Pain in ISSUE REPORT the Nation: THE DRUG, ALCOHOL AND SUICIDE CRISES AND THE NEED FOR A NATIONAL RESILIENCE STRATEGY NOVEMBER 2017 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization Data analysis and projections were provided by Berkeley dedicated to saving lives by protecting the health of every community Research Group (BRG), a global strategic advisory and expert and working to make disease prevention a national priority. consulting firm that provides independent advice, data analytics, authoritative studies, expert testimony, investigations, and Founded in late 2016 with a $100 million endowment from regulatory and dispute consulting to Fortune 500 corporations, Providence St. Joseph Health, Well Being Trust is a national financial institutions, government agencies, major law firms, and foundation dedicated to advancing mental, social and spiritual regulatory bodies around the world. www.thinkbrg.com. health. Created to include participation from organizations across sectors and perspectives, Well Being Trust is committed to This report is supported by grants from the Robert Wood Johnson innovating and addressing the most critical mental health challenges Foundation and WBT. TFAH thanks the foundations for their facing America, and transforming individual and community generous support. The opinions in this report are those of the wellness. www.wellbeingtrust.org. Twitter: @WellBeingTrust authors and do not necessarily reflect the views of the supporters. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN Theodore Spencer Octavio N. Martinez, Jr., MD, MPH, Umair Shah, MD, MPH President of the Board, TFAH Secretary of the Board, TFAH MBA, FAPA Executive Director and Local President and Founder Senior Advocate, Climate Center Executive Director Health Authority Ntianu Center for Healing Natural Resources Defense Council Hogg Foundation for Mental Health Harris County Public Health  and Nature at the University of Texas at Austin David Fleming, MD Vince Ventimiglia, JD Cynthia M. Harris, PhD, DABT Vice President C. Kent McGuire, PhD Chairman  Vice President of the Board, TFAH PATH President and CEO Vice Chairman of Leavitt Partners Director and Professor Southern Education Foundation Board of Directors Stephanie Mayfield Gibson, MD Institute of Public Health, Florida Leavitt Partners Board of Managers Senior Physician Adviser and Karen Remley, MD, MBA, MPH, A&M University Population Health Consultant FAAP Robert T. Harris, MD Private Contractor CEO/Executive Vice President  Treasurer of the Board, TFAH American Academy of Pediatrics David Lakey, MD Medical Director Chief Medical Officer and Associate Eduardo Sanchez, MD, MPH North Carolina Medicaid Support Vice Chancellor for Population Health Chief Medical Officer for Prevention Services The University of Texas System American Heart Association CSC, Inc. REPORT AUTHORS CONTRIBUTORS PEER REVIEWERS Laura M. Segal, MA Benjamin F. Miller, Psy.D. TFAH thanks the following individuals and organizations for their Vice President of Public Affairs Chief Policy Officer time, expertise and insights in the reviewing all or portions of the Trust for America’s Health Well Being Trust report. The opinions in the report do not necessarily represent the Anne De Biasi, MHA Tyler Norris, MDiv views of these individuals or their organizations. Director of Policy Development Chief Executive Jay C. Butler, MD Corey Davis, JD, MSPH Trust for America’s Health Well Being Trust Chief Medical Officer Deputy Director, Southeastern Region Jennifer L. Mueller, JD Genny Olson, MPH Alaska Department of Health & Network for Public Health Law Consultant Policy Development Associate Social Services Gary Mendell Trust for America’s Health Kendra May, MPH The Honorable Mary Bono Founder & CEO Consultant Principal Shatterproof Faegre Baker Daniels Consulting Molly Warren, SM Vivek H. Murthy, MD, MBA Former Member of Congress Health Policy Research Manager Former Surgeon General of the Trust for America’s Health Sean Clarkin United States EVP, Senior Program Officer Corinne Peek-Asa, PhD Partnership for Drug-Free Kids Associate Dean for Research and Nathaniel Z. Counts, JD Director of the Injury Prevention Cover photos: Phil Lowe/Shutterstock.com and Shutterstock Senior Policy Director Research Center Mental Health America College of Public Health, University of Iowa 2 TFAH • WBT • PaininTheNation.org Pain in the TABLE OF CONTENTS Table of Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . 4 3. Expand and Improve the Mental Health and Behavioral Health Workforce. Nation: SECTION 1. PROJECTIONS: Possible Futures of Drug, Alcohol and Suicide Deaths . . . . . . . . 15 Financial incentives, expanding types of providers, training and evidence-based guidance, knowledge sharing . . . . . . . 