number of 12- to 17-year-olds who report cigarette use in the past month reached an all-time low of 5.6 percent in 2013. This represented a decline from 13 percent in 2002, and from 26 percent in 1992.131 This indicator examines how many also can help reduce smoking rates pleasure and reward. Nicotine is highly states have adopted smoke-free air laws by limiting opportunities for smoking addictive — and can be as difficult to that prohibit smoking in workplaces, initiation and use.136 The decline in quit as cocaine or heroin.139 Research restaurants, bars and other public teen smoking rates has been credited suggests that children and teens may be spaces. Thirty states, Washington, to a combination of smoke-free laws, especially sensitive to nicotine, making D.C., Puerto Rico and the U.S. Virgin along with awareness about associated it easier for them to become addicted Islands have comprehensive smoke-free health risks, more successful cessation and even those who only smoke a few laws. In addition, hundreds of cities treatments and growing social cigarettes per month can have cravings and counties around the country have unacceptability. for cigarettes.140, 141 smoke-free laws.132 Tobacco remains the leading cause Nearly all tobacco use begins during These laws help protect individuals of preventable diseases, disability youth or young adulthood. Among from exposure to secondhand smoke.133 and death in the United Sates.137 It adults who smoke daily, 88 percent Secondhand smoke — which contains causes about one-third of all cancers, reported that they first smoked by the around 70 toxic chemicals that can cause increases the risk of heart disease and age of 18, and 99 percent reported that cancer — contributes to a wide range is associated with leukemia, cataracts they first smoked by the age of 26.142 of health problems including more and pneumonia. On average, smokers Preventing smoking initiation in youth frequent and severe asthma attacks, die 10 years earlier than nonsmokers.138 is an important strategy for reducing respiratory infections, ear infections, Regular exposure to second-hand smoke a person’s chance of ever smoking. infant deaths, heart disease, heart kills approximately 41,000 nonsmokers A recent study by the Institute of attacks, stroke and lung cancer.134, 135 a year. Tobacco contains nicotine, Medicine (IOM) found that raising the which increases levels of dopamine, Smoke-free laws help limit the exposure legal age to purchase tobacco products a neurotransmitter associated with of youth to secondhand smoke — but from 18 to 21 has the most public 36 TFAH • healthyamericans.org health benefit and is likely to prevent or delay initiation among 15- to 17-year- Current Cigarette Use Among Youth (YRBSS) 2013 olds. One reason cited is that younger teens need older kids to buy their cigarettes. And while there is social overlap between younger and older teens, fewer 15- to 17-year-olds interact with 21-year-olds. The report finds that raising the legal age to buy tobacco products from 18 to 21 would result in 249,000 fewer premature deaths among people born between 2000 and 2019, and 12 percent fewer smokers by 2100. In addition, there would be 286,000 fewer preterm births, 438,000 fewer cases of low birth weight and about 4,000 fewer sudden infant death cases Source: CDC, YRBSS, 2013 among mothers aged 15 to 49.143 Tobacco taxes are another policy measure that have been shown to be $1.54, and the rates vary significantly Washington, D.C. in the FY 2013 Annual one of the most effective ways to reduce from a low of $0.17 in Missouri to a high Synar Reports: Tobacco Sales to Youth smoking and other tobacco use. An of $4.35 in New York. In addition, on was 9.6 percent, an increase from 9.1 analysis of more than 100 studies April 1, 2009, the federal cigarette tax percent in FY 2012.147 found that, “Significant increases in increased by 62 cents, to $1.01 per pack. Teens who smoke (traditional or electronic tobacco taxes are a highly effective Limiting sales to minors under 18-years- cigarettes) are also more likely to drink tobacco control strategy and lead to old is another important strategy alcohol, binge drink, smoke marijuana significant improvements in public to curtail teen smoking. In July and/or use other illegal substances, such health.”144 Tobacco tax increases result 1992, Congress enacted the Alcohol, as cocaine.148, 149, 150, 151, 152, 153 In addition, in higher product prices and encourage Drug Abuse, and Mental Health the more dependent an individual is tobacco users to stop using, prevent Administration Reorganization Act on nicotine, the more likely it is the potential users from starting and (P.L. 102-321), which includes the Synar individual will use and be dependent on reduce consumption among those that Amendment (section 1926) aimed at other drugs.154 The rate of illegal drug continue to use. The Congressional decreasing youth access to tobacco. The use among teens (12- to 17-year-olds) who Budget Office (CBO) reports that a amendment required states to enact smoked cigarettes in the past month was 10 percent increase in cigarette prices and enforce laws prohibiting the sale around 8.5 times higher than among those will cause people under age 18 to or distribution of tobacco products to who did not smoke cigarettes in the past reduce their smoking by 5 percent to individuals under 18-years-old. Each month (54.6 percent versus. 6.4 percent). 15 percent, and, among adults over age state and U.S. jurisdiction is required to 18, they find that the decline would be 3 Teens often use more than one substance conduct annual, random, unannounced percent to 7 percent.145 Higher tobacco at a time.155 Among young adults, drinking inspections of retail tobacco outlets taxes also save money by reducing alcohol is associated with increased use of and to report the findings to the U.S. tobacco-related healthcare costs, traditional cigarettes (by four times) and Department of Health and Human including Medicaid expenses.146 Thirty e-cigarettes (by nine times); and smoking Services (HHS) Secretary. The national states and Washington, D.C. currently marijuana is associated with greater risk weighted average rate of tobacco sales have an excise tax of $1 or more per of smoking traditional cigarettes and to minors as reported by states and pack of cigarettes. The average tax is e-cigarettes (by 2 to 3 times).156 TFAH • healthyamericans.org 37 ELECTRONIC CIGARETTES Electronic cigarettes are battery-operated olate. E-cigarettes are relatively new and products which enable inhalation of long-term use trends and effects are not nicotine and other chemicals. These yet available. Monitoring the Future found products are often made to look like that many teens initiate e-cigarette use in cigarettes, cigars, pipes or pens.157 part because they feel they are not harmful to health — with only 14.2 percent of 12th There are currently no federal regulations graders viewing them as harmful.161 preventing the marketing and sale of e-cigarettes to children or teens, and they While e-cigarettes may be safer than tradi- are widely available for sale online. The tional cigarette because they do not contain Food and Drug Administration (FDA) had tar, e-cigarette vapor is filled with chemi- originally stated it would have regulations cals and nicotine, which is inhaled (versus complete by June 2015, but extended the “smoked”).162 In addition, liquid nicotine comment period on Nicotine Exposure also poses a poisoning risk if handled in Warnings and Child-Resistant Packaging an unsafe manner and poisonings of small for Liquid Nicotine, Nicotine-Containing children are increasing.163 Testing of some E-Liquid(s), and Other Tobacco Products to e-cigarette products found the vapor to the end of September 2015.158 Despite contain known cancer-causing and toxic attempts at restrictions, a University of chemicals.164 Poisoning cases involving North Carolina study found that only five e-cigarettes and liquid nicotine rose 148 out of 98 attempts by teens to buy e-cig- percent from 2013 to 2014 and have in- Increase in Youth E-cigarette Use arettes online were blocked by online ven- creased more than 14 fold since 2011.165 dors’ attempts to verify customer age.159 In addition, a number of experts express As of September 2015, 46 states and concern that youth who use e-cigarettes 2011 1.5% Washington, D.C. have prohibited sales of will later go on to become traditional electronic nicotine delivery systems (ENDS) cigarette smokers — and that the exposure to minors — such as e-cigarettes, alterna- to nicotine can prime the brain for future tive nicotine products and/or or electronic substance misuse.166, 167, 168 However, it is 2014 13.4% product/devices that deliver nicotine. still unknown if the exposure to nicotine through e-cigarettes may increase the While cigarette smoking among youth has likelihood of nicotine addiction. been on a steady decline for years, the use of e-cigarettes has been increasing Studies are showing that teens who since they entered the U.S. market in use ENDS are more likely to also use 2007. Reported use has grown among regular cigarettes and other tobacco high school students from 1.5 percent products.169, 170, 171 The same factors in 2011 to 13.4 percent in 2014, and that contribute to trying/initiation of 3.9 percent of middle school students traditional cigarettes are correlated to reported using e-cigarettes in 2014. 160 trying/initiating e-cigarette (e.g. having parents or close friends that smoke, More teens now use e-cigarettes than tradi- having positive attitudes towards tobacco tional cigarettes or any other tobacco prod- products or having a lower perception uct. The product is available in a variety of that smoking/nicotine use is harmful). flavors — including bubble gum and choc- 38 TFAH • healthyamericans.org 37 states and D.C. have dram shop laws that hold 13 states do not have dram shop laws that hold INDICATOR 4: establishments liable for selling alcohol to underage establishments liable for selling alcohol to underage customers. (1 point) or clearly intoxicated customers. (0 points) PREVENTING UNDERAGE Alaska Nebraska Alabama ALCOHOL SALES Arizona New Hampshire Connecticut Arkansas New Jersey Delaware California New Mexico Hawaii Key Finding: 37 states Colorado New York Kansas D.C. North Carolina Kentucky and Washington, D.C. have Florida North Dakota Louisiana “dram shop” laws that hold Georgia Ohio Maryland Idaho Oklahoma Nevada establishments liable for selling Illinois Oregon South Carolina Indiana Pennsylvania South Dakota alcohol to underage costumers. Iowa Rhode Island Virginia Maine Tennessee West Virginia Massachusetts Texas Michigan Utah Minnesota Vermont Mississippi Washington Missouri Wisconsin Montana Wyoming Source: National Conference of State Legislatures and NOLO Twelve- to 20-year-olds drink 11 percent of all alcohol consumed in the United States, and more than 90 percent of that consumption is in the form of binge drinking.172 Underage drinking is both illegal and l U nwanted, unplanned and has a higher risk for consumption in unprotected sexual activity; high quantities and settings that can l D isruption of normal growth and lead to serious immediate and long-term sexual development; consequences. l P hysical and sexual assault; According to the Surgeon General’s report on preventing underage drinking l H igher risk for suicide and homicide; and CDC, youth who drink alcohol are l A lcohol-related car crashes and other more likely to experience:173, 174 unintentional injuries, such as burns, l S chool problems, such as higher falls and drownings; absence and poor or failing grades; l M emory problems; l S ocial problems, such as fighting and l M isuse of other drugs; lack of participation in youth activities; l C hanges in brain development that l L egal problems, such as arrest for may have life-long effects; and driving or physically hurting someone while drunk; l D eath from alcohol poisoning. l P hysical problems, such as hangovers The Community Preventive Services or illnesses; Task Force — which reviews the research TFAH • healthyamericans.org 39 and evidence-base for health prevention or serving alcohol to individuals who serve a person under the legal drinking strategies — has analyzed multiple public cause injuries or death as a result of age. Hawaii and South Carolina do not policies to reduce alcohol misuse and their intoxication.177 These laws serve have dram shop laws, but allow dram has recommended several, including two purposes: to disincentivize retailers shop claims under state liquor control “dram shop” liability laws. The Task from serving minors or the intoxicated law (Hawaii) or Supreme Court case Force found that holding alcohol because of the risk of litigation resulting hearings (South Carolina). Louisiana retailers liable for injuries or damage in monetary losses, and to allow parties has two exceptions to the prohibition done by their intoxicated customers can injured as a result to gain compensation against dram shop claims — if the reduce motor vehicle deaths, violence, from those responsible. While the minor vendor forcibly causes the intoxication homicides, injuries and other alcohol- or intoxicated person would be the first or if the vendor misrepresents an alcohol related problems.175 The Task Force to be sued by the injured party, dram beverage as non-alcoholic. Illinois’s also recommended increasing alcohol laws allow the injured to seek monetary dram shop law includes the selling of taxes, maintaining limits on the days damages from the establishment that illegal substances to minors. Nevada’s and hours of sale of alcohol and the served the individual.178 dram shop law exempts licensed regulation of alcohol outlet density as establishments from liability, except if a Thirty-seven states and Washington, other effective policies for curtailing third party is injured by a minor. South D.C. have statutory provisions related to excessive and underage alcohol misuse.176 Dakota exempts licensed establishments dram shop that holds an establishment The measures also were related to fewer from liability.181 Efforts to prevent sales civically liable or assesses federal alcohol-related motor vehicle crashes and of alcohol and tobacco to minors are penalties for selling alcohol to a person fatalities and lower violence rates. most effective when they also engage under the legal drinking age.179, 180 and encourage the commitment of the Dram shop liability laws — named The specific terms of the statues can stores, restaurants and other businesses after a common measure of alcohol vary, however. For instance, Louisiana as integral members of any community. — involve holding the owner or server exempts licensed establishments from of an establishment liable for selling liability except in the cases where they ALCOHOL TAXES 40 TFAH • healthyamericans.org Source: Tax Foundation182, 183 TFAH • healthyamericans.org 41 PALCOHOL Palcohol is a new form of alcohol that As of August, 2015, 23 states have powdered alcohol. Maryland and when mixed with water creates an banned powdered alcohol. Alabama, Minnesota have temporary one-year alcoholic beverage — including products Alaska, Connecticut, Georgia, Hawaii, statutory bans. Colorado, Delaware, such as freeze-dried rum, vodka and Kansas, Illinois, Indiana, Louisiana, Michigan and New Mexico have “powder-ritas.” In March 2015, the Maine, Nebraska, Nevada, New York, included powdered alcohol in their U.S. Alcohol and Tobacco Tax and Trade North Carolina, North Dakota, Ohio, statutory definitions of alcohol so that Bureau (TTB) approved labels for Palcohol, Oregon, South Carolina, Tennessee, the product can be regulated under allowing it to be sold legally in the United Utah, Vermont, Virginia and Washington their existing alcohol statutes. States unless otherwise prohibited.184 statutorily prohibit the sale of CURBING UNDERAGE ALCOHOL MISUSE Alcohol is the most widely used substance misused by teens and youth. Nearly one-quarter of 12- to 19-year-olds reported drinking IT’S NEVER TOO EARLY TO START TALKING ABOUT UNDERAGE DRINKING alcohol in the past month according to SAMHSA.185 Early use of alcohol is often an indicator of future substance use — and delaying use can significantly improve later health. Heavy alcohol use by More than 10% 20% youth can also impair potential brain development. In addition, under aged drinking increases the risk for motor vehicle crashes, injuries, unsafe sexual practices, sexual victimization, violence, OF 9- TO 10-YEAR-OLDS HAVE OF UNDERAGE DRINKERS BEGIN suicide and suicide ideation and impaired academic performance. ALREADY STARTED DRINKING.1 DRINKING BEFORE AGE 13.2 In 2015, SAMHSA issued a Report to Congress on the Prevention and Reduction of Underage Drinking, which included a review of a More than 92% 90% range of policies and strategies to prevent and reduce youth alco- OF THE ALCOHOL CONSUMED BY 12- TO 14-YEAR-OLDS IS IN THE hol use, some of which included:186, 187 FORM OF BINGE DRINKING.3 OF HIGH-SCHOOL SENIORS SAY THAT l E ducating parents and others about the impact of alcohol mis- IT IS EASY OR VERY EASY TO GET ALCOHOL.4 use — including not supplying underage youth with alcohol, Parents, you have the power to help prevent underage drinking by limiting the ability of youth to access alcohol at home and not talking to your children early and often about the dangers of alcohol. hosting parties where underage drinking is tolerated; Prepare for one of the most important conversations you may ever have with SAMHSA’s “Talk. They Hear You.” Mobile Application, available for download on iTunes, Google Play, and the Windows Store. Learn more at l R estricting marketing of alcohol to youth; http://www.underagedrinking.samhsa.gov. l M aintaining and enforcing minimum drinking age, through policies such as enhanced enforcement of laws prohibiting sales to minors Donovan, J., Leech, S., Zucker, R., Loveland-Cherry, C., Jester, J., Fitzgerald, H., et al. (2004). Really underage drinkers: Alcohol use among 1 elementary students. Alcoholism: Clinical and Experimental Research, 28(2), 341–349. 2 Centers for Disease Control and Prevention. (2012). Youth risk behavior surveillance—United States, 2011. Surveillance Summaries. and related sale limitations like dram shop liability laws, increasing Morbidity and Mortality Weekly Report, 61, SS-4, 1–162. 3 Pacific Institute for Research and Evaluation. (2002). Drinking in America: Myths, realities, and prevention policy. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. alcohol taxes, maintaining limits on days and hours of sales, limiting 4 Johnston, L.D, O’Malley, P.M., Bachman, J.G., & Schulenberg, J.E. (2013). Monitoring the Future national survey results on drug use, 1975–2012. Volume I: Secondary school students. Ann Arbor: Institute for Social Research, University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2012.pdf alcohol outlet density and electronic screening and brief intervention; l E nsuring teens do not drink and drive — including with gradu- l E ncouraging and incentivizing colleges to adopt best practices ated drivers licenses that restrict the hours and number of pas- to prevent underage drinking on campuses and in the sengers for novice drivers, “use and lose” license laws for teens, surrounding community. first-time offense ignition interlocks and other limitations; and 42 TFAH • healthyamericans.org 32 states and D.C. have Medicaid or private insurance 18 states do not have billing Medicaid or private INDICATOR 5: billing codes for SBIRT. (1 point) insurance billing codes for SBIRT. (0 points) Alabama** p Montana+ Arizona^ Nebraska SCREENING, BRIEF Alaska+ Nevada§ Arkansas^ New Hampshire^ INTERVENTION California** New Jersey+ Florida North Dakota^ Colorado§ New Mexico+ Georgia Pennsylvania^ AND REFERRAL TO Connecticut+ New York** Hawaii^ Rhode Island TREATMENT D.C.+ North Carolina+ Illinois South Dakota^ Delaware+ Ohio** Massachusetts Texas Idaho+ Oklahoma+ Michigan Utah^ Key Finding: 32 states and Indiana+ Oregon+ Mississippi West Virginia Iowa§ South Carolina +p Washington, D.C. have billing Kansas§ Tennessee+ codes and fees for Screening, Kentucky+ Vermont+ Louisiana** Virginia+ Brief Intervention and Referral Maine+ Washington+ Maryland+ Wisconsin+ to Treatment in their medical Minnesota+ Wyoming** health (Medicaid or private Missouri§ Sources: Institute for Research Education & Training in Addictions and Community Catalyst insurance) programs. Notes: +States with only commercial insurance SBIRT codes (CPT codes). (Medicaid programs can often use commercial billing codes for services also). **States with only Medicaid SBIRT codes (HCPCS codes). §States with both commercial insurance and Medicaid SBIRT codes. p States with codes that currently only include pregnant women ^ States allow providers to bill Medicaid for SBIRT using Health and Behavior Assessment/ Intervention (HBAI) codes but do not have distinct or explicit SBIRT codes. Screening, Brief Intervention and Referral to Treatment is a comprehensive, integrated public health approach to early intervention and treatment for persons with substance use disorders or are at risk for developing these disorders.188 The AAP and the NIAAA support routine currently report asking teens about alcohol screenings (through questionnaires) — and and other drug use, and fewer than 25 percent providing brief intervention (supportive short report asking teens about drinking and counseling with a health provider) and/or driving.192 It is a quick, low-cost way to reach connection to care, treatment and services teens and young adults on a broad scale to when they are needed.189, 190, 191 deter risky behavior. Without programs like SBIRT, many teens And, the brief interventions — even short are never directly asked about aspects of their counseling sessions or conversations with behavioral or mental health — and when primary care providers, in emergency given the opportunity to connect with help or departments or in school settings by trained support in a safe environment and by a trained, professionals — have shown that they can caring provider, they will be open about help prevent or reduce alcohol and marijuana their needs. Fewer than half of pediatricians use.193, 194, 195, 196, 197, 198 TFAH • healthyamericans.org 43 A meta-analysis found “compelling counseling about health and other evidence that brief alcohol interventions risks) in community settings showed can yield beneficial effects on significant reductions in marijuana [reducing] alcohol consumption and use.200 Early interventions may be alcohol-related problems” among teens particularly important before or and young adults — demonstrating while teens are beginning to reach at least incremental reductions in experimental periods (i.e., when they drinking, with the effects lasting for have not yet faced decisions about use more than year.199 And, even a single or have developed a significant history session of motivational interviewing of use or dependence). (questionnaire combined with FOUR STEPS AT A GLANCE Refer to the following pages for detailed steps. STEP 1: ASK THE TWO AGE-SPECIFIC SCREENING QUESTIONS • One about friends’ drinking • One about patient’s drinking frequency NO Does the YES patient drink? STEP 2: GUIDE PATIENT STEP 2: ASSESS RISK For patients who DO NOT drink alcohol For patients who DO drink alcohol • Reinforce healthy choices. • Identify Lower , Moderate , or Highest risk If friends drink: level using the age-specific risk char t on page 10. • Explore your patient’s views about this. • Use what you already know about your • Ask about his or her plans to stay alcohol free. patient, and ask more questions as needed. • Rescreen at next visit. If friends don’t drink: • Praise the choice of nondrinking friends. STEP 3: ADVISE AND ASSIST • Elicit and affirm reasons for staying alcohol free. LOWER RISK • Rescreen next year. • Provide brief advice to stop drinking. MODERATE RISK • Provide brief advice or, if problems are present, Screening conduct brief motivational interviewing. complete for • Arrange for followup, ideally within a month. patients who HIGHEST RISK do not drink • Conduct brief motivational interviewing. • Consider referral to treatment. • Arrange for followup within a month. STEP 4: AT FOLLOWUP, CONTINUE SUPPORT • Ask about alcohol use and any related consequences or problems. • Review the patient’s goal(s) related to alcohol and his or her plans to accomplish them. • and encouragement. • Complete a full psychosocial interview, if not done at the previous visit. Source: National Institute on Alcohol Abuse and Alcoholism 44 TFAH • healthyamericans.org The SBIRT approach emphasizes prevention and quick response — rather than the traditional methods of waiting for substance use to emerge as a major problem before responding to it. Making SBIRT routine practice also helps destigmatize the issue — acknowledging that it is a concern across all communities, socio-economic and racial and ethnic groups — and that providing positive support is the most effective means of reducing misuse. SBIRT also supports a continuum of care approach, with an integrated, seamless transition across the need for prevention, brief treatment and more extensive treatment or services as is appropriate for different individual needs. vary within these states — where some of services and providers is also very SBIRT includes: are Medicaid, some are commercial different across communities and states. l creening quickly assessing the severity S insurances, some are both and some The research on SBIRT to date on teens of substance misuse and identifying are limited, such as only for pregnant and young adults has been limited, but has the appropriate level of treatment — women in Alabama. shown promising results and is endorsed conducted through conversations and In addition, while some states may still by pediatricians, NIAAA and others as a counseling that help determine and allow for billing of SBIRT or other low-cost, low-risk, brief way to reach out respond to risk. screenings via Medicaid Health and teens to support their well-being. There l rief intervention provides education B Behavior Assessment/Intervention has been more research on the impact and support — as well as motivation (HBAI) codes or justify under the of SBIRT with adults — showing it is toward behavioral change. Early and Periodic, Diagnosis and highly effective in reducing the misuse Treatment (EPSDT) program, the lack of tobacco, alcohol and other drugs in a l eferral to treatment ensures R of a unique billing code is a signal of range of settings and locations.204, 205 In individuals identified as needing more less of a commitment and priority to addition, an analysis of Missouri’s SBIRT extensive treatment with access to the delivery of the services. Having a (MOSBIRT) program has shown that specialty care and support.201, 202 distinct billing code also allows for the individuals receiving brief interventions Currently, despite the support from tracking and reporting of delivery and demonstrated reductions in risky use, AAP, NIAAA and other groups, SBIRT use of the services. This helps be able along with improvements in employment, has not been fully incorporated into to ensure that SBIRT becomes a more housing, legal involvement and physical regular practice, school-based health universal practice. and mental health.206 Evaluations of the centers or other school-based programs. return on investment for adult SBIRT Even with billing codes, the extent of services has ranged from $3.81 to $5.60 This indicator examines which states the coverage of available interventions for each dollar spent. This is the fourth have distinct and explicit billing and treatment still varies significantly by largest return on medical investment after codes to support the use SBIRT in state. Substance use treatment services daily aspirin use, childhood immunizations practice — which includes 32 states and are defined at a state level and can range and smoking cessation programs.207 Washington, D.C.203 The billing codes dramatically — and the availability TFAH • healthyamericans.org 45 INDICATOR 6: MENTAL 29 states and D.C. increased funding for mental 21 states either decreased or maintained the same health services for FY 2015. (1 point) funding for mental health services for FY 2015. HEALTH TREATMENT (0 points) Alabama New Hampshire Alaska Montana* Arizona New Jersey Arkansas Nebraska Key Finding: 29 states and California New Mexico Georgia* Nevada* Colorado New York Illinois* North Dakota* Washington, D.C. increased Connecticut Ohio Indiana* North Carolina funding for mental health Delaware Oklahoma Hawaii Oregon* D.C. Pennsylvania Kentucky Rhode Island services in FY 2015. Florida South Carolina Louisiana Tennessee* Idaho South Dakota Massachusetts* Texas* Iowa Utah Michigan Wyoming Kansas Vermont Mississippi* Maine Virginia Maryland Washington Minnesota West Virginia Missouri Wisconsin Source: National Alliance on Mental Illness Note: *Level funding from FY2014 to FY2015. Funding is based on non-Medicaid state general fund dollars allocated to inpatient and outpatient mental healthcare for children, youth and adults as available. As many as one in five children (20 percent) have a serious debilitating mental disorder.208 Approximately 50 percent of children with mental disorders receive treatment.209 Many individuals with mental health from a drug use disorder. Conversely, disorders are at higher risk for substance individuals with a drug disorder use — and substance misuse can are around twice as likely to also lead to or exacerbate mental health have a mood or anxiety disorder.212 disorders.210 Substance use disorders Untreated ADHD and conduct and other mental illnesses are related to disorders in children can also put them overlapping factors such as underlying at increased risk for substance use. brain deficits, genetic vulnerabilities l T oxic stress and traumatic experiences and/or early exposure to stress or during childhood increases the risk trauma. According to NIDA, drug use for social, mental health, behavioral and mental health disorders are both and cognitive problems (leading developmental disorders that often begin to low academic performance and in childhood or teen years — drug use behavior problems in school); may bring about symptoms of another engaging in poor health behaviors mental illness, and mental disorders can and developing psychiatric disorders lead to drug use — possibly as a means of and chronic health diseases; and “self-medication.”211 makes it more difficult to establish l P ersons diagnosed with mood or fulfilling relationships — and in anxiety disorders and antisocial adulthood maintain employment — personality or conduct disorders are and to become productive members around twice as likely to also suffer of society.213, 214 46 TFAH • healthyamericans.org l I n addition, chronic misuse of some in PRTF, more than 40 percent showed drugs can cause changes to the brain improvement in school attendance that can lead to paranoia, depression, and grades as well as improvement in aggression and hallucinations. behavioral and emotional strengths, Addiction also changes the brain, including interpersonal relationships, changing a person’s hierarchy of needs self-confidence, family connections and and desires — making procuring and interpersonal relationships. In addition, using the drug a driving priority — there was a 64 percent decrease in youth and weakens impulse control. attempting suicides; nearly a 50 percent decrease in youth being arrested; and 40 Among 16- to 17-year-olds, 6 percent percent of children showed a decrease in had a co-occurrence of a mental health clinical mental health symptoms. disorder and a substance use disorder; 4 percent had a co-occurrence of a Following the recession — from 2009 to serious mental health and substance 2012 — state funding for mental health use disorder; and 3 percent had a major services dropped significantly across the depressive episode and substance use nation. States cut $4.35 billion from disorder.215 Some children and teens use their mental health budgets. Budgets in alcohol or drugs to cope with feelings of many states have steadily increased since anxiety; depressive moods; symptoms of in Medicaid’s EPSDT program; access then, but not enough in most cases to ADHD or a traumatic episode, such as to reduced cost of care in psychiatric make up for the recession drop-offs. physical, emotional and/or sexual abuse. residential treatment facilities; psychiatric consultations for pediatricians treating In 2014, a few states enacted legislation Early identification and access to quality children with mental health needs; aimed at youth and mental health. For mental health services can help reduce mobile crisis response and stabilization example, Minnesota allocated $300,000 the risk that an individual may initiate services for defusing and de-escalating for 2015 ($175,000 each year after) toward drug use to “self-medicate” — related to difficult mental health situations to grants to community mental health mental disorders. Early identification prevent out-of-home placement of a child centers to provide care to uninsured youth of substance misuse can reduce the risk or adolescent; and outpatient treatment under age 21. Wisconsin has allocated of contributing to the development of for youth with substance use disorders — $500,000 a year to fund a child psychiatric mental disorders. including individual, group, and family consultation program administered by counseling; partial hospitalization; and primary care pediatricians. This indicator examined which states increased funding for mental health medication-assisted treatment.217 NAMI’s policy recommendations for services. According to an analysis by According to NAMI, investments states in 2015 include: the National Alliance on Mental Illness help ensure individuals have effective l S trengthen public mental health (NAMI), 29 states and Washington, D.C. treatment and can function well and funding; increased funding for mental health be productive contributors to society.218 services for FY 2015.216 Eleven states The Psychiatric Residential Treatment l H old public and private insurers maintained their 2014 levels and 10 Facility (PRTF) Demonstration Program and providers accountable for states cut their funding from FY 2014. — a Children’s Mental Health Initiative appropriate, high-quality services with (CMHI) program for children and measurement of outcomes; Mental health funding encompasses a broad range of services, for example adolescents with serious mental challenges l E xpand Medicaid with adequate medical professional development — found that implementing home and coverage for mental health; and and training for assessing, treating and community-based services improved the quality of life for those children, l I mplement effective practices such as managing children with mental health youth and families and saved Medicaid first episode psychosis (FEP), assertive disorders; intensive in-home therapy for $40,000 per year per child served.219 community treatment (ACT) and crisis children and adolescents; mental health For children and youth participating intervention team (CIT) programs. and substance use disorder screenings TFAH • healthyamericans.org 47 ADVERSE CHILDHOOD EXPERIENCES (ACEs) Adverse Childhood Experiences can have percent.222 The other most significant a profound impact on the physical, mental, ACEs include physical abuse, sexual behavioral and social-emotional health abuse, parent divorce or separation. throughout an individual’s lifespan. Research has demonstrated a strong re- ACEs increase a child’s risk for a series lationship between ACEs and a variety of of health and social problems — includ- substance-related behaviors, including: ing increased risk for substance misuse. l E arly initiation of alcohol use; More than half of children (52 percent) l E xperiencing an alcohol problem into experience at least one ACE, 27 percent adulthood; experience at least two, 14 percent ex- perience three and 7 percent experience l I ncreased likelihood of early smoking four or more. The risk for developing re- initiation; lated problems increases in a strong and l C ontinued smoking and heavy smoking graded fashion with the increase in the during adulthood; number of ACEs a child experiences.220, 221 l P rescription drug use; and Growing up with substance misuse in the l L ifetime illicit drug use, ever having a household is one of the most serious and problems caused by alcohol/drugs and pervasive reported adverse childhood self-reported addiction.223 experience — at more than 26.9 ACE Score and Drug Abuse 14 Percent With Health Problem (%) 12 ACE Score 0 1 2 3 4 >=5 10 8 6 4 2 0 Ever had a Ever addicted Ever injected drug problem to drugs drugs Source: Dube SR, Felitti VJ, Dong M, et al., 2003; ACEs Study 48 TFAH • healthyamericans.org Death Early Death Disease, Disability and Social Problems Scientific Adoption of gaps Health-risk Behaviors Social, Emotional, and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences Conception Mechanisms by Which Adverse Childhod Experiences Influence Health and Well-being Throughout the Lifespan Source: Centers for Disease Control and Prevention (CDC) STRENGTHENING FAMILIES: PROTECTIVE FACTORS FRAMEWORK ACEs and their impact on children and language, social and emotional teens can be reduced by helping reduce development (including age-appropriate risks in the families and households — and developmental expectations, being and by building supportive protective attuned and emotionally available, factors. The Center for the Study of Social nurturing, responsive, predictable, Policy developed a framework summary of interactive, and having a safe and protective factors, which includes: 224 educationally stimulating environment); l P arental Resilience: Managing stress l C oncrete Support in Times of Need: and functioning well when faced with Having access to concrete support and challenges, adversity and trauma services that address a family’s needs (including general life stressors and and help minimize stress caused by parenting stressors); challenges (including navigating and accessing service systems and building l S ocial Connections: Having positive financial security); and relationships that provide emotional, informational, instrumental and l S ocial and Emotional Competence spiritual support; of Children: Having family and child interactions that help children develop l K nowledge of Parenting and Child the ability to communicate clearly, Development: Understanding child recognize and regulate their emotions development and parenting strategies and establish and maintain relationships. that support physical, cognitive, TFAH • healthyamericans.org 49 INDICATOR 7: 30 states and D.C. had rates for treatment of 20 states had rates for treatment of adolescents with adolescents with major depressive episodes at major depressive episodes at or below the national DEPRESSION TREATMENT or above the national percentage of 38.1 percent percentage of 38.1 percent (aggregate 2009-2013). (aggregate 2009-2013). (1 point). (0 