95 Public Health Report 1. rug-Related, Alcohol-Related or Suicide D Deaths: 1999, 2016, 2025 Projected 4. rioritize Needs in Underserved P Scenarios . . . . . . . . . . . . . . . . . . . . . . . 15 Areas – Including Rural and Low- Income Communities. Bolster federal Projected Annual Growth Rate Scenarios for National Deaths . . . . . . . . . . . . . . . . . . . 16 investment, use leverage as public payer, maximize coverage enrollment, expand series State-by-State Drug, Alcohol and Suicide workforce and telehealth, incentivize Deaths . . . . . . . . . . . . . . . . . . . . . . . . . 20 behavioral health careers, community programs to fill gaps . . . . . . . . . . . . . 96 SECTION 2. Healthcare Costs Associated With 5. onnect Healthcare and Behavioral Health C Drug, Alcohol and Suicide Diagnoses . . . . .26 Services with Social Service Supports. 1. rug-Alcohol-Suicide Average vs. Overall D Two-generation support; prenatal and Healthcare Spending . . . . . . . . . . . . . . . 26 preconception care; crisis services; trauma- informed services and systems . . . . . . . 98 Drug-Alcohol-Suicide Diagnosis Prevalence . . 26 6. educe Stigma. Non-discriminatory R State-by-State Costs . . . . . . . . . . . . . . . . 27 evaluations procedures; stigma-reduction messaging and communications SECTION 3. Review Of Key Policies For programs . . . . . . . . . . . . . . . . . . . . 103 Improving Well-Being . . . . . . . . . . . . . . . . . 28 7. Early Identification of Issues and A: educing Drug and Alcohol Misuse and R Connections to Services and Care. Early Suicide . . . . . . . . . . . . . . . . . . . . . . . . . 29 childhood screenings; family risk factor 1. reventing and Reducing Opioid and Other P screening; and school-based and tween/ Drug Misuse. Community-based strategies; teen screenings . . . . . . . . . . . . . . . . 104 surveillance; responsible prescribing — provider education and Prescription C: rioritizing Prevention – Promoting P Drug Monitoring Programs; safe storage, Healthier Communities and Raising disposal and Take Back programs; tamper- a Mentally and Physically Healthier resistant formulations; stopping illicit Generation of Kids . . . . . . . . . . . . . . . . 112 supply; reducing harm and preventing 1. Supporting Local Multi-Sector overdoses — naloxone, Good Samaritan Partnerships. Expert and technical laws, diversion, sterile syringes . . . . . . 30 assistance . . . . . . . . . . . . . . . . . . . 113 2. educing Excessive Alcohol Consumption. R 2. Impact of the Opioid Epidemic on Pricing policies; access and availability; Child Welfare – and the Need for Multi- limiting underage and intoxicated customer Generational Care . . . . . . . . . . . . . . 119 sales; reducing underage drinking; reducing 3. arly Childhood Well-being Policies. Home E drinking and driving . . . . . . . . . . . . . . . . 60 visiting programs; evidence-based parent 3. ffective Approaches for Preventing E education/support initiatives; child care Suicides. Statewide prevention plans; and childhood education; social-emotional risk and treatment training for medical learning programs; continuum of services professionals; mental health parity and early care to elementary school . . . . . . 123 access; limiting “hotspots” and lethal 4. chool-Aged Children, Tweens and Teens S means; expanding National Violent Death Policies. Prioritize a healthy, positive school Reporting System; responsible media climate; evidence-based social-emotional reporting . . . . . . . . . . . . . . . . . . . . . . 69 learning, life and coping skills programs; B: mproving Behavioral Healthcare – to I sustained evidence-based substance Support “Whole Health” . . . . . . . . . . . . 80 misuse prevention; anti-bullying programs; expand personnel, professional development 1. odernize Behavioral Health Services. M opportunities; school health services; Improve health insurance coverage school-based suicide prevention plans . . 129 and affordability; delivery and payment models; effective treatment and recovery 5. Family Opportunities – Addressing Core NOVEMBER 2017 practices; models and practices for Needs and Promoting Stability. Income behavioral healthcare integration . . . . . 86 assistance; housing assistance and transportation; nutrition assistance; 2. odernize Substance Use Disorder M health insurance, creating economic Treatment. Expand the workforce; provider opportunity . . . . . . . . . . . . . . . . . . . 141 guidelines and insurance policies and provider practices . . . . . . . . . . . . . . . . 90 SECTION 4. Recommendations for Building a National Resilience Strategy . . . . . . . . . . 