points). Alaska (41.6%) New Mexico (39.7%) Alabama (24.9%) Indiana (31.9%) Key Finding: 30 states and Connecticut (52.3%) New York (41.3%) Arizona (29.0%) Louisiana (35.9%) D.C. (40.1%) North Dakota (42.8%) Arkansas (29.9%) Mississippi (33.8%) Washington, D.C. have rates of Delaware (45.1%) Ohio (38.5%) California (31.0%) Missouri (36.8%) treatment for teens with major Iowa (48.8%) Oregon (40.8%) Colorado (37.2%) Nevada (29.9%) Kansas (41.8%) Pennsylvania (42.5%) Florida (31.0%) North Carolina (36.0%) depressive episodes at or above Kentucky (44.1%) Rhode Island (48.5%) Georgia (33.1%) Oklahoma (38.0%) Maine (47.7%) South Dakota (50.5%) Hawaii (30.9%) South Carolina (24.7%) 38.1 percent. Maryland (38.2%) Utah (44.6%) Idaho (35.6%) Tennessee (32.7%) Massachusetts (46.9%) Vermont (48.0%) Illinois (37.6%) Texas (35.5%) Michigan (44.2%) Virginia (40.4%) Minnesota (54.0%) Washington (41%) Montana (41.1%) West Virginia (47.0%) Nebraska (44.0%) Wisconsin (42.2%) New Hampshire (47.1%) Wyoming (39.0%) New Jersey (41.8%) Source: SAMHSA, Behavioral Health Barometer: United States, 2014 In the United States, only 38.1 percent of adolescents ages 12 to 17 with a major depressive episode (MDE) (an estimated 977,000 adolescents) received treatment for depression in 2013. This indicator examined which states adolescents aged 12 to 17 (359,000 had rates of teens who were treated adolescents) in the United States had for MDE at or above the national both a substance use disorder and a percentage of 38.1 percent (aggregate MDE in the past year.230, 231 2009-2013). According to the Behavioral The symptoms of MDE include: 232 Health Barometer, 2014 Report, 30 states treated for MDE at or above the l L oss of interest or pleasure in all national percentage (38.1 percent).225 activities; Teens with untreated depression are at l C hange in appetite or weight; a higher risk to be aggressive, engage in l S leep disturbances; risky behavior misuse drugs or alcohol, do poorly in school or run away. When l F eeling agitated or feeling slowed down; experiencing an episode, teens have an l Fatigue; increased risk for suicide. Suicide is the second-leading cause of death among l F eelings of low self-worth, guilt or children aged 15 to 19.226, 227 Violence shortcomings; can also be a cause and an effect of l D ifficulty concentrating or making depression.228, 229 decisions; and/or Substance use and depression often l S uicidal thoughts or intentions. interrelate. In 2013, 1.4 percent of 50 TFAH • healthyamericans.org According to SAMHSA’s 2013 NSDUH, teens (12- to 17-years-old) were defined as having MDE if they had a period of 2 weeks or longer in the past 12 months when they experienced a depressed mood or loss of interest or pleasure in daily activities, and they had at least four of seven additional symptoms, such as problems with sleep, eating, energy, concentration and self-worth. Teens were defined as having MDE with severe impairment if their depression caused severe problems with their ability to do chores at home, do well at work or school, get along with their family or have a social life.233 For teens ages 12 to 17 in 2013: l A pproximately one in 10 (2.6 million) The most common treatments for experienced a MDE in the past year; depression are medication and l A n estimated 7.7 percent of psychotherapy. Treatment for MDE, (1.9 million) had past year MDE with according to SAMHSA’s 2013 NSDUH, severe impairment; and is defined as seeing or talking to a medical doctor or other professional l T he percentage of MDE was about or using prescription medication for three times higher among females depression in the past year. 235 (16.2 percent) than among males (5.3 percent). l O f the 2.6 million adolescents in 2013 with past year MDE, 977,000 Healthy People, 2020, which sets national received treatment for depression. health goals for the nation, set a goal This represented 38.1 percent of to reduce the percentage of teens who adolescents with past year MDE. experience a MDE to 7.5 percent.234 Instead, the rates have been increasing l A mong adolescents in 2013 who had — the baseline set in 2008 was 8.3 past year MDE with severe impairment percent; by 2013, the rates had risen to in carrying out responsibilities, 45.0 10.7 percent. percent (832,000) received treatment for depression. Currently, Healthy People, 2020 does not include an MDE treatment goal for l I n 2013, among U.S. adolescents who teens, but for adults it includes the goal reported having an MDE within the of increasing the proportion of adults year prior to being surveyed, a higher with an MDE treated to 78.2 percent, percentage of females (40.9 percent) which would be an increase from the than males (29.7 percent) received baseline of 71.1 percent in 2008. treatment for their depression. TFAH • healthyamericans.org 51 INDICATOR 8: 31 states and D.C. have a law in place to provide a 19 states do not have a law in place to provide a degree degree of immunity from criminal charges or mitigation of of immunity from criminal charges or mitigation of GOOD SAMARITAN LAWS sentencing for an individual seeking help for themselves sentencing for an individual seeking help for themselves or others experiencing an overdose. (1 point) or others experiencing an overdose. (0 points) Alabama Minnesota Arizona North Dakota Key finding: 31 states and Alaska Mississippi Idaho Ohio Arkansas Nevada Indiana Oklahoma Washington, D.C. have laws in California New Hampshire Iowa Rhode Island place to provide a degree of Colorado New Jersey Kansas South Carolina Connecticut New Mexico Maine South Dakota immunity from criminal charges D.C. New York Michigan Texas Delaware North Carolina Missouri Utah or mitigation of sentencing Florida Oregon Montana Wyoming for an individual seeking Georgia Pennsylvania Nebraska Hawaii Tennessee help for themselves or others Illinois Vermont Kentucky Virginia experiencing an overdose. Louisiana Washington Maryland West Virginia Massachusetts Wisconsin Source: Network for Public Health Law Drug overdose was the leading cause of injury death in 2013, exceeding motor vehicle crashes. Although most of these types of deaths could be prevented with quick and appropriate medical treatment, fear of arrest and prosecution may prevent people who witness an overdose or find someone who has overdosed from calling 911. l T here were 43,982 drug overdose aware of the law, they would be more likely deaths in the United States in 2013. to call 911 during future overdoses.237 Of these, 22,767 (51.8 percent) were Teens and young adults may be even related to prescription drugs. Of the more wary to call for help if they or a 22,767 deaths relating to prescription friend are in danger of overdosing, due drug overdose in 2013, 16,235 (71.3 to added consequences from parents percent) involved opioid painkillers, and schools. and/or 6,973 (30.6 percent) involved benzodiazepines.236 State laws have been put in place to provide a degree of immunity from “Good Samaritan” laws are designed criminal charges or mitigation of to encourage people to help those in sentencing for an individual seeking help danger of an overdose. For instance, a for themselves or for others experiencing study following passage of Washington’s an overdose. They remove perceived 911 Good Samaritan Law found that 88 barriers to calling 911 through the percent of people who use prescription provision of limited legal protections. painkillers indicated that once they were 52 TFAH • healthyamericans.org Thirty-one states and Washington, D.C. charged or prosecuted for possession legal action. Alaska and Maryland received a point for this indicator for of a controlled substance. Vermont, have more limited Good Samaritan having some form of Good Samaritan Hawaii, Nevada and Delaware have the statutes. Utah requires and Indiana law that reduces legal penalties broadest version of the law — providing permits courts to take the fact that a for an individual seeking help for protection from arrest on all drug Good Samaritan summoned medical themselves or others experiencing offenses, as well as protections against assistance into account at sentencing. an overdose.238 These laws, however, asset forfeiture, the revocation of In addition, Good Samaritan policies vary significantly from state to state. parole or probation or the violation of are in effect on more than 90 U.S. Among the Good Samaritan laws, all restraining orders, for people who seek college campuses. Such policies have states except two (Indiana and Utah) help for overdose victims. Some states been proven to encourage students to and Washington, D.C. prevent an have more limited laws where people call for help in the event of an alcohol individual who seeks medical assistance assisting an overdosing individual or other drug overdose.239 for someone experiencing a drug- receive protection but the individual related overdose from either being themselves may not be protected from PREVENTING PRESCRIPTION DRUG MISUSE AND THE RISING HEROIN EPIDEMIC The prescription drug epidemic — and the in their capabilities and requirements for l I nformation to pediatricians, doctors related increase in heroin use, which is use. PDMP use should be mandated and school-based staff: Additional ed- typically easier to access and cheaper for for providers in every state, and PDMPs ucation and training is also needed for people who have become addicted to pain- should be modernized and fully funded so prescribers — as well as school-based killers — has some additional important that they are real-time, can communicate health providers and educators about the strategies that can used to prevent mis- across state lines and across different prescription drug epidemic — including use. Some of these include: 240 types of providers and are incorporated about issues of overprescribing and signs into electronic health records. of potential misuse and ways to provide l E ducation for providers: Efforts should positive support to patients and students. be increased to ensure responsible l E ducation for patients — including par- prescribing practices from every medical ents and educators — and expanded l I ncreased research into alternative pain professional with the ability to prescribe take-back programs: Many people as- management strategies: Additional painkillers and other prescription drugs. sume that prescription drugs are safe be- research is needed into how to best ad- This includes increasing education of cause they were at some point prescribed dress pain through other strategies that healthcare providers and prescribers to by a doctor. Public education should be ex- would reduce the potential for overuse and better understand how medications can panded to ensure teens and their parents misuse of prescription pain medication. be misused and to identify the signs of understand the risks of misusing prescrip- l A ccess to rescue drugs and expan- addiction so patients who need treat- tion medications, as well as how to safely sion of Good Samaritan laws: All ment can be referred for it. store and dispose of potentially addictive states should expand protections for drugs. Efforts should also be expanded l trengthening Prescription Drug Moni- S healthcare professionals to be able to to provide increased information and toring Programs (PDMPs): PDMPs can prescribe naloxone — a drug that can training to educators about the epidemic, be a useful tool to help prescribers and be used to counter an overdose — for its harms and prevention strategies. pharmacists keep track of what medica- at-risk patients and families, and provide This should include concerted efforts tions a patient is using — and also for legal protection for individuals who help to discuss safe use of medications and health and other officials to track pat- and report an overdose in good faith. monitoring use of painkillers when they are terns of potential overprescribing by cer- Research has shown that availability of prescribed to teens — such as for sport-in- tain healthcare professionals or clinics. rescue drugs does not encourage or in- juries and removal of wisdom teeth — with Every state except Missouri currently has crease drug use. parents and the patients themselves. a PDMP, but the systems vary significantly TFAH • healthyamericans.org 53 INDICATOR 9: 30 states and D.C. provide Medicaid coverage for 20 states do not provide Medicaid coverage for all all three FDA-approved medications for treatment of three FDA-approved medications for treatment of TREATMENT AND painkiller addiction. (1 point) painkiller addiction. (0 points) RECOVERY SUPPORT Alabama New Hampshire Alaska Mississippi Arizona New Jersey Arkansas Montana FOR PRESCRIPTION California New Mexico Colorado Nebraska DRUG MISUSE Connecticut New York Idaho North Dakota D.C. North Carolina Illinois Oklahoma Delaware Ohio Indiana South Carolina Key Finding: 30 states and Florida Oregon Iowa South Dakota Georgia Pennsylvania Kansas Tennessee Washington, D.C. provide Hawaii Rhode Island Kentucky West Virginia Maine Texas Louisiana Wyoming Medicaid coverage for all three Maryland Utah FDA-approved medications Massachusetts Vermont Michigan Virginia for the treatment of painkiller Minnesota Washington Missouri Wisconsin addiction (as of 2014). Nevada Source: American Society of Addiction Medicine Accessible, affordable treatment is critical to helping individuals with substance use disorders be successful in recovery. Substance use treatment is paid for through a combination of federal, state and local government programs and services and/or coverage through private and public health insurance programs. The United States faces a “treatment psychiatric disorders and other factors gap” for substance use disorders. Only that impact treatment, such as family around 10 percent of teens and adults dynamics, motivation for treatment, who need treatment for substance use gender, culture, ethnicity, self-esteem, disorders get treatment. In 2013, 22.7 peer group influences, and social million Americans ages 12 and older influences. Teens under 18-years-old needed treatment for a substance use are also still minors and under the problem, but only 2.5 million received care and supervision of their parents treatment at a substance use facility.241 or guardians, which impacts treatment options and decisions. Many are There are special considerations that directed toward treatment in response need to be taken into account when to acute problems — such as difficulties providing treatment for teens and in school or in the community, when young adults. They are still maturing family members become aware of a — and depending on their age and problems or noticeable behavioral other factors may be at different changes — and many of these youth are developmental stages in their cognitive, not seeking treatment on their own or emotional, social and physical may seek treatment after experiencing development.242, 243 Treatment plans the consequences of long-term must also take into account the types substance use. A majority of teens in of substance use, if there are coexisting 54 TFAH • healthyamericans.org publicly funded substance use programs taking new patient’s with expanded have been referred to treatment coverage.250 There also remains a through the juvenile justice system.244 widespread shortage of substance use However, treating teens is particularly treatment providers, including state law important because effective approaches limitations on the number of providers can help prevent them from future allowed to treat opioid dependence with substance use related problems as they buprenorphine. transition into adulthood Medicaid coverage of substance use There is currently no uniform treatment is one of many essential consensus about the extent to which components in any strategy to ensure state governments or private insurers millions of Americans in need of require coverage for substance use treatment have affordable, accessible treatment. Around one-third of care. 251 State Medicaid programs youth are covered under Medicaid currently provide a significant percentage or the Children’s Health Insurance of overall spending for substance use Program (CHIP), while a majority are treatment — accounting for one in every covered under their parents’ insurance five dollars spent as of 2009.252 plans.245 The ACA requires plans that Substance use disorder treatment for offer dependent coverage to make youth can include behavioral counseling, coverage available until the dependent family-based approaches and ongoing reaches age 26. Most teens and many recovery support and services.253 young adults rely on access to medical, behavioral and/or psychological care Treatment for prescription painkillers through their parents. and other opioids is also typically most effective when it pairs counseling Prior to the ACA, about one-third of with Medication-Assisted Treatment Americans covered in the individual (MAT), which can ease or eliminate market had no coverage for substance the withdrawal symptoms and relieve use disorder services.246 With the passage cravings.254, 255 Research indicates of ACA, and in conjunction with the that MAT can increase retention and Mental Health Parity and Addiction decrease drug use, infectious disease Equity Act, substance use and mental transmission and criminal activity.256 health treatment and benefits have Other research has shown that patients been expanded to approximately 60 are more likely to relapse if they only million people.247 However, even with go through a detoxification or are the expanded benefits and services, treated with one of the three approved individuals may still experience barriers treatment medications.257 to substance use disorder services. Often, even if addiction treatment is covered, The three medications approved by there is a cap on how long or how many FDA to help treat painkiller addictions times a person can receive services.248 include methadone, buprenorphine or Furthermore, the shift towards managed naltrexone. They act on the parts of care has resulted in shorter average stays the brain and neuropathways that have in treatment programs.249 Many inpatient been affected and altered by opioids drug treatment centers continue to and provide a maintenance treatment, have Medicaid billing restrictions — stabilize neurological processes, prevent limiting centers to only 16 beds — de- opioid withdrawal, reduce chronic incentivizing treatment centers from dependence and prevent relapse.258 TFAH • healthyamericans.org 55 The tested and approved options for methadone treatment is funded in treating individuals under the age of their state through using funds from 16 are more limited. FDA has only their Substance Abuse Prevention approved use of the treatment drugs for and Treatment Block Grant (federal ages 16 and older. While FDA has not program) and/or state or county funds: approved the use of buprenorphine for Alaska, Illinoi and Nebraska.263, 264 pediatric use, some research indicates Even for those providing MAT coverage, a that it has been prescribed and has number of states and insurance providers been effective for use by older have placed lifetime limits on coverage adolescents.259, 260 In select cases and of buprenorphine-naloxone treatment. in some states, opioid-dependent Given that addiction is a recurring adolescents between the ages of 16 illness, multiple courses of treatment are and 18 may be eligible for methadone often necessary and placing restrictions treatment, provided they have two on the number of treatment courses documented failed treatments of opioid covered can prevent many