148 I NT RO D UC TION Pain in the INTRODUCTIION Introduction Nation: The United States is facing a new set of epidemics — more than Public Health 1 million Americans have died in the past decade from drug Report overdoses, alcohol and suicides (2006 to 2015).1 Life expectancy in the country decreased last year for the first time in two series decades — and these three public health crises have been major contributing factors to this shift. In 2015 alone, 127,500 Americans died policies, practices and programs to take from drug- or alcohol-induced causes or a more comprehensive approach to suicide.2 That equates to 350 deaths per counter these crises. day, 14 per hour and one person dying If more action is not taken, these trends every four minutes. will become significantly worse. These trends are a wake-up call that In fact, a new analysis conducted by the there is a serious well-being crisis in this Berkeley Research Group (BRG) for this country. In stark terms, they are signals report found that if the current rise in of serious underlying concerns facing too drug, alcohol and suicide death trends many Americans — about pain, despair, continue — over the next decade, these disconnection and lack of opportunity — three epidemics would be expected to and the urgent need to address them. result in more than 1.6 million deaths In this report, the Trust for America’s (by 2025). This would represent a 60 Health (TFAH) and Well Being Trust percent increase over the current level. (WBT) call for the need to develop a There could be a rise in deaths from national strategy to improve resilience 127,500 (39.7 per 100,000 in 2015) to in the United States. The report 192,000 (55.9 per 100,000 in 2025) examines current trends and evidence- nationally. based and expert-recommended U.S. Drug, Alcohol, or Suicide-Related Deaths NOVEMBER 2017 For a growing majority of states, the would result in 2 million deaths over the outlook posed by these threats is even next 10 years. (Note: final data for 2016 more concerning. rates will be revised and confirmed in late 2017 or early 2018). l A s of 2015, five states had death rates of 60 per 100,000 or higher, with New The rapid rise of these epidemics over Mexico having the highest rate of 77.4 the past 15 years constitute three of per 100,000. Alaska, New Hampshire, the most serious public health crises West Virginia and Wyoming were of this century. The life-and-death between 60 and 70 per 100,000. consequences of drug and alcohol misuse and suicide have reached urgent levels l B y 2025, if current trajectories in many communities. In addition, wide- continue, 26 states are projected to scale substance misuse and insufficient reach 60 deaths or more per 100,000, attention to mental health disorders have with two states possibly reaching 100 broad impact. The added recent dramatic deaths per 100,000 (New Mexico and increase of illicit opioids — heroin and its West Virginia). blending with the more potent fentanyl The latest reports from the Centers for and even more potent carfentanil — have Disease Control and Prevention (CDC) made the immediate situation even more using provisional data for trends in dire and complicated. 2016 have found that drug overdoses While the crises have received much have grown at an even faster pace than attention — this report finds the expected during the first nine months of actions that have been taken to date are 2016,3 which, based on this analysis, would severely inadequate. put the country on a worst-case track and TFAH • WBT • PaininTheNation.org 5 THE CURRENT CRISIS l D rug-related deaths have tripled since all alcohol-attributable deaths — l hile overall death rates are higher W 2000 — and were responsible for more including alcohol-related motor vehicle, among Blacks and other people of than 52,400 deaths in 2015.4, 5 More violence and other fatalities — total color, the Surgeon General noted than 33,000 of these were from opioids, 88,000 a year. 10, 11 that substance misuse and suicide mainly prescription opioids (pain • 5.7 million Americans (5.9 percent) 1 are leading drivers of lowered U.S. reducers), heroin and fentanyl. have an alcohol use disorder. life expectancy for the first time • .7 million Americans (2.9 percent) 7 in decades, with an unprecedented • n addition, millions of Americans I have a drug use disorder. increase in mortality among middle-aged consume alcohol “excessively” Whites in the past 15 years.16 • here was a 72.2 percent increase in T (binge or heavy drinking) putting fentanyl-related deaths (fentanyl is a them at risk for injuries or other • ife expectancy rates declined 20 L synthetic drug that is 50 to 100 times harms. Nine out of 10 excessive percent among middle-class Whites more potent than heroin, and is often drinkers do not have an alcohol use with less than a college education “cut” with heroin); and 20 percent rise disorder, but excessive drinking is a during this time period, with deaths in heroin-related deaths between 2014 risk factor for