addicts from detoxification or drug-free treatment and receiving life-saving treatment. Three have a written consent for methadone states (Illinois, Michigan and Washington) signed by a parent or legal guardian. and Washington, D.C., established a States differ significantly in their Medicaid 1-year limit in total length of treatment coverage for the three FDA-approved with buprenorphine-naloxone, six states painkiller treatment medications. (Arkansas, Maine, Mississippi, Montana, Virginia and Wyoming) established a This indicator examined which states 2-year treatment limit, and one state provided Medicaid coverage for all three (Utah) established a 3-year treatment limit. FDA-approved medications — which included 30 states and Washington, D.C., Physicians, other healthcare providers according to a review by the American and treatment centers must receive Society of Addiction Medicine.261 special authorization under federal law to treat painkiller addiction with l I n addition, according to a 2014 report controlled substances, including by SAMHSA, 30 states and Washington, methadone and buprenorphine so the D.C. have Medicaid fee-for-service number of providers and availability programs that cover methadone of medications for treatment is limited maintenance treatment provided and often difficult for patients to access, in outpatient narcotic treatment and there is also a limit to the number programs, including: Alabama, of patients each authorized doctor may Arizona, California, Connecticut, treat with the drugs. Delaware, Florida, Georgia, Hawaii, Maine, Maryland, Massachusetts, Approximately two-thirds of states have Michigan, Minnesota, Missouri, fewer than six medical professionals per Nevada, New Hampshire, New every 100,000 people approved to treat Jersey, New Mexico, New York, North patients with buprenorphine — Indiana Carolina, Ohio, Oregon, Pennsylvania, has the fewest at 0.7 per 100,000 people Rhode Island, Texas, Utah, Vermont, and Arizona has the highest at 33.1 per Virginia, Washington and Wisconsin.262 100,000 people.265 Another three states reported that 56 TFAH • healthyamericans.org 31 states and Washington, D.C. have taken action to 19 states have not taken action to roll back “one- INDICATOR 10: roll back “one-size-fits all” sentences for nonviolent size-fits all” sentences for nonviolent drug offenses. drug offenses. (1 point). (0 points) SENTENCING REFORM Arkansas Minnesota Alabama North Carolina California Mississippi Alaska South Dakota Colorado Missouri Arizona Tennessee Key Finding: 31 states and Connecticut Nevada Florida* Utah Washington, D.C. have taken D.C. New Jersey Idaho Vermont Delaware New Mexico Iowa Washington action to roll back “one-size-fits- Georgia New York Kansas West Virginia Hawaii North Dakota Montana Wisconsin all” sentences for nonviolent Illinois Ohio Nebraska Wyoming drug offenses. Indiana Oklahoma New Hampshire Kentucky Oregon Louisiana Pennsylvania Maine Rhode Island Maryland South Carolina Massachusetts Texas Michigan Virginia Sources: The Vera Institute of Justice for 2000-2013 laws. For 2014 updates, The Sentencing Proj- ect, National Conference of State Legislatures and additional legislative scans for states meeting the thresholds set by the Vera Institute review. Note: * In 2014, Florida rolled back some minimum sentencing requirements for prescription drug possession/sales. In the 1980s and 1990s, a series of “tough FIGURE 2 on crime” laws were adopted, including a Inmates age 17 or younger held in adult state and federal prison facilities, 2000–2013 number of drug laws which were developed as Number of state prisoners Number of federal prisoners an attempt to deter drug use and sales. Many 4,000 300 of these laws and practices included longer mandatory sentences for specific types of State prisoners drug offenses and sentencing youths as adults. 3,000 225 Research shows, however, that these laws have Federal prisoners done little to deter crime, reduce recidivism or “rehabilitate” individuals. They have resulted 2,000 150 in rapid growth in prison, probation and parole populations — with corresponding increases in correctional system spending — while harming 1,000 75 the development and future prospects of many of the nation’s youth.266 Around 73,000 individuals ages 10- to 17-years-old, more 0 0 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 than 15,700 individuals ages 18- to 19-years-old and 173,200 Note: Counts based on inmates age 17 or younger in custody of state and federal individuals ages 20- to 24-years-old are incarcerated.267 Of correctional authorities, regardless of sentence length. The Federal Bureau of Prisons those ages 17 and younger, around 1,200 are in state adult holds inmates age 17 or younger in private contract facilities. Counts for BOP may include some inmates under the jurisdiction of U.S. probation being held by the BOP correctional facilities (23 percent of those are in New York in private contract facilities. Source: Bureau of Justice Statistics, National Prisoner Statistics Program, 2000–2013. and Florida).268 TFAH • healthyamericans.org 57 l Y outh incarceration costs state and This indicator examines actions states Community-based programs local governments as much as $21 have taken to revisit mandatory or one- have shown to reduce billion annually — costing states an size-fits-all sentencing for nonviolent average of $400 per person per day and drug offenses. recidivism by up to 20 percent. over $140,000 per person per year.269 When teens and young adults are l B lack youth (605 per 100,000) are arrested, incarcerated or under almost five times more likely to be correctional supervision — even for incarcerated than Whites (127 per minor offenses — their development 100,000), and Latino and American is impaired and their education Indian youth are two to three times and employment prospects become more likely to be incarcerated.270 severely limited. l F or all ages: more than half of The majority of youth (40 individuals in federal prisons (98,200 percent) who are incarcerated are out of 193,775) were sentenced institutionalized for nonviolent for drug offenses; 16 percent of offenses — such as probation individuals in state prisons (210,000) violations, drug possession, low-level were sentenced for drug offense — 25 property offenses (including status percent of females in state prisoners offenses which are not considered and 15 percent of males in state prison crimes among adults, such as school had a drug offense (in 2012).271 truancy, alcohol possession, curfew violations). Imprisonment of individuals with nonviolent offenses — including for drug offenses — is less State & Federal Prison Population by Offense, 2014 cost-effective than other alternative Federal State strategies — where for every $1 7.3% Violent 53.2% invested a state receives $0.29 to $0.39 50.1% Drug 15.7% in public safety benefits versus a $7 return for drug misuse treatment.273 6% Property 19.3% Incarceration can have long-term 35.9% 8.9% 15.9% 11.1% Public Order 11% Immigration Weapons Other negative consequences for youth — 0.7% Other 0.8% putting them at increased risk for Source: Carson, E.A. (2015). Prisoners in 2014. Washington, D.C.: Bureau of Justice Statistics. developing psychological issues, such as stress related illnesses, psychiatric problems and suicidal behavior, and l I n 1980, the total number of lowering their ability to develop Americans incarcerated for drug social skills, such as self-control and offenses was 41,000. In 1986, the conflict resolution.274 Youth who have average time served for a federal been incarcerated are less likely to drug offense was 22 months. Due graduate from high school and more to changes in increased mandatory likely to have unstable employment minimums, by 2004, the average time and reduced earning potential, served for comparable offenses was and are in worse health, including 62 months.272 increased risk of mortality.275, 276 58 TFAH • healthyamericans.org In many states, individuals are — most of which focused on adjusting reducing the prosecution of individuals required to declare that they have penalties for nonviolent drug offenses ages 17 and younger in the adult justice been convicted of a crime on many through use of one or a combination of system or preventing minors from job and housing applications. In the following reform approaches: being placed in adult jails or prisons.283 addition, youth who have been Around 95 percent of approximately l xpanding judicial discretion by E incarcerated have high rates of 250,000 individuals under the age of creating so-called “safety valve” recidivism — one-third of incarcerated 18 tried in adult courts nationwide provisions. These laws allow judges youths return to jail or prison within a are non-violent offenders. Minors to depart from statutorily prescribed few years after being released. placed in the adult justice system have mandatory penalties by taking into significantly higher rates of recidivism Instead of incarceration — early account certain circumstances or and are 36 times more likely to commit intervention approaches and conditions; suicide than those in juvenile detention connection to services and treatment l imiting automatic sentence L facilities. As of the 2014 review: have a more effective impact for enhancements. These laws limit deterring youth from the judicial l E leven states had enacted laws or adjust circumstances that trigger system and preventing youth from limiting states’ authority to house longer sentences, like speeding in a being at risk for developing a range of youths in adult jails and prisons: construction zone or selling drugs within physical and mental health problems Colorado, Hawaii, Idaho, Indiana, a certain distance from a school; and/or and risk of institutional violence.277 Maine, Nevada, Ohio, Oregon, For instance, community-based l epealing or revising mandatory R Pennsylvania, Texas and Virginia; programs have shown to reduce minimum sentences. Mandatory l F ive states increased the age for recidivism by up to 20 percent and minimum sentences fail to distinguish juvenile court jurisdiction (where programs like multi-system therapy between low-level non-violent offenses older teens cannot automatically be and functional family therapy are and serious, violent offenses and the tried in adult courts): Connecticut, more cost-effective than incarceration role of an individual in a crime (e.g., a Illinois, Massachusetts, Mississippi and — every dollar spent yields up to low level offense of carrying drugs can New Hampshire; $13 in benefits in public safety.278 receive same penalty as a drug kingpin). Large states like California, Illinois, l F ourteen states and Washington, D.C. The information are based on a New York, Ohio and Pennsylvania revised laws on the transfer of youth legislative review conducted by the are realigning their fiscal resources to the adult criminal justice system, Vera Institute of Justice’s Center away from correctional institutions making it more likely young people on Sentencing and Corrections for and towards more community-based remain in the juvenile justice system: legislation between 2000 and 2013 services — resulting in curbing the Arizona, Colorado, Connecticut, — and was updated to include 2014 number of repeat offenses and crimes Delaware, Indiana, Illinois, Maryland, information from reviews of legislative committed by youth.279 Between 2001 Nebraska, Nevada, New York, Ohio, scans conducted by the Sentencing and 2011, incarceration of youths Utah, Virginia and Washington; and Project’s The State of Sentencing 2014: dropped 46 percent, and the rate of Developments in Policy and Practice and l T welve states changed mandatory crimes committed by youth decreased the National Conference of State minimum sentencing laws: California, 31 percent. Legislatures.280, 281, 282 Colorado, Florida, Georgia, Hawaii, Thirty-one states and Washington, D.C. Indiana, Iowa, Missouri, Ohio, Texas, In addition, a review by the Campaign took steps between 2000 and 2014 to Washington and West Virginia. for Youth Justice found that 23 states roll back mandatory sentences that had made changes in their juvenile apply to “one-size-fits-all” sentences for justice policies in the past decade, certain types of nonviolent offenses TFAH • healthyamericans.org 59 SENTENCING REFORM: EXAMPLE EFFORTS AND APPROACHES New York City together. While drug courts vary based on to prevent future crimes. Participants volun- New York State’s Rockefeller drug laws, the jurisdiction, a typical drug court requires tarily participate in a treatment plan that was enacted in 1973, mandated lengthy prison individuals to take random drug testing; built by court staff and mental health profes- sentences for people convicted of a range of attend treatment and counseling; and meet sionals, with the entire process supervised felony drug offenses and contributed to dra- with probation officers and/or social work- by the judicial system. Additionally, pro- matic increases in state prison populations. ers. If an individual successfully completes grams often link offenders to vital community In 2009, they were essentially dismantled in the program, he/she likely avoids having a services such as housing, healthcare and reforms that eliminated mandatory minimum conviction on their record and jail time. 286 life skills training to help prevent relapse. A sentences for the possession, use, or small- The Government Accountability Office con- recent Urban Institute study evaluated the ef- scale sale of illicit drugs and increased eligi- ducted an analysis of 23 different adult fectiveness of the Bronx Mental Health Court bility for diversion to treatment. 284 drug court programs, finding lower rates of programs, finding participation reduces the re-arrest/re-conviction and fewer recidivism chance of being re-arrested and that those The National Institute of Justice-funded study events across different types of offenses.287 who recidivate are more likely to commit focusing on New York City, found that drug Other research suggests drug courts: 288 drug crimes rather than violent crimes.289 law reform led to a 35 percent rise in the l R educe crime — 75 percent of drug Reclassifying Offenses rate of diversion of individuals eligible to court graduates remain arrest free for at treatment, which is associated with reduced Another type of sentencing reform is reclas- least 2 years; recidivism rates. Thirty-six percent of a sam- sifying offenses so that “the punishment fits ple of individuals who received treatment l S ave money — for every $1 spent on the crime.”290 Some states found that their following the reforms were re-arrested within drug courts, taxpayers save up to $3.36 felony classes (A, B, C, D, etc.) and their sen- two years, compared to 54 percent of those in fewer future criminal justice costs and tencing structures did not sufficiently differ- who were sentenced to prison, jail, probation, up to $27 for every dollar in total; entiate between minor and serious offenses or time served before the laws changed. Ra- l C ombat addiction — courts increase and that, in many cases, penalties were too cial disparities were cut in half as well. methamphetamine treatment program harsh. For example, in Indiana, three grams graduation rates by nearly 80 percent; and of cocaine with intent to deliver carried a California l R estore families — family re-unification harsher sentence than rape. A number of In November 2014, California voters passed states, including Indiana, along with Colo- is 50 percent higher for Family Drug Proposition 47, a law that changes some rado, Connecticut, Maryland, Oregon, South Court participants. low level crimes like drug possession and Dakota and Vermont, reclassified offenses minor theft from potential felonies to mis- Mental Health Courts to realign their sentencing, creating more fel- demeanors. State prison cost savings from Mental health courts take a similar approach ony categories per type of criminal offense, the changes will be invested in grants for to Drug Courts by substituting a prob- reclassifying low-level crimes from felonies to drug treatment and mental health services lem-solving model for the traditional court misdemeanors and introducing or increasing for people in the criminal justice system, process and taking a partnership approach felony thresholds for certain crimes. programs for at-risk students in K-12 schools and victim services.285 Drug Courts “BAN THE BOX” FAIR CHANCE EMPLOYMENT LAWS Drug courts are a partnership-based, As of September 2015, 18 states, Wash- for jobs, delaying the background check problem solving-solution to drug use and ington, D.C. and more than 100 addi- inquiry until later in the hiring process.291 misuse. The courts intend to help non-vi- tional cities and counties have adopted States with ban the box laws include: olent drug offenders get rehabilitation and “ban the box” fair chance employment California, Colorado, Connecticut, Dela- recovery to prevent further drug and social laws, which limit the ability of employ- ware, Georgia, Hawaii, Illinois, Maryland, problems. As such, a wealth of partners ers to ask applicants about conviction Massachusetts, Minnesota, Nebraska, (law enforcement, treatment, social service, histories to help reduce the stigma or New Jersey, New Mexico, Ohio, Oregon, mental health, judiciary, prosecution, and discrimination when candidates apply Rhode Island, Virginia and Vermont. defense and probation communities) work 60 TFAH • healthyamericans.org SECTI O N 2: Conclusions SECTION 2: CONCLUSIONS AND RECOMMENDATIONS Conclusions and Recommendations & Preventing and reducing teen substance misuse is important for Recommendations improving the health and quality of life for millions of young Americans. Currently, however, many of the most A. Puts prevention first — using effective strategies and policies for evidence based approaches across achieving this goal are not being widely communities and in schools; used or well implemented. B. Makes screening and early intervention The rapid rise of prescription drug routine practice — including connecting and heroin use epidemics makes it teens and families to support services; and imperative to act quickly — and the C. Supports comprehensive and progress that has been made toward sustained treatment and recovery. reducing alcohol, tobacco and other drugs misuse shows that redoubled Achieving these goals will require a efforts can make a significant difference much stronger investment in the well- in persistent concerns. being of children and teens — leading to a return of improved outcomes not TFAH has identified a set of just during youth but for a lifetime. It recommendations to modernize the will also mean thinking differently about nation’s strategy to substance use using some aspects of school, health and social research-based approaches to support a service delivery and funding systems — full continuum-of-care that: in pragmatic, achievable ways. A. PUTTING PREVENTION FIRST Research shows that the most effective Despite more than 40 years of research, prevention strategies focus on most prevention approaches have not reducing risks and boosting protective translated into widespread, regular real- factors starting early in a child’s life world use. In recent years, there have — and continuing through the tween, been even more advances in brain science teen and early adult years. Putting and evaluations of prevention programs prevention first would be a marked that can help inform the development shift in national substance misuse and successful implementation of NOVEMBER 2015 policy — since traditionally, the policy effective programs. Many of these has been focused on when problems efforts support general well-being and are emerging or have already development — and may not necessarily emerged, which is often too late to be viewed as “substance abuse prevention” have as strong a benefit. strategies — but they have been shown to have the largest impact. Some key recommendations include that efforts must: Start Younger — and Sustain Support throughout Youth: The most effective way to prevent and reduce substance misuse is to invest upstream — before problems emerge — partnering with larger positive development programs that help build protective factors and reduce risks for children, youth and families. Support must be sustained over time, particularly when tweens and teens reach life transition points. For instance, addressing early risk signs — such as behavior and academic concerns in preschool or elementary school — and providing multi-generational services that support parents as well as young children can have some of the biggest long-term payoffs. Integrate School-based and Wider Community Efforts — via Multisector Collaboration: Studies repeatedly show that strategies work best when they are integrated and reinforce each other — at home, in schools, within the community and in media. To achieve optimal results, efforts must engage families, schools and school systems, peers (including youth themselves and youth advocates), health professionals and insurers, mental and behavioral health specialists, non-traditional health providers, counselors, social services, juvenile justice programs, community and faith groups, colleges and employers to work together as partners to have a reinforcing effect. Local multi-sector coalitions or collaborations that engage a range of stakeholders can help bring different expertise areas, perspectives, resources and the potential for diverse funding streams to support child and youth development. The goal is not to duplicate cross-sector efforts already in place — but to build onto and integrate with existing child and youth development collaborations in a community and state. 62 TFAH • healthyamericans.org Prioritize the Collection, Analysis and Integration of Teen Health, Well-being and Services Data to be Able to Better Assess Trends and Target Services and Programs: Currently, most communities do not have enough quality information to develop strategies and target programs in the most effective and efficient ways possible. It is essential to have good measurement to understand the issues within a community; be able to match the most effective types of programs to those needs; and to assess how effective the programs are at reducing risks, increasing protective factors and lowering substance use rates. There needs to be more systematic and standardized systems for collecting and correlating data — to do needs assessments, measure results and assure accountability of efforts. A better understanding of how child and teen health trends, patterns of underlying risk and protective factors, social service supports, income and nutrition assistance programs interrelate are important to be able to: l M atch the most appropriate types of to better understand how the data programs with community needs; work together to evaluate trends and implement policies and programs. The l U nderstand how to evaluate the federal government should support effectiveness of programs and an evaluation to determine how to adjustments that may need to be align and update the surveys — and made; and determine what changes should be l E nsure accountability and demonstrate made, such as including additional the ongoing value of programs and questions to measure risk and protective services. This data collection and analysis factors in communities (such as those can functionally serve as electronic asked in the Communities that Care health records at a community level — and/or the Pennsylvania Youth Survey) and are essential to effectively determine and also how to make the data available strategies, deliver programs, assess the and accessible for communities to use impact of efforts and determine how to to inform their needs assessments and best allocate resources. evaluations. Communities should be trained in ways to collect and use real- Current federal surveys, including time data to inform and improve on NSDUH, YRBS and MTF, all provide their prevention and public health different and important data. strategies for reducing substance misuse However, it important to find ways and improving youth well-being. TFAH • healthyamericans.org 63 Have End-to-End Support — From Selection to Implementation to Evaluation and Improvement: An expert and technical assistance backbone support organization at the state level provides assistance to help programs be successful and sustained over time. Strategies, programs and services need end-to-end support — including through networks of experts, access to research and evidence-based practices and guidance on multi-sector collaboration. A backbone organization — housed at an academic center or a nonprofit organization — can provide assistance to support the development and efforts of community-based multi-sector collaborations and coalitions — and to help identify and braid different funding streams. One model is to have a public-private partnership “backbone” organization in a state that can: l P rovide needs assessments to match — performing regular evaluations to the best policy and program choices to measure results, ensure accountability a specific community’s needs; and inform continuous quality improvement and updates to improve l E nsure programs are adopted and programs. Community level analyses implemented successfully by providing can help identify patterns of concerns training support for a range of profes- — including of risks and protective sionals from different backgrounds and factors — and help understand where sectors; technical assistance; and access and how to direct programs and to learning networks; efforts; and l E ngage and sustain the participation l C ontinue to build the evidence base of a wide range of stakeholders and by ensuring implementation with high partners; fidelity and building the networks and l P rovide technical support and relationships to conduct additional ongoing data collection and analysis research. 64 TFAH • healthyamericans.org Support Sustained and Multi-sector Funding for Youth Development: Improved models should be developed to allow for sustained resources for youth development programs — in schools and communities — and for cross-sector coalitions. Since successful programs require the participation of multiple stakeholders, it is important to find better systems for both requiring multisector participation to receive funding for programs and allowing for flexibility to use and leverage multiple funding streams to support efforts. Investing in prevention yields longer-term returns in reduced costs for a wide range of healthcare and social service needs. l A t a federal level, programs and and braid public and private funding grants across agencies — including steams to support place-based youth the Department of Education, development initiatives. At a minimum, SAMHSA, CDC, Office of National all HHS programs and the Department Drug Control Policy (ONDCP), DOJ of Education should work to ensure and others should be fully funded collaboration and coordination across and coordinated to be mutually programs and funding of existing and reinforcing and integrated through new resources; and the National Prevention Council or l N on-traditional funding mechanisms other similar mechanism — to cut should be explored, including down on bureaucracy and leverage for outcome-based health reform resources. Requirements of programs models (including Accountable should include the adoption and Health Communities), working with effective implementation of evidence- community benefit programs at based programs; incentives and nonprofit hospitals, pay-for-success flexibility to support multi-sector programs and/or the delegation of collaboration; state, local and/ sin taxes, such as those from legalized or private matching resources and marijuana, alcohol or tobacco sales, maintenance of a state-level backbone to support substance use prevention organization to support local grantees; and treatment efforts. The Center for and evaluations and accountability; Medicare and Medicaid Innovation l A t a state and local level, there should (CMMI) should also explore the be ongoing support for assuring a advantages of supporting backbone strong expert backbone organization is organizations in states — which result established and maintained — and all in achieving better health outcomes available mechanisms are used to sustain and lowering healthcare spending. TFAH • healthyamericans.org 65 NIDA’S PREVENTING DRUG USE AMONG CHILDREN AND ADOLESCENTS: A Research-Based Guide for Parents, Educators and Community Leaders Key Principles for Successful Substance Use Prevention Programs More than 40 years of research shows that: l P revention efforts are most successful when they address the individual level and community influence concerns. l I ntegrated strategies should include “universal” approaches that benefit all individuals, “targeted” support for children and teens and communities with increased risk and “indicated” programs for those who are already using substances. Prevention Principles Risk Factors and Positive Factors Programs should enhance protective factors and reverse or reduce risk factors. l R isk involves the relationship between the number and type of risk factors and protective factors. l T he potential impact of specific risk and protective factors changes with age. l E arly intervention often has a greater impact than later intervention — changing a child’s trajectory away from problems and toward positive behaviors. l R isk and protective factors impact the entire population, but can have different effects also depending on age, gender, ethnicity, culture and environment. Programs should address all forms of substance use — legal and illegal — and the potential for use in combination. Programs should target specific community risks. Programs should be tailored to match the intended group or audience — such as being age or culturally appropriate. Family-Based Prevention Family-based programs should enhance bonding and relationships, including accurate education about risks of substance use, developing parenting skills and clear limit setting. School-Based Prevention Preschool programs should address risk factors such as aggressive behavior, poor social skills and academic difficulties. Elementary school programs should also address academic and social-emotional learning — addressing aggression, academic difficulties and school dropout or absenteeism. Middle and high school programs should increase academic and social competence — including study habits and academic support; communication, peer relationships; self-efficacy and assertiveness; drug resistance skills; reinforcement of antidrug attitudes; and strengthening personal commitments against drug use. Community Programs General community programs should focus on periods of life transitions — such as transition to middle school — can benefit the entire population, not just high-risk families. Community programs that combine two or more effective programs — such as family-based and school-based programs — can be more effective than a single program alone. Community programs across multiple settings (schools, clubs, faith-based organizations, media, etc.) are most effective when they present consistent, community-wide messages in each setting. Prevention Program Delivery When communities adapt programs to match their needs, community norms or cultural requirements, they should retain core elements of the original research-based interaction (structure, content and delivery). Programs should be long-term with repeated interventions to reinforce the original goals. Research shows that the benefits from middle school prevention programs diminish without follow up programs in high school. Prevention programs should include teacher training on good classroom management practices, such as rewarding appropriate behavior, in addition to fostering positive peer behavior, achievement, academic motivation and school bonding. Prevention programs are most effective when they employ interaction — such as peer discussion groups, parent role-playing — that allow for active involvement in learning about drug use and reinforcing skills. Research-based prevention programs can be cost-effective — saving up to $10 in avoided treatment for every $1 invested. 66 TFAH • healthyamericans.org PUBLIC-PRIVATE NETWORK MODELS Evidence-based Prevention and Intervention Support Center (EPISCenter) Evidence-based Prevention and help best address the identified needs Intervention Support Center is a state- (many of which start in early childhood level prevention support system that helps and continue through youth) technical connect research, policy and the real-world assistance and support for quality practice of child and youth development implementation of the programs and programs.292 The center serves as a evaluations of efforts and continued backbone organization that promotes the community needs. EPISCenter also dissemination, high-quality implementation supports the Pennsylvania Youth Survey and sustainability of: community-level — which helps communities collect infrastructure for prevention planning; data about rates of substance use as evidence-based programs and practices; well as underlying protective and risk and continuous improvement of locally- factors to inform needs assessments and developed juvenile justice and substance evaluations. use programs, which also provide much EPISCenter is a collaborative partnership broader support for positive childhood between the Pennsylvania Commission and youth development. They help on Crime and Delinquency (PCCD), the communities assess their specific needs Pennsylvania Department of Human through a process designed to help Services (DHS) and the Bennett Pierce communities identify and prioritize the Prevention Research Center, College of risk and protective factors they want to Health and Human Development at Penn focus on; and provide information about State University. which programs and interventions can Translating Science to Practice Assess Monitor Public Quality of Health Set & Collect Program Impact Provide Performance Implementa- Technical Measures tion Implement Assistance & Evaluate Develop & Programs Identify Test Inter- Risk and ventions Define the Protective Problem Factors Problem Response This diagram shows the multiple, coordinated steps involved in taking research from the lab into communities (“research to practice”). The first four steps show the research activities that lead up to introducing programs into the field. The last four steps show the translation and implementation activities that are undergone to run programs in “real-world” settings. Source: EPISCenter, 2014 Pennsylvania’s Approach to Research-based Prevention As a state-level intermediary organization, developed in partnership between PCCD and the PRC, the EPISCenter is in a unique position to put research into real-world practice. We focus on promoting the dissemination, high-quality implementation and sustainability of: • community-level infrastructure for prevention planning; TFAH • healthyamericans.org 67 • evidence-based programs and practices; and • continuous improvement of locally-developed juvenile justice programs. Communities that Care Communities that Care (CTC) was devel- percent); and were less likely to have en- oped and tested by researchers at the gaged an act of violence (14 percent).295  Social Develop Research Group at the The CTC operating system approach al- University of Washington to provide a pre- lows each community to conduct its own vention-planning system and network of ex- needs assessment using the CTC survey. pert support for the use of evidence-based The Communities that Care Youth Survey approaches to promote the positive devel- helps identify prevalence rates — but also opment of children and youth and prevent measures a comprehensive set of risk and problem behaviors, including substance protective factors that affect a community’s use, delinquency, teen pregnancy, school teen populations — which are factors that drop-out and violence.293 Hundreds of impact academic performance and positive U.S. and international communities have youth development, as well as problems used the approach, which includes involv- Source: The UW Center for Communities that Care that inhibit development, which provide ing all parts of a community — engaging communities with important information on multi-sector collaboration — to target risk and protective factors. The community predictors of problems, rather than waiting creates its own data-based community for problems to occur. It is grounded in re- need profile; develops a focused, long- search from public health, psychology, ed- range community action plan for building ucation, social work, criminology, medicine on existing resources and filling gaps with and organizational development. new tested, effective programs, policies and A randomized controlled test of CTC pro- practice that best match community needs. grams in 24 communities across seven It helps bring together elected officials, states that followed 4407 5th grade youth youth, parents, law enforcement, schools, found that by the spring of 8th grade, public health officials, agencies and organi- significantly fewer students from CTC zations serving local youth and families, the communities had health and behavior faith community, the business community problems, and were 25 percent less likely and residents. It also includes evaluation to have initiated delinquent behavior; 32 tools to understand the impact and ongo- percent less likely to have initiated alcohol ing/remaining concerns within a community. use; and 33 percent less likely to have ini- CTC uses a five-phase process, including: tiated cigarette use.294 The results were l G etting Started (Phase 1): defining the sustained through 10th grade; by the end community to be involved; recruiting a of 10th grade, these students also had community-leader champion to guide the 25 percent lower odds of engaging in vio- process; assessing community conditions, lent behavior. Cost-Benefit analyses find activities and initiatives that may affect a $4.23 benefit for every dollar invested readiness; identifying building blocks and in the Communities that Care operating stumbling blocks; and identifying commu- system. Another long-term study found nity stakeholders who need to be involved. that 12th graders who were part of the CTC-prevention system were more likely l G etting Organized (Phase 2): educating than their non-CTC prevention system and engaging identified stakeholders; de- peers to have abstained from any drug veloping a shared vision for the future of use (32 percent); were more likely to have the community’s children; and putting an avoided ever using alcohol, cigarettes or organizational structure in place to help marijuana (31 percent); were more likely the community move toward the vision. to have avoided delinquent behavior (18 68 TFAH • healthyamericans.org l D evelop a Community Profile (Phase l C reate a Community Action Plan (Phase programs, policies and/or practices into 3): collecting