alcohol use disorders from drug overdoses, alcohol and 2015. In 2016, provisional data — as well as for suicide and other poisoning, liver disease and suicide show fentanyl became the leading forms of violence — and one in all tripling among this cohort. These cause of drug overdose — at 21,000 five individuals who die from opioid trends have not been seen within other overdose deaths, which would be overdoses also have alcohol in their racial and ethnic groups.17, 18 double the rate in 2015.6 system at time of death. • verall, however, death rates among O • In 2015, the amount of opioids Blacks remain significantly higher than l Suicides increased by 28 percent from prescribed could medicate every for Whites. For instance, among middle- 2000 to 2015, accounting for more American around the clock for aged individuals (ages 25 to 64 years than 44,000 deaths a year. Although three weeks. Opioids are currently 7 old), death rates among Blacks are 67 suicide rates are higher among men, prescribed at rates three times higher percent higher than Whites in urban the highest increases have been than they were compared to 1999 areas, 30 percent higher in suburban among middle-aged women (63 percent (prescribing rates peaked at more than areas, 46 percent higher in small/ increase) and girls ages 10 to 14 (200 four times that level in 2010). 8 medium metro areas and 39 percent percent increase).12, 13 higher in rural areas. These differences l A lcohol-induced deaths have reached • lcohol use is involved in around 23 A have implications for examining a range a 35-year high — growing by 37 percent of suicides and around 40 of root causes that impact premature percent from 2000 to 2014 — with percent of suicide attempts, and 16 death and behavioral health, such as 33,200 Americans dying from liver percent of suicides are from poisoning poverty and adverse circumstances, diseases, alcohol poisoning and other (including drug overdoses).14, 15 which can impact life expectancy.19, 20 diseases as of 2015. 9 The rate for ECONOMIC COSTS A new BRG analysis conducted for this report also found that Around 3.8 percent of the population had at least one of the healthcare spending for individuals who have a diagnosis diagnoses in 2014. Combined, these patients had annual related to drugs, alcohol or individuals at risk for suicide healthcare costs of $249 billion — roughly 9.5 percent of total are 2.5 times higher than the average American adult, at health expenditures in the United States. $20,113 per patient per year. 6 TFAH • WBT • PaininTheNation.org A National Resilience Strategy This report calls for the creation of a National Resilience Strategy — a comprehensive approach to improve the lives of Americans — and address the factors that contribute to substance misuse, suicide and other related harms. The country has long struggled with the country views and manages mental effective approaches to promoting positive health, pain and despair — and without mental and behavioral health — and to better strategies that focus on preventing effectively manage all forms of pain.21 problems and providing effective support, services and treatment, the trends are The confluence of “despair deaths” are likely to be perpetuated and get worse. directly related to pervasive issues with how l M ental Health and Substance Use health workers and 77 percent report around 100 million experience Disorders: In 2016, 44.7 million American unmet behavioral health needs. 27 chronic pain; millions experience adults experienced a mental illness, acute pain from injury, disease or • ore than 40 percent of adults with M 20.1 million experienced a substance medical procedures; and millions a substance use disorder in the use disorder and 8.2 million experienced experience mental, emotional and other past year also experienced mental both — and these numbers are likely to be psychological forms of pain.31 illness compared with 16 percent underestimated due to issues of stigma.22 among the rest of the population (2.5 • n the 1990’s, there were I • s many as one in five children and A times likelihood); and 18.5 percent developments in the availability of teens have had a serious debilitating of adults with a mental illness also prescription opioids — and they mental disorder, with half of the mental had a substance use disorder in the were rapidly adopted and used as health conditions starting by the age past year compared with 5.4 percent a major pain management strategy. of 14 — and more than 25 percent of among the rest of the population Prescription opioids have been teens are impacted by at least mild (three times likelihood).28 important for helping many patients symptoms of depression. 