community-specific data; 4): defining clear, measurable desired place; identifying policymakers, organiza- constructing a profile from the data — outcomes using the community profile; tions, service providers and practitioners allowing the community to analyze its reviewing evidence-based programs that to implement the chosen approaches; unique strengths and challenges; col- best match the community’s self-identi- training implementers; building and sus- lecting data on risk factors and protec- fied needs and priorities; and creating taining collaborative relationships among tive factors to help the community focus plans for putting new tested, effective organizations and other stakeholder efforts and resources; identifying and programs, policies and practices into groups; developing information and com- assessing community resources that place; and developing an evaluation plan munication systems to support the collab- currently address the priority risk and for collecting and analyzing data to mea- oration; educating and involving the entire protective factors; and identifying gaps sure progress toward desired outcomes. community; adjusting programing to meet to be filled in existing resources by ex- plan goals; and celebrating successes. l I mplement and Evaluate (Phase 5): form- panding the resources or implementing ing task forces to put the evidence-based new, tested effective approaches. Partnerships in Prevention Science Institute at Iowa State University296 Since the early 1990s, the Partnerships Over the past few decades, 17 stud- uating these interventions. Some major in Prevention Science Institute has been ies have been conducted, including six programmatic findings include:297 a large-scale research program focused randomized, controlled intervention l I owa Strengthening Families Program (ISFP) on interventions designed to build family outcome studies. Altogether the Insti- — estimated reduction of adult alcohol and youth competencies, which would tute’s research has resulted in long-term use disorder rates by 13 percent, returning likely prevent substance use and other reductions in substance use; long-term $9.60 for every $1 spent in implementing; behavioral problems. The Institute intends positive effects on school engagement to enhance the well-being of participating and academic success; long-term con- l P reparing for the Drug Free Years (PDFY) families and children through scientifical- duct/behavior problem reduction; positive — estimated reduction of adult alcohol ly-tested programs and practices by forging youth protective factor and skills-build- use disorder rates by 6 percent, returning important community partnerships. The ing outcomes; and positive returns on $5.85 for every $1 spent on the program; goal of all Institute research is to increase investments. Additionally, the Institute l L ife Skills training returned $25.61 for youth competencies, strengthen families, has demonstrated that the types of part- every $1 invested; and reduce youth problem behaviors, and im- nerships they utilize — school-communi- prove community capacity to implement sci- ty-university — are effective in delivering l P roject Alert returned $18.02 for every entifically-tested prevention interventions. evidenced-based interventions and eval- $1 invested. PROSPER The PROSPER project (PROmoting School/ delivery system has been shown to reduce community-university Partnerships to a number of negative behavioral out- Enhance Resilience), developed by the comes, including drunkenness, smoking, Institute and the cooperative extension, marijuana use, use of other substances is an evidence-based delivery system for and conduct behavior problems, with high- supporting sustained, community-based er-risk youth benefiting more.298, 299, 300 implementation of scientifically-proven pro- PROSPER also demonstrates positive grams that reduce adolescent substance effects on family strengthening, parenting use or other problem behaviors and pro- and youth skills outcomes and reduces mote youth competence. The PROSPER negative peer influences.301, 302 TFAH • healthyamericans.org 69 COMMUNITY PROGRAMS Community partnerships are a necessary Every day 12-17olds year The prevalence of youth substance use 4,000 component of any strategy to reduce pre- increases P use drugs er scription drug use and misuse. as their ce for the perception pt io e first time Us One major system for support of n of harm of Ha substance use prevention is the from use rm ce 21% tan Community Anti-Drug Coalitions of of high school students reported decreases bs Su binge drinking in the past 30 days America (CADCA), a national membership organization that works to strengthen the capacity of community coalitions to create and maintain drug-free Youth Parents communities. CADCA has engaged in on- going educational and communications Substance Abuse Business efforts around prescription drug use Organizations including putting out publications to provide community anti-drug coalitions State/ Local Problems with the research and tools they need to Local/Tribal Government Require Local Solutions Media implement effective prevention strategies and training community anti-drug coalitions in effective community problem- Healthcare Schools solving strategies using local data.303 Professionals The federal grant program Drug Free Communities Support Program (DFC) Religious/ Youth Serving Fraternal Organizations provides funding to community-based Organizations coalitions that organize to prevent Civic/ Law Volunteer youth substance use. The program is a Enforcement Organizations match, meaning that all grantees must secure dollar-for-dollar non-federal funds, Since its Coalition Strategies which demonstrates the community Inception DFC has Funded buy-in and participation necessary to be More Than... successful.304 Providing Enhancing Changing Providing 2,000 Information Skills Physical Design Support DFC was funded at $93.5 million in FY Community coalitions 2015. The President’s FY 2016 budget DFC supports requests $85.7 million — a $7.8 million 4.4 million Enhancing Access/ Reducing Barriers Changing Consequences Modifying/ Changing Policies middle school students cut to the program. (age 12-14) and 6.3 million DFC Works! Sources: DFC-funded community coalitions have high school students Youth substance use has decreased among SAMHSA- NSDUH 2013 (age 15-18) achieved significant reductions in youth all grantees since program inception Monitoring the Future 2012 alcohol, tobacco, and marijuana use.305 Representing 2012 DFC For middle school youth living in DFC- 36% National Evaluation of all Alcohol Tobacco Marijuana Report funded communities, data from the United States youth YRBS 2013 DFC National Evaluation indicate a Source: Office of National Drug Control Policy, Drug-Free Communities 70 TFAH • healthyamericans.org 24.4 percent reduction in alcohol use, DFC funded community coalitions reported 29.4 percent reduction in tobacco use and significant decreases in past 30-day illicit 15.1 percent reduction in marijuana use. prescription drug use. Data from the DFC High school-aged youth have reduced their National Evaluation indicate a 21.4 percent use of alcohol by 15.5 percent, tobacco reduction in past 30-day illicit prescription by 23.7 percent and marijuana by 4.9 drug use for middle school youth and a 14.5 percent in DFC-funded communities. percent reduction for high school youth. 697 Drug-Free Communities Program Grantees for Fiscal Year 2015 ( ! New Mentoring Grantee (20) ( ! (( !! ( ! New Grantees (188) ( ! ( ! ( !( ! ( ( ! ! ! Mentoring Grantees (3) ( ( !(( !! ( ! ( ! (( !! ( ( ! ! ( ( ! ! ! Continuation Grantees (486) ( ( ! ( ! ( ! (( !! (( !! (( !! ( ! ( ! ( ! ( ! counties ( ( ! ! ( ! ( ! ( ! ( ( ! ! ( ! ( ( ! ! ( ! (( !! ( ( ! ! (( ( !! ! ( ! ( ! ( ! ( (( ! !! ( ! ( ! (( !! ( ! ( ! (( !! ( ! (( ( ( !! ! !( ! ( ! ( ! ( ! ( ( ! ! ( ! ( ( (( ! ! !! ( ! ((( !!! ( ! ( ! ( ( ! ! ( ! ( ! ( (( ! !! ( (( ((( ! !! !!!( ! ( ! ( ( ( ( (( ( ! ! ! ! !! ! ( ! ( ( ! ! ( ( ((( ! ! !!!( ! ( ! ( ! ( ! ( ! ( ( ! ! (( ( ( ( ( !! ! ! ! ! ( ! ( !( ! ( ! ( ( ( ! ! ! ( !( ! ( ! ( ! ( ( ( ! ! ! ( (( ! !! ( (( ! !! ( ! ( ( ! ! (( ( !! ! ( ! ( ( ! ! ( ( ! ! ( ! ( ! (( !! (( (( (( (( !! !! !! !! (( ( !! ! ( ! ( ! ( (( ! !! ( ! ( !( ( ! ! ( ! ( ! ( ! ( (( ! !! (( ( (( !! ! !! ( (( ( ! !! ! ( !( ! ( ( ! ! (( (((( !! !!!! ( ( ! ! ( ((( ( ! !!! ! (( !! ( ( ! ! ( ! ( (( ! !! ( ! ( (( ! !! ( ! ( ! ( ! ((( ( !!! ! (( !!( ! (( ( !! ! ( ! (( !! ( ! ( ! (( ( !! ! ( ! (( ( !! ! ( !( ! ( ! ( ! (((( !!!! (( !! (( !! ( ! ( ! ( ! ( ! ( ! (( !!( ! (( ( (( (( ( !! ! !! !! ! ( !( ! ( ( ! ! ( ! ( ! (( !! ( ! ( ! ( (( ( ! !! ! ( ! ( ( ! ! ( ! ( ! (( ( !! ! ( ! ( ! ((( ( !!! ! ( ((( ( ! !!! ! ( ! ( ! ( ! ( ! ( ! ( (( ( ! !! ! ( ! ( ! (( ( !! ! ( ! ( (( ! !! ( ( ! ! (( !! ( ! ( ! ( ! ( ! (( !! ( ( ! ! ( ! (( !! (( !! ( ! ( ! (( !! ( ! ( ! (( ( !! ! ( ! ( ! ( !( ! ( ! ( ! (( ( !! ! ( ! ( ! ( ( ! ! ( ! ( !( ! ( ! (( ( ( !! ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( !( ! ( ! (( !!( !( ! ( ! ( ! ( ! ( ( ! ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ( (( ( ! ! !! ! ( ! ( ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( ( ! !( ( ( ! ! ! ( ! (( !!( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ( ! ! ( ! ( ! ( ! ( !( ( ( ! ! ! ( ! (( ( ( !! ! ! (( !! ( !( ! ( ! (( !! ( ! ( ! ( ! ( ( ( ( ! ! ! ! ( ( ! ! (( !! ( ! ( ! ( ! ( ( ! ! ( ( ! ! ( ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! (( ( ( !! ! ! ( !( ! (( !! ( ! ( ! ( (( ! !!(( !! ( ! ( ! ( ! ( ! ( ! ( ! (( !! ( ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( !( ! ( ! ( ! (( !! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ( ! ! ( ! ( ! (( !!( ! ( ! ( ( ! ! ( ! ( ! ( ( ( ! ! ! ( ( ! ! ( ! (( !! (( !! ( ! ( ! (( !! (( !!( ! ( ( ! ! ( ! ( ! ( ! ( ! ( (( ( ! !! ! ( ! ( ! ( ! (( !! ( ! ((( !!! ! ( ( ! ( ! ( ! ( ! ( ! ( ! Puerto Rico American Samoa ONDCP003437 ( ! ( ( ! ! ( ! ( ! ( ! A new grantee is also located Source: Drug-Free Communities ( ! on the Yap Islands of Micronesia. Program, ONDCP (August 2015). SAMHSA PARTNERSHIPS FOR SUCCESS (PFS) GRANTS PFS supports a positive change ap- lend assistance to the highest need proach at the community level by pro- areas. Successful programs leverage, viding funding to eligible jurisdictions to redirect and realign funding for preven- reduce rates of substance misuse by in- tion. Another important element of PFS creasing the state and local capacity to is bringing SAMHSA’s Strategic Preven- prevent misuse in the first place. 306 The tion Framework to a national scale by partnerships are aimed at filling gaps in providing grant recipients with opportuni- preventive services and helping states ties to acquire additional funding. TFAH • healthyamericans.org 71 SCHOOLS: EXPANDING THE ADOPTION AND IMPLEMENTATION OF EVIDENCE-BASED PROGRAMS Traditionally, substance use prevention acknowledging or providing a sensitive en- programs have often been targeted via vironment for dealing with substance use schools — but schools cannot solve the has resulted in a negative impact on a problem alone, and school-based pro- school’s reputation and support from the grams cannot work in isolation. parents and larger community. However, schools will always be a central The research supports what most teach- component of any strategy. Children and ers, principals and other educators al- teens spend a significant amount of time at ready know best: substance use harms a school and with peers they meet at school, student’s academic performance, behavior and they are influenced by what they learn and attendance; and that social-emotional and culture of the school. More than 90 learning can benefit all children starting percent of the 42 million 10- to 19-year-olds in early childhood — has not received are enrolled in school. 307 One key element enough support; and that the most ef- of improving substance use prevention and fective programs also provide additional reduction programs is to increase the num- time, attention and resources to support ber of schools adopting and implementing children who struggle with behavior and evidence-based programs. academic performance throughout their entire school career. In the past, a number of substance use prevention strategies have focused on The most effective school-based ap- providing limited “information-based” proaches incorporate: individual behavior programs in middle and high schools change; skills training (academic and — often in the form of a “pep rally” or social competence and resistance skills); rapid-response to a crisis in a community norms education; cognitive/behavioral that often serve as a “feel good” quick interventions; social emotional learning; fix for parents and administrators. Many environmental change; media literacy; and substance use prevention programs have persuasive communications. In addition, focused on the latest in a series of gim- approaches should involve families, ed- micky campaigns that focus on individual ucators and other school staff. Strong willpower of tweens and teens — from performing programs also must address “just say no” to “scared straight” and oth- the larger school climate — and support ers. According to the research, however, a more sensitive response, early interven- programs that have been shown to be tion and support services for behavior and ineffective include information only, tes- academic problems. timonials (including by celebrities), scare Despite growing research distinguishing tactics and stand-alone, limited affective effective from ineffective approaches, as of education or self-esteem building efforts. 2005, only 23 percent of middle schools In addition, there is also a long-standing reported using evidence-based programs cultural stigma attached to substance use for most of their substance use prevention disorders — where students are often efforts, and less than half (42.6 percent) judged as “bad” and/or are punished used some evidence-based programming.308 for behavior rather than being connected Only around 13 percent of elementary to help and support. The stigma-effect schools use evidence-based programs for can extend to the school level, where most of their substance use efforts, and 72 TFAH • healthyamericans.org only 35 percent use some evidence-based disorder; 2) the latest research on the programming.309 Even within schools that positive impact of reducing risks and adopt evidence-based programs, there are building protective factors throughout still concerns about how effectively or thor- childhood — and how this helps improve oughly they may be implemented. academic performance and reduce behavior problems in classrooms and Adopting and implementing evidence-based schools; and 3) how and why some of programs will require a commitment to the strongest evidence-based programs devote the resources, time and training to work — and work better than other support these efforts — as well as a shift efforts — and processes that allow to understanding that many of these initia- communities to find and choose the pro- tives focus on broader positive development grams that can best match the needs — that start with younger children and of their particular schools and commu- go far beyond direct education about the nities. Many educators are skeptical harms of substance use. Moving toward a based on experiences with ineffective more impactful approach will require: approaches and programs in the past. n roviding Increased Education About P It is important to engage leading experts What Works Best — For Parents, Edu- and community leaders to translate the cators, School Administrators, School latest research and approaches in a Superintendents and Boards, Civic and way that educators and parents will un- Community Leaders and Policymakers: derstand and appreciate their value. In Research has advanced significantly addition, information must be conveyed about: 1) the most recent brain sci- in culturally-competent ways via cultural- ence and how substance use works ly-competent messengers to effectively as a physical, mental and behavioral reach different communities. TFAH • healthyamericans.org 73 n Ensuring Sustained, Sufficient Funding sociation of School Psychologists (NASP) and End-to-End Support for Adoption, reported a shortage of more than 9,000 Implementation and Evaluation of Pro- school psychologists in 2010, with a grams: It is important to provide more projected shortage of 15,000 by 2020. stable and sustained funding to support The national ratio was 457 students to a long-term commitment to effective, on- one school psychologist. In some areas, going evidence-based programs — which the ratio is as high as 2,000 or 3,500 is a culture change from previous prac- to one.310 In 2012, there were 262,300 tices of funding limited and short-term school counselors in around 99,000 campaigns or grant programs. It is also public and 30,000 private elementary important to have a backbone expert and secondary schools in the United network to support schools in selecting States.311 Currently, school psycholo- which of a select menu of evidence-based gists, counselors and behavior special- programs best fit their needs, starting ists spend a significant portion of their and effectively maintaining a new program time supporting the academic needs of — including with training and ongoing students and/or dedicated to addressing technical support, provide evaluations the needs of around 13 percent of U.S. and advise on continuous quality improve- students who receive special education ment. Training, guidance and program services. There is little time or re- performance analyses should be provided sources to provide support for additional throughout the education system — for mental health and/or social, behavioral teachers, counselors, principals, admin- and emotional problems. It is important istrators, superintendents and school to increase the number of trained profes- boards — to help sustain longevity and sionals to provide support to the school ongoing understanding of why and how community and students.312, 313 These programs are working. professionals help students in academic achievement, personal/social develop- n artnering with Larger Community and P ment and career development. They Multi-sector Efforts: School-based can provide support and intervention efforts should be made in context with to students; consult with families and other programs and supports in a com- teachers; promote positive peer relation- munity. Schools and school districts ships, social problem solving and conflict should work with multi-sector child and resolution; develop school-wide practices youth development coalitions and col- and approaches; and connect and col- laborations. This can help ensure that laborate with community providers for programs and efforts are mutually rein- needed services. forcing and the combined efforts yield better overall results. n mproved Delivery of Health — and I Mental Health — Services in Schools n Increasing Resources and Professional and Better Coordination and Integration Training Opportunities to Recruit and Across the Education, Healthcare and Retain More School Counselors, Psy- Social Service Sectors: When children chologists and Behavioral Specialists: have unmet needs — including medical, There is a shortage of trained profes- mental and behavior health issues — it sionals to support social-emotional can make it difficult to be able to be development and to address the behav- effectively ready to participate and learn ioral and mental health needs of U.S. in school. And, screenings and identifi- students. For instance, the