23, 24, 25 manage pain when used effectively • edicaid accounts for 25 percent of M and appropriately under provider • nly around one in 10 individuals O all mental health and 21 percent of supervision. However, their widespread (10.6 percent) who needed substance use disorder spending.29 availability and use has contributed to substance use treatment received the Nearly half of Medicaid spending misuse, increased addiction and the recommended treatment at a specialty is on care for the 20 percent of “masking” of the need to develop other facility in 2016. Comparatively, four beneficiaries who have a behavioral effective and integrated approaches in nine adults with any mental illness health diagnosis.30 to address pain — and the need to received mental health services.26 l C hronic Pain: Millions of Americans address the factors that contribute to • ifty-five percent of U.S. counties do F suffer from pain — the National different types of pain and suffering. not have any practicing behavioral Academy of Medicine (NAM) estimates TFAH • WBT • PaininTheNation.org 7 Children whose parents misuse l A dverse Childhood Experiences: Two- below the poverty line, and 45 percent thirds of Americans report having are in low-income families.42 Children alcohol and other drugs are three experienced an adverse childhood who grow up in persistent poverty or times more likely to be abused experience (ACE) while growing up — low-income families are more likely to and more than four times more across all socio-economic levels. Nearly remain poor as adults, and have lower 40 percent experienced two or more educational attainment and employment likely to be neglected ACEs, and 22 percent experience three — and have more adverse mental and or more ACEs.32, 33, 34, 35, 36 physical health status.43 • Children who grow up in an environment l M altreatment of Children: More than where a member of the family has 680,000 children experience severe a mental illness or alcohol or drug forms of maltreatment annually (79 use disorder can have lifelong health percent from neglect and 18 percent consequences — with the impact being from physical abuse), one-third of strongest for infants and toddlers — these are children under the age of and is considered an ACE. 37 four.44 Around 400,000 are in out-of- home foster care at any time.45 Of • hildren whose parents misuse C these children, more than 60 percent alcohol and other drugs are three of infants and 40 percent of older times more likely to be abused and children are from families with active more than four times more likely to alcohol or drug misuse.46 be neglected than children from non- substance misusing families.38 This • he opioid epidemic is intensifying the T in turn increases the risk that they strain on child welfare systems. The will develop anxiety disorders, severe number of children in foster care across personality disorders and misuse the country increased by 8 percent alcohol and drugs themselves.39, 40 between 2012 and 2015.47, 48 Some states with particularly high increases • arents who misuse alcohol or P around this timeframe include Florida other drugs are more likely to be (24 percent increase), Georgia (74.5 experiencing multiple sources of percent increase), Indiana (37 percent stress themselves, including low socio- increase), Kentucky (33 percent economic status, lack of social support increase) and Minnesota (33 percent and resources, financial or emotional increase).49, 50 A number of states have distress, mental health problems such issued emergency pleas for additional as depression, or have experienced foster parents, and there are increased abuse when they were growing up.41 reports of grandparents and other l C onsequences of Persistent and family members caring for children Prolonged Stress: One in five babies whose parents are struggling with and toddlers (around 23 percent) live opioid use disorders. 8 TFAH • WBT • PaininTheNation.org The opioid crisis has gained urgent national attention. It has led to Presidential commissions, numerous states declaring states of emergency and communities around the country struggling with managing the life-and- death issues of first responders, hospital emergency departments confronting high rates of overdoses and major gaps in the ability to provide treatment for individuals with opioid use disorders. States and communities are also facing the consequences of the crisis on children and families — with significant increases in the number of babies born with neonatal opioid withdrawal syndrome, children being placed in foster care and other family members being called upon to care for children of parents struggling with addiction. Many of the strategies to address the opioid epidemic have focused on trying to limit the supply of prescription and illicit forms of opioids along with measures to poor working conditions and eroded It presents a scan of the evidence respond to overdoses and attempts to try social capital in depressed communities, and summary of the fragmented to address major gaps in the country’s accompanied by hopelessness and and often inadequate national support substance use disorder treatment despair.” 