National As- cation of concerns need follow up with 74 TFAH • healthyamericans.org appropriate care and services to have an ment from public insurance programs and formance and graduation rates. Safer, impact. However, schools are often over- private health plans; local, state and fed- positive school climates help: reduce bul- stretched and underfunded to meet their eral grants; philanthropic foundation; and lying and other forms of violence; support core responsibilities to educate children in-kind contributions from school districts social-emotional learning; improve school and teens. Providing, or even linking, and other partners.314 connectedness; implement positive dis- children and families to health and social cipline and restorative justice; implement l S chool systems are also working to de- services is beyond the scope and capac- school-wide positive behavioral supports; velop systems and models that align the ity that most schools can currently offer. identify at-risk students and school vul- health (Health Insurance Portability and nerabilities; and provide crisis prevention l ome schools and school systems have S Accountability Act (HIPAA)) and education and intervention services. They can help been developing different models and (Family Education Rights and Privacy Act families better understand their child’s approaches to try to address these needs (FERPA)) privacy protection requirements learning and mental health needs — and — which often do involve working across — to allow educators, health providers help staff understand and respond to sectors, programs and funding systems — and social service professionals to be diverse cultures, backgrounds and needs but help ensure students receive services able to better work together and coor- of students. As one important element on the school campus or are connected dinate needed services and treatments of improving school climates, a number with the services they need. Models while maintaining family privacy.315 of states are eliminating “zero tolerance” range from full on-site school based n Promoting Positive School Climate school punishments, reducing the number health centers (SBHCs) to mobile health Efforts: Positive behavior and school of suspensions and expulsions — which centers to expanding school nursing staff climate improvement initiatives help shift end up contributing to increased atten- to strong partnerships with local commu- the focus from punishing “bad” behavior dance, behavior, academic and attrition nity health centers (CHCs) and designated toward prevention and providing help and problems. The Department of Education case managers. There also a range of support to children and teens with behav- has developed the Safe Supportive Learn- potential payment models — for instance, ior issues. These approaches have been ing Web site (safesupportivelearning. in California, there are more than 230 shown to be more effective in reducing ed.gov) to provide resources, information SBHCs serving nearly a quarter million behavior incidents and substance misuse and technical assistance and planning children — which are financed through while improving attendance, school per- tools for school districts and schools.316 a variety of sources including reimburse- TFAH • healthyamericans.org 75 DIFFERENT NEEDS FOR DIFFERENT COMMUNITIES It is important to have programs match needs of particular can increase risk for substance use. In addition, higher-income school communities, including recognizing and acknowledging students have increased resources to be able to access drugs that substance use issue impact all socio-economic levels — to and alcohol. Students from affluent families often initiate and normalize the need to address the underlying factors for individ- regularly use substances starting in younger grades — often by uals and across the school community. In fact, while smoking 7th grade. Families with teens or youth often have an increased is higher among teens of parents with lower levels of incomes desire to not want to acknowledge individual or community-level and education, alcohol use, binge drinking and marijuana use problems because of potential stigma or fear of impacting their are higher for teens of parents with higher levels of income and child’s future or the reputation of their school — and may also education.317, 318, 319 have increased resources to deal with problems privately. This contributes to the lack of attention — and resources — devoted So, for instance, at schools with higher-income, high-achiev- to the problem at a community level. The research shows that ing students, there is often significant pressure to achieve in it is particularly important to begin prevention programs for high- academics, sports, in a range of extracurricular activities and er-income youth before they enter middle school years. socially. This is often interrelated with high rates of depression, anxiety and other mental health disorders — by middle school, For lower-performing and lower-income schools, by the time stu- these rates are as high or higher than students in low-income dents enter middle and high school, substance use concerns families, even among those who experience toxic stress — which are often interrelated with school performance, attendance and Source: Patrick ME et al., 2012 Source: Patrick ME et al., 2012 76 TFAH • healthyamericans.org behavior problems. Often, lower-income families have less social It is also important to ensure culturally and linguistically appro- capital and resources to provide support or get treatment for stu- priate education, interventions and support are available within dents at an individual level — and substance use has often been and across communities. dealt with in terms of punishing “bad behavior,” including in some Prevention programs and starting efforts in younger years — in- cases involving the juvenile justice system. In some communities, cluding “universal” approaches — help recognize that the prob- substance use issues are interwoven with what has been named lem exists across all social and economic strata and can 1) lower the “school-to-prison pipeline” or “schoolhouse to jailhouse track” risk across an entire community; 2) help benefit positive develop- because of the significant number of lower-income students who ment for all children and youth; and 3) provide additional protec- are arrested and/or incarcerated — often for minor and non-vio- tive benefits to children at higher risk. By integrating programs lent offenses related to drugs — rather than connecting children into schools as a routine practice, it also helps lead to increased to treatment or other support services.320, 321 Many lower-income ability to help identify and destigmatize the need to provide added schools are disproportionately under-funded to address core ac- support to many. A number of evidence-based programs target- ademic programs and a wide range of other pressing concerns ing elementary, middle and high schools exist — and communi- — and often do not have sufficient or dedicated funding to support ties and schools can conduct needs assessments to determine child and youth development prevention programs aimed at reduc- which programs are the best fit to address their needs. ing substance misuse and related factors. Source: Patrick ME et al., 2012 Source: Patrick ME et al., 2012 TFAH • healthyamericans.org 77 S EC T I ON 1 : School-Based Prevention Interventions322 Longitudinal research over the past several decades from NIDA has identified risk factors and interventions — as well as specific evidence-based school-focused programs — that have shown effective results. Developmental Stage Modifiable Risk Intervention Early Childhood Inability to share Child social practice Lack of school readiness Early education Inconsistent discipline Parent skill training Elementary School Aggressive behavior Good classroom management Failure to read Remedial reading support Lack of parental involvement Parent/teacher communication Middle School School failure Academic skills Poor social skills Social competence Poor parental monitoring Parent skills High school Misperceptions of acceptability/extent of peer use Normative education/refusal skills Family conflict Family therapy Lack of self-control Social skills Examples of Evidence-Based Drug Use Prevention Programs Resources, such as CTC, NIDA’s review of evidence-based prevention programs, CDC’s Health Education Curriculum Analysis Tool (HECAT), SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP), the Center for the Study and Prevention of Violence’s Blueprints for Healthy Youth Development, the Coalition for Evidence-based Policy, the Institute of Education Sciences’ What Works Clearinghouse, the National Institute of Justice’s Crimesolutions.gov and others can help school districts, schools and communities identify which of the range of evidence-based programs best match with their needs.323, 324, 325, 326, 327, 328, 329, 330 Good Behavior Game (GBG) GBG is a universal classroom prevention strategy of behavior management that centers on positive reinforcement [Elementary School Program] of rules. Teachers use GBG to help students develop skills such as teamwork and self-regulation. GBG is integrated into the school day, including instructional time, transition times, lunch, etc. Teachers give students positive reinforcement for meeting behavioral expectations, monitoring and managing their own behaviors and supporting the positive behavior of peers. GBG has been demonstrated to reduce aggressive, disruptive and off-task behavior in elementary school males, reduction in smoking and use of mental health services in middle school males, and reduction in alcohol use, tobacco use, illicit drug use and suicide attempts in young adult males (ages 19 to 21). In Cincinnati, GBG is being layered onto the walking school bus in a partnership between the state education, school safety and transportation agencies. A Washington state analysis of implementing the GBG estimated a benefit-to-cost ratio of $31.19 and 25 percent rate of return on investment. Life Skills Training (LST) Program LST is designed to address a wide range of risk and protective factors by teaching general personal and social [Middle School and High School skills, along with drug resistance skills and normative education. This universal program consists of a 3-year Booster Program] prevention curriculum for students in middle or junior high school. LST contains 15 sessions during the first year, 10 booster sessions during the second, and 5 sessions during the third. The program can be taught either in grades 6, 7 and 8 (for middle school) or grades 7, 8 and 9 (for junior high schools). LST covers three major content areas: 1) drug resistance skills and information, 2) self-management skills, and 3) general social skills. The program has been extensively tested over the past 20 years and found to reduce the prevalence of tobacco, alcohol and illicit drug use relative to controls by 50 percent to 87 percent. When combined with booster sessions, LST was shown to reduce the prevalence of substance use long term by as much as 66 percent, with benefits still in place beyond the high school years. Although LST was originally tested predominantly with White youth, several studies have shown that the LST program is also effective with inner-city minority youth. An age-appropriate version of the LST program for upper elementary school students was recently developed and shown to reduce tobacco and alcohol use. It contains 24 classes (8 classes per year) to be taught during either grades 3 to 5 or 4 to 6. The Strengthening Families Pro- SFP program offers seven sessions, each attended by youth and their parents. Program implementation and gram (SFP): For Parents and Youth evaluation have been conducted through partnerships that include state university researchers, Cooperative (Ages 10–14) Extension System staff, local schools and community implementers. A longitudinal study of comparisons with control [Middle School and High School] group families showed positive effects on parents’ child management practices (for example, setting standards, monitoring children, and applying consistent discipline) and on parent-child affective quality. In addition, a recent evaluation found delayed initiation of substance use at the 6-year follow up. Other findings showed improved youth resistance to peer pressure to use alcohol, reduced affiliation with antisocial peers, and reduced levels of problem behaviors. Conservative benefit cost calculations indicate returns of $9.60 per dollar invested in SFP . 78 TFAH • healthyamericans.org B. MAKING SCREENING, EARLY INTERVENTION, TREATMENT AND CONNECTION TO SERVICES ROUTINE PRACTICE There has generally been little emphasis screening for sight, vision, fitness and and normalizes the use of systems for on screening tweens and teens for scoliosis — as well as some school providing help and resources. health issues. Often, older children and districts requiring annual physical AAP and NIAAA both support routine teens struggle with problems at home, well care exams — there has not been screening, brief intervention and mental and behavioral health issues and comparable support to identify mental referral to treatment as routine pressures around substance use on their health and behavior concerns, including care.331, 332 This approach can help own or it is a treated as an individual substance use and experimentation, prevent the potential initiation of family problem. Routinely checking and the ability to connect children to substance use in the first place; provide in with tweens, teens and youth is an help and support. Making these types early intervention support in many important way to help reduce substance of screenings routine — through quick cases, avoiding escalation to more misuse and provide quick and effective questionnaires and brief counseling serious substance use problems; and/ help for those who may be at risk or with teens and youth — helps reduce or ensure teens with problems get struggling with dependence. the stigma associated with mental and appropriate care and treatment when behavioral health concerns; emphasizes While middle and high schools necessary.333, 334 a cultural value of care and support; often have routine requirements for Screening, Brief Intervention and Referral to Treatment Should Be Incorporated as a Routine Screening Practice in Middle and High Schools — Along With Other Regular Health Screenings: Evidence-based screening tools, including SBIRT, have been developed to help identify individuals — including tweens, teens and youth — at risk for experimenting with alcohol or drugs, initiating substance use or developing a substance use disorder — in sensitive ways, and connecting them to care and support resources. l M odels should be developed and be disseminated and supported via l D evelopment of the most effective tested for the best way to make SBIRT national, federal and state agencies ways to professionally staff SBIRT routine for teens — such as completely and expert backbone organizations. should also be explored and evaluated. school-based programs; hybrid school- For instance, in many cases, schools For instance, potential models could and-medical professional approaches; could directly bill Medicaid and/or address delivery in schools with in- and requiring screening for states and private insurance plans. In December house or mobile SBHCs; training school districts with annual well care 2014, CMS issued a clarification of of nurses, counselors and/or select requirements for school attendance a longstanding rule that permits teachers or administrators; or bringing — to see what is most effective and schools to be reimbursed for health in externally trained professionals. if/how efforts can be adaptable to services provided to students who Other approaches that involve different schools and school-systems are covered by Medicaid.335 This potential hybrid delivery via schools while ensuring they are still effective. updated interpretation could have and pediatricians/doctors can and a significant impact in the delivery should be considered, accounting for l F unding and payment issues should of health services through schools ways to ensure that all students have also be explored as part of developing — including the ability to conduct the opportunity for screening and effective models — and information SBIRT in schools. support. about approaches that work should TFAH • healthyamericans.org 79 SBIRT Should Be Adopted as Part of a Continuum of Regular Well-being Screenings — That Start in Early Childhood and Continue through Youth: Screenings for issues that can contribute to underlying risk factors that increase chances for future substance use and other problems can and should actually begin in early childhood. Identifying and providing early intervention for risks can help prevent, delay or mitigate the impact of different concerns, and put a child on course for improved health and well-being throughout their entire life. Health providers can also help screen parents’ well-being and a child’s living and environmental conditions to help identify and mitigate potential risks, such as by connecting families to help, medical services and a range of other support services. While early childhood screenings and care are supposed to be routine, there are still significant gaps in the number of children not receiving regular screenings or recommended follow up care and services, particularly among low-income students. SCHOOL-BASED SBIRT Northampton Public Schools, Massachusetts Northampton Public Schools implemented a SBIRT for ninth graders, which called for universal counseling and screening; parental education and notification, with an opt-out provision; providing positive reinforcement for students to encourage them to avoid alcohol/substance use; having outside referral resources for at- risk students; and asking students about potential future alcohol or drug use. According to the most recent data, 86 percent of students were “completely Source: Community Catalyst honest” with the school nurse about settings, federally qualified health centers days of drug use per month. An eco- their alcohol and drug use and 27 per- (FQHCs), public health offices and SBHCs. nomic analysis found that the treatment cent were less likely to use drugs or In addition, the initiative provided access population demonstrated savings of alcohol after screening.336 to a connected and integrated statewide $97,356.67 per month.338 telehealth network to provide clinical super- New Mexico  Another study published in the National vision, training and patient case consulta- To focus on individuals with severe sub- Center for Biotechnology Information tions. In total, SDCCHP has implemented stance use, New Mexico created a SBIRT found that participants reported significant 20 clinical partner sites and 21 SBHCs.337 initiative by contracting with an independent reductions in the frequency of drinking to non-profit organization (Sangre de Cristo A study of follow-up change found a 58 intoxication and drug use if they received Community Health Partnership (SDCCHP)) percent improvement of participants any intervention. The study stated “these to provide implementation and administra- who did not use alcohol or illegal drugs, findings support school-based SBIRT for tion expertise. The plan was to integrate a 60 percent reduction in binge drinking adolescents, but more research is needed the SBIRT into rural primary care medical and a 54 percent reduction in the mean on this promising approach.”339 80 TFAH • healthyamericans.org CHILDHOOD SCREENINGS Childhood developmental screenings can help identify and provide opportunities to provide early intervention support for a range of physical, behavioral and mental health con- cerns — reducing a child’s risk for later sub- stance use and other potential problems. l E arly and Periodic Screening, Diagnosis and Treatment Program is Medicaid’s child health program which insures that young children from low-income fami- lies receive the unique and appropriate health, mental health and developmental services they need.340  Children covered by Medicaid are guaranteed compre- identifying and reducing risky behaviors child’s needs. An assessment released hensive coverage including access to — and includes SBIRT screening for in June 2014 by the U.S. Department of mental health therapies (this may not be tweens and teens. 