51, 52, 53, 54, 55, 56 In addition, constellation of existing policies capabilities, rapidly attempting to expand causation goes in both directions — and programs to address these pressing and modernize the types of treatment substance misuse and untreated mental issues. One thing is clear: there is an available to those in need. health issues can adversely impact immediate need to develop an actionable health, academic and career attainment, national response to alcohol and drug However, these efforts are inherently relationships with family and friends and misuses and death by suicide. Not only insufficient — and will not succeed the ability to be a connected part of a are these urgent health crises across this unless there are corresponding efforts community. country, they are indicators of the need to address the broader issues that to go deeper and to look at underlying contribute to adverse well-being and A National Resilience Strategy is needed causes and opportunities to create an underlying pain. The rise of multiple to create a more comprehensive, focused integrated approach to well-being for despair deaths and related trends show and effective approach that prioritizes all people, and especially for those who there is a more significant dynamic that putting prevention first, promoting are at a high risk for experiencing these needs to be addressed. positive mental health, and that develops challenges. The findings of this report systems of support to identify issues While the availability of drugs and alcohol serve as a call to action from leaders early and ensures Americans receive the does contribute to higher use, there are across all sectors and regions/states to support and care they need to thrive. many other factors that contribute to come together to develop a thoughtful substance misuse and risk for suicide — This report offers a critical look at both and inclusive framework for systemic including family and social relationships, past and projected impacts and outcomes change that measurably improves social-emotional development, ACEs of opioid and alcohol misuse, including outcomes tied to well-being and health. and “lack of economic opportunity, overdoses, and death by suicides. TFAH • WBT • PaininTheNation.org 9 Tweens and teens are coming of age with new and different substance misuse risks of prescription opioids, heroin and heroin mixed with other drugs. Family and community influences also increase the risk for a child’s future misuse of alcohol and for both suicidal thoughts and suicide. There must be a paradigm shift in the Experts have identified a broad range of better well-being. Key factors response to these challenges — with top of policies and programs that can include: nurturing, stable caretakers priorities that include: achieve results for reducing substance and relationships; good nutrition misuse and suicide, and promoting and physical activity; positive l ncreasing Access to Policy and I resilience by reducing risk factors and learning experiences; a safe home, Programmatic Advice and Support supporting positive protective factors neighborhood and environment; and – Establishing Expert Networks. (such as stable, secure families, homes high-quality, preventive healthcare. The opioid crisis is a stark and clear and communities). These programs, Early intervention to prevent issues demonstration of the intergenerational however, are often ad hoc — and are not can help avoid a “cascade of risk,” impact of behavioral health issues — provided at scale or coordinated to work including the multi-generational and the urgent need to address the together to achieve maximum results impact of adverse experiences.57 effect on children. Solutions must for families. There needs to be new Improved systems are needed to focus on providing support for the models and infrastructure that support coordinate the services and supports individual with a substance use disorder better alignment, integration and case available to children and families at — but also for the children, parents management of services and supports risk — helping to identify problems and families impacted. The epidemic for families — across healthcare, early and ensure families receive is creating a new compounded and behavioral health services and other necessary care. Some impactful complicated generation of ACEs — social services. New mechanisms must early childhood programs include: which research shows have a long-term also be supported to help lead, integrate