343 Education found that 36 states met the covered or may be limited in the CHIP).341 requirements of IDEA Part C — which Despite the guarantee of coverage, many l S creening parents for ACEs and their includes being able to ensure that early children still do not receive the required well-being can help also better identify if intervention will be administered for every care or services due to lack of access, a family could use additional support — eligible child and his or her family.346 follow-up support or other issues. For ranging from parent education to social instance, only 17 states and Washing- services to mental health services for par- According to AAP “adolescence has usually , ton, D.C. achieved at least an 80 percent ents — to help improve a child’s well-being. been thought of as a period characterized EPSDT participation rate among children For instance, AAP’s Safe Environment for by good health; however, millions of ado- ages 1- to 2-year-olds, and only 2 states Every Kid (SEEK) screening tool includes lescents face significant challenges that reach 80 percent for 3- to 5-year-olds. questions about potential use, parental can result in physical, emotional, and so- depression and substance use, smoking in cial morbidities. Among these challenges l F or children covered by their family’s the home and other risks. 344 Pediatricians are high-risk behaviors such as alcohol, private insurance plans, under the ACA, and other childcare professionals can also tobacco, and other drug use, and sexual these insurers are required to cover provide important advice for ways to help behaviors that can lead to adolescent preg- a set of preventive services — such promote healthy development. nancy and sexually transmitted diseases; as regular pediatrician visits, immuni- mental health concerns such as eating dis- zations, developmental assessments, l P art C of the Individuals with Disabilities orders and depression; learning disabilities hearing and vision screening and nutri- Education Act (IDEA) helps provide screen- and school dropout rates; serious family tion counseling — recommended by AAP ing services for children from birth to age problems, including neglect and use; and through the Bright Futures Initiative.342 2 for disabilities and helps connect fam- socioeconomic factors such as poverty As part of the Bright Futures initiative, ilies with early intervention services.345 and lack of health insurance. These health AAP has developed screening tools The goals of IDEA Part C are to enhance issues, most of which are preventable, and a set of advice and suggestions the development of infants and toddlers can lead to significant morbidity and even for teens, young adults and their par- with disabilities, reduce educational costs mortality. Unintentional injuries, homicide, ents around a wide range of topics to by minimizing the need for special educa- and suicide are leading causes of death in support well-being — including basic tion through early intervention, minimize adolescence.”347 Unintentional injuries can health concerns, physical changes, so- the likelihood of institutionalization and include overdose, alcohol poisoning and cial-emotional development and related maximize independent living and enhance other harm from substance use. concerns, mental health issues and the capacity of families to meet their TFAH • healthyamericans.org 81 C. COMPREHENSIVE AND SUSTAINED TREATMENT AND RECOVERY SUPPORT Around 22.7 million Americans ages 12 can be effectively treated.349, 350 But, even with these changes, private and or older — 8.6 percent — need treatment public insurance still varies dramatically, Any strategies to prevent and reduce for a substance use disorder. However, and coverage is often limited and does substance misuse must focus on only 2.5 million — 10.9 percent — of not match what is needed to provide providing sustained and ongoing those individuals received recommended effective and ongoing treatment. treatment and recovery support – treatment in a specialty facility.348 otherwise they are inherently incomplete And, the existing system for substance Around 1.3 million teens (ages 12 to and ineffective. The final component of use treatment has been underfunded 17) — 5.4 percent — were classified as developing a full-spectrum strategy is to for decades and has a severe shortage of needing treatment, but only around have an effective, funded, compassionate trained professionals to provide services. 122,000 of these individuals received treatment system in place. The rapid rise in prescription drug misuse treatment at a specialty facility, leaving The ACA and the Paul Wellstone and is increasing the need for treatment; around 1.2 million without the Pete Domenici Mental Health Parity while there has been a five-fold increase recommended treatment. and Addiction Equity Act of 2008 are in treatment admissions for prescription Substance use disorder is defined as a significantly changing the accessibility drug misuse in the past decade, millions chronic, relapsing brain disease that is and affordability of mental and substance are still going untreated.352 The characterized by compulsive drug seeking misuse treatment services for millions of “treatment gap” has been fueled by lack and use, despite harmful consequences. Americans by defining these services as of funding, limits on insurance coverage, Drug use changes the structure of the essential benefits and requiring that they ongoing social stigma around substance brain and how it works, which can be covered on parity with general medical use disorders and misperceptions about be long lasting and lead to harmful and surgical care under individual, group how effective treatment works. behaviors — and is a brain disease that and Medicaid expansion plans.351 KEY RECOMMENDATIONS FOR EXPANDING ACCESS TO QUALITY, EFFECTIVE CARE AND RECOVERY SUPPORT INCLUDE: Increasing Funding Support for Mental Health and Substance Misuse Treatment: States and insurance providers should significantly increase access to substance use treatment programs, which can help reduce overdose injuries and deaths, avoid relapses and support ongoing recovery. Only around 7.4 percent of all health spending in the United States is devoted to mental health treatment services and one percent is devoted to substance use treatment.353 The United States spends around $24 billion on substance use treatment annually (as of most available recent data, 2009).354 Around 69 percent of the spending was government supported — by Medicaid, Medicare, federal grants and state and local government programs. State and local government spending accounted for $9.4 billion. SAMHSA’s Substance Abuse Prevention and Treatment Block Grant supported around 5 percent of the total spending — providing priority treatment for individuals without insurance; services not covered by public or private insurance; community- based prevention activities; and program performance evaluations.355 More than 30 percent of overall spending was private insurance and out-of-pocket spending. 82 TFAH • healthyamericans.org Addressing Workforce Gaps and Modernizing Treatment to Match the Latest Research for Best Practices: There is an acute shortage of professionals trained to provide substance use services. Nationally, there are only 32 behavioral health specialists for every 1,000 with a substance use disorder, with the numbers ranging from a low of 11 per 1,000 in Nevada to a high of 70 per 1,000 in Vermont, according to a 2014 analysis by Advocates for Human Potential, Inc.356 A reported 55 percent of rural U.S. counties do not have a single practicing psychiatrist, psychologist or social worker.357 Behavioral therapy specialists often having lower-pay scales compared to fields with comparable training is considered a key factor. In addition, according to SAMHSA’s Action Plan for Behavioral Workforce Development, treatment services are often silo-ed from other aspects of the healthcare system, and there is relatively little training for other healthcare professionals in how to identify and learn the most effective ways to provide treatments.358 There should be a concerted effort empowerment specialists (CARES), to expand the workforce for mental parent peer specialists and youth mental health services and substance misuse health peer specialists.359, 360, 361 treatment — through recruitment and As part of this endeavor, a concerted incentive programs — and to improve effort should be made to support training and standards for those directly programs designed to recruit and providing treatment. A number of states train specialists and counselors who are also supporting models to expand can focus on the treatment needs of the use of use trained alternative youth. In addition, more training care providers, such as certified peer should be provided to pediatricians and specialists, to help fill some of the primary care providers — to be able to treatment provider gap. Many of these deliver SBIRT, identify issues and know states support Medicaid reimbursement the most up-to-date prevention and for these specialists, which can treatment options available. include certified addition recovery RECOVERY HIGH SCHOOLS362 Recovery high schools are intentionally tainment. While no single recovery high designed for students recovering from school is the same, they often feature a substance use disorder as part of intensive therapeutic and peer recovery the continuum of recovery care. These support and are typically small (with stu- schools offer programs that uniquely dent to counselor ratios as small as 10 meet the education and therapeutic to 1). In addition, they intentionally com- challenges faced by those in recovery bine the academic curriculum with struc- and who were struggling to succeed in tured recovery-focused programming. A traditional school settings. They provide study found that complete avoidance of an alternative to the justice system and alcohol or other drugs increased from delinquency and a way to reduce school 20 percent during the 90 days before violence while improving education at- entering the school to 56 percent after. TFAH • healthyamericans.org 83 Components of Comprehensive Drug NIDA’S PRINCIPLES OF ADOLESCENT SUBSTANCE USE DISORDER TREATMENT: Abuse Treatment A RESEARCH-BASED GUIDE363 l A dolescent substance use needs to be l S taying in treatment for an adequate identified and addressed as soon as period of time and continuity of care possible; afterward are important; and l A dolescents can benefit from a drug l T esting adolescents for sexually trans- use intervention even if they are not mitted diseases like HIV, as well as hep- addicted to a drug; atitis B and C, is an important part of drug treatment. l R outine annual medical visits are an opportunity to ask adolescents about Some Evidence-based Treatment for drug use; Adolescents l F amily pressure may play an important l B ehavioral Approaches. Examples role in getting adolescents to enter, stay (many used in combination) include: Source: National Institute on Drug Abuse in and complete treatment; Adolescent Community Reinforcement Approach — addressing coping, prob- l S ubstance use disorder treatment lem-solving and communication skills should be tailored to the unique needs and encouraging active participation in of the adolescent; recreational activities; Cognitive-Behav- l T reatment should address the needs ioral Therapy — anticipating problems, of the whole person, rather than just monitoring feelings and thoughts and focusing on his or her drug use; developing effective coping strategies; Contingency Management — positive l B ehavioral therapies are effective in incentives combined with psychosocial addressing adolescent drug use; treatment; Motivational Enhancement l F amilies and the community are an Therapy — motivational interviewing; important aspect of treatment; Twelve-Step Facilitation Therapy — ado- lescent-specific 12-step program facili- l E ffectively treating substance use tation; and Group Therapy — providing disorders in adolescents requires also positive social reinforcement through identifying and treating any other mental peer discussion. health conditions they may have; l F amily-based Approaches. Often focus l S ensitive issues such as violence and on whole-being, family communication child abuse or risk of suicide should be and conflict resolution, co-occurring identified and addressed; behavior and mental health disorders, l I t is important to monitor drug use problems with school or work atten- during treatment; dance and peer networks. FEDERAL APPROPRIATIONS AND REQUEST364, 365 (Dollars in Millions) FY 2016 2011 2012 2013 2014 2015 President’s Budget NIDA (scientific and biomedical research support) $1,050.50 $1,051.40 $1,058.60 $1,051.40 $1,015.70 $1,047.70 SAMHSA Block Grant $1,800.20 $,1,800.20 $1,811.30 $1,815.40 $1,819.80 $1,819.80 84 TFAH • healthyamericans.org Appendices APPENDICES Appendix A Table 8.3 Comparison of NSDUH, MTF, and YRBS Past Month Prevalence Estimates among Youths: Percentages, 2002-2013 Substance/ Survey 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Marijuana NSDUH 8.2a 7.9a 7.6 6.8 6.7 6.7 6.7 7.4 7.4 7.9a 7.2 7.1 MTF 13.1 12.3 11.2a 10.9a 10.4a 10.0a 9.8a 11.2a 12.4 12.4 11.8 12.5 YRBS -- 22.4 -- 20.2a -- 19.7a -- 20.8a -- 23.1 -- 23.4 Cocaine NSDUH 0.6a 0.6a 0.5a 0.6a 0.4a 0.4a 0.4a 0.3 0.2 0.3 0.1 0.2 MTF 1.4a 1.1a 1.3a 1.3a 1.3a 1.1a 1.0a 0.9 0.8 0.8 0.7 0.7 YRBS -- 4.1 -- 3.4 -- 3.3 -- 2.8 -- 3.0 -- -- Ecstasy NSDUH 0.5a 0.4a 0.3 0.3 0.3a 0.3 0.4a 0.5a 0.5a 0.4a 0.3 0.2 MTF 1.6a 0.9 0.8 0.8 1.0 0.9 1.0 1.0 1.5a 1.1 0.8 0.9 YRBS -- -- -- -- -- -- -- -- -- -- -- -- LSD NSDUH 0.2 0.2 0.2 0.1 0.1 0.1 0.2 0.1 0.2 0.1 0.1a 0.2 MTF 0.7 0.6 0.6 0.6 0.6 0.6 0.6 0.5 0.7 0.6 0.4 0.6 YRBS -- -- -- -- -- -- -- -- -- -- -- -- Inhalants NSDUH 1.2a 1.3a 1.2a 1.2a 1.3a 1.2a 1.1a 1.0a 1.1a 0.9a 0.8a 0.5 MTF 3.1a 3.2a 3.5a 3.2a 3.2a 3.2a 3.1a 3.0a 2.8a 2.5a 2.1 1.8 YRBS -- -- -- -- -- -- -- -- -- -- -- -- Alcohol NSDUH 17.6a 17.7a 17.6a 16.5a 16.7a 16.0a 14.7a 14.8a 13.6a 13.3a 12.9a 11.6 MTF 27.5a 27.6a 26.9a 25.2a 25.5a 24.7a 22.4a 22.7a 21.4a 20.0a 19.3a 18.0 YRBS -- 44.9a -- 43.3a -- 44.7a -- 41.8a -- 38.7a -- 34.9 Cigarettes NSDUH 13.0a 12.2a 11.9a 10.8a 10.4a 9.9a 9.2a 9.0a 8.4a 7.8a 6.6a 5.6 MTF 14.2a 13.5a 12.6a 12.1a 11.6a 10.6a 9.6a 9.8a 10.4a 9.0a 7.9a 6.8 YRBS -- 21.9a -- 23.0a -- 20.0a -- 19.5a -- 18.1 -- 15.7 MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health; YRBS = Youth Risk Behavior Survey. -- Not available. NOTE: NSDUH data are for youths aged 12 to 17. Some 2006 to 2010 NSDUH estimates may differ from previously published estimates due to updates (see Section B.3 in Appendix B of this report). NOTE: MTF data are simple averages of estimates for 8th and 10th graders. MTF data for 8th and 10th graders are reported in Johnston et al. (2014), as are the MTF design effects used for variance estimation. NOTE: Statistical tests for the YRBS were conducted using the "Youth Online" tool at http://www.cdc.gov/HealthyYouth/yrbs/. Results of testing for statistical significance in this table may differ from published YRBS reports of change. a Difference between this estimate and 2013 estimate is statistically significant at the .05 level. Sources: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002-2013. National Institute on Drug Abuse, Monitoring the Future Study, University of Michigan, 2002-2013. Centers for Disease Control and Prevention, Youth Risk Behavior Survey, 2003, 2005, 2007, 2009, 2011, and 2013. 109 NOVEMBER 2015 Appendix B: Drug Overdose Death Rates Analysis Methodology State death rates from drug overdose confidence intervals were overlapping, not include all causes, by accidents and vio- overlapping, and if the difference between lence (unintentional and intentional). The the rates exceeded 1.96 standard errors. data come from CDC’s Web-based Injury Data is available at: http://www.cdc.gov/ Statistics Query and Reporting System injury/wisqars/fatal_injury_reports.html, (WISQARS), Fatal Injury Reports. The drug WISQARS, Fatal Injury Reports 1999- overdose death rates by state are between 2013, for National, Regional, and States the ages of 12 and 25 and are not age (RESTRICTED). adjusted. The rates are based on 3-year av- eraged data for the years 1999-2001, 2005- For Drug Poisoning Deaths and Rates, 2007 and 2011-2013 to stabilize the death Years 1999-2001: Choose All Intents, rates for comparison purposes, and refer to Drug Poisoning, Choose State, Years of deaths per 100,000 teens and youths. report 1999-2001, Choose Custom Age Range 12 to 25, Select Output Groups State death rates for drug overdose for State and Sex, Submit Request teens and young adults were individually compared between 1999-2001 and 2005- For Drug Poisoning Deaths and Rates, 2007 and between 2005-2007 and 2011- Years 2005-2007: Choose All Intents, 2013 to determine if the state rates Drug Poisoning, Choose State, Years of had a significant increase or decrease report 2005-2007, Choose Custom Age between the grouped years. This was Range 12 to 25, Select Output Groups done by individually calculating the differ- State and Sex, Submit Request ence between the state rate (1999-2001, For Drug Poisoning Deaths and Rates, 2005-2007 and 2011-2013), standard Years 2011-2013: Choose All Intents, error (S.E.), confidence intervals (C.I.) and Drug Poisoning, Choose State, Years of standard error of the differences between report 2011-2013, Choose Custom Age the two state rates, expressed as propor- Range 12 to 25, Select Output Groups tions, using the following formulas: State and Sex, Submit Request S.E. = R / square root of N For Teen Drug Poisoning Deaths and C.I. = R +/- (1.96 *S.E.) Rates, Years 2011-2013: Choose All Intents, Drug Poisoning, Choose State, p q n n + p q √ 1 1 1 2 2 2 Years of report 2011-2013, Choose Cus- tom Age Range 12 to 18, Select Output Groups State and Sex, Submit Request Where R is equal to age-adjusted rates, N is number of deaths, p is equal to num- For Young Adult Drug Poisoning Deaths ber of deaths per births and q is equal and Rates, Years 2011-2013: Choose to 1-p and n is the population size. The All Intents, Drug Poisoning, Choose State, differences between the two rates were Years of report 2011-2013, Choose Cus- regarding as statistically significant at the tom Age Range 19 to 25, Select Output 95% confidence level by determining if Groups State and Sex, Submit Request 86 TFAH • healthyamericans.org Endnotes 1 iech RA, Johnston LD, O’Malley PM, et al. M 9 iqueira L, Smith VC. Binge Drinking. Pedi- S 18 ohnston LD, O’Malley PM, Bachman JG, J Monitoring the Future. 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