high-quality home visiting programs; effect on children’s lives. Tweens and and manage community-based efforts evidence-based parent education teens are coming of age with new and to address the opioid, alcohol and and support; high-quality child care different substance misuse risks of suicide crises — and improve well-being and early education; and services prescription opioids, heroin and heroin — to help ensure that the top needs that support the transition from early mixed with other drugs. Family and and problems are being addressed in childhood programs to elementary community influences also increase ways that effectively use the expertise school. It is also important to provide the risk for a child’s future misuse of and resources available across local support for families to support stability alcohol and for both suicidal thoughts institutions and businesses to support and resilience, including financial, and suicide. Systems and supports these efforts. In addition, it is important food, housing and transportation must be aligned and maximized to to bring the leaders and resources of assistance — and quality healthcare. support family needs — to provide a community together to support an support for prevention and treatment • ebooting School-Community Efforts R improved sense of community, social services for mental health and to Support Tweens and Teens. There connectedness and commitment to substance use disorders, supporting in- is significant evidence for approaches work together to promote economic home parenting skills and ways to keep to support better well-being during opportunity initiatives. children with parents or other family the tween and teen years — at a members when possible. • ocusing on Early Childhood. F time when many individuals face Investing in early childhood many transitions, including changes l utting Prevention First. A multi- P policies and programs will have in schools and relationships when generational system must include the biggest impact for reducing mental health concerns become a coordinated, effective system for risks and supporting a lifetime evident and risk for substance supporting children and families. 10 TFAH • WBT • PaininTheNation.org misuse may emerge. There should be a reboot and recommitment to supporting evidence-based prevention efforts among school- aged children and youth, moving past years of ineffective or inexistent school-based efforts. There are many effective programs that have been shown to have results but have never been widely implemented. Some key strategies include: school-community connected efforts; social-emotional learning and life and coping skills; positive and inclusive school environments; anti-bullying efforts; training for educators and other “gatekeepers” to help identify when youth are at-risk; expanding school counselors, mental health personnel and health services; and screening, early intervention and connection to appropriate services as needed. provide a greater focus on improving treated through separate systems. There l ncreasing Access to Expert Advice I well-being and health in communities must be a concerted effort to expand and Support — Establishing Expert in more lasting and effective ways. the availability and access to behavioral Networks. There must be increased Successful models for developing this health services and include coverage, support for communities who are type of network include Communities payment reform and expanding and struggling with the opioid and related That Care and EPISCenter. developing new systems of service epidemics to be able to access experts delivery and workforce models, to better inform decisions about the l chieving the Vision of Parity and A including those integrated or connected most effective, evidence-based and Integration — Improving and Expanding to primary healthcare. It is particularly promising strategies available to meet a Behavioral Health Services and Aligning important to develop incentives to community’s specific needs — including with Healthcare to Support the “Whole expand the delivery and quality of care receiving technical assistance and Health” of Individuals and Families. in communities where there are limited evaluation supports to ensure the efforts Over the past two decades, federal or no options for behavioral healthcare are well-implemented and achieve and state policies shifted to recognize — especially in many rural and some results. Currently, there are national the need to provide mental health urban areas. Expanding the availability resources at federal agencies and and substance use disorder treatment and quality of services will also include philanthropies, as well as within some (often combined to be referred to as supporting new models for delivery, communities. However, most states and behavioral health) on parity with the such as telehealth and other innovative communities do not have this type of level of treatment for physical health practices, and increasing workforce access to expert assistance and support. problems. Legacy systems, views and development initiatives and greater Creating state-level support and advisory approaches remain, however, which use of community health workers and centers would ensure communities are make achieving parity and integration a peer-counselor/support models where able to tap into assistance from leading challenge. Mental health and substance appropriate. academic and government experts and use disorders have traditionally been TFAH • WBT • PaininTheNation.org 11 • arly Identification of Issues and E the spectrum of proven policies Connection to Supports and Services. and programs, as well as new ideas, A priority for a modernized and that aim at preventing, reducing the effective approach to whole health harm, and/or better understanding is supporting systems that focus on the issues around drugs/opioids, early identification of problems and alcohol and suicide. connecting people to the services • Improving Behavioral Health they need. This involves improved Services To Support “Whole Health.” case management within healthcare Expanding the availability of mental and connection to other social health and substance use disorder service supports that can have a treatment and recovery, and shifting significant impact on health. There it towards a whole health mentality, are a number of tools to effectively as well as taking on long-standing identify children and families at risk, stereotypes and stigmas, is essential as well as for identifying tweens, teens, to support the millions of Americans youth and adults at risk for substance with behavioral health issues. The misuse, mental health concerns and pervasive nature of these issues shows suicide. Models like Accountable that they are “normal” and part Health Communities and Nurse of everyday life — and that legacy Family Partnerships help support approaches that often try to hide, systems for identification, referral, deny or shame them are ineffective, connection to care and follow-up. inappropriate and harmful. l mproving Pain Management and I • Prioritizing Prevention — Treatment. The opioid epidemic also Supporting Healthier Communities demonstrates the need to improve how and Raising a Mentally and Physically the country views and manages pain. Healthier Generation of Kids. A This is both a cultural need to better range of factors impact the health understand pain and its impact as well and well-being of individuals and as a need within the healthcare system families. The opportunities and to develop and support different pain circumstances where they live treatment approaches, and to provide can have a bigger impact than ongoing training for responsible, genetics. This section reviews recommended prescription opioid policies and programs that can prescribing practices. promote well-being for children, teens and families, as well as within In this report, TFAH and WBT explore: communities to reduce risks for l rojections. The potential P substance misuse, suicide and a consequences if action is not taken range of related harms. — reviewing projections for how the l ecommendations for Building a R epidemics could continue to grow. National Resilience Strategy. A review l ealthcare Costs Associated with Drug, H of the range of policies and programs Alcohol and Suicide-Risk Diagnoses. available to inform an effective, comprehensive continuum approach — l eview of Current Key Policies that R from prevention and early identification Promote Resilience: and connection to services and supports • educing Drug and Alcohol Misuse R to treatment and recovery. and Suicide. This subsection reviews 12 TFAH • WBT • PaininTheNation.org EXAMPLES OF RETURN ON INVESTMENTS FOR RESILIENCE PROGRAMS Focusing on preventing problems and HEALTH AND/OR SOCIETAL DOLLARS SAVED FOR EVERY $1 INVESTED providing support can help Americans Five Strongest School-based Substance Misuse Prevention Programs $3.80 – $3462 thrive, with proven results for improving School-based Social Emotional Learning Programs $1163 mental and physical health and school and career achievement. They also School-based Violence Prevention Programs (including Suicide) $15 – $8164, 65, 66 provide a sound financial investment, Early Childhood Education Programs $4 - $1267 with many prevention programs yielding Nurse Home Visiting for High-Risk Infants $5.7068 positive returns on investments Women, Children and Infant (WIC) Program $2 - $369 ranging from $3.80 to $34 returns for Effective Substance Use Treatment Programs $3.7770 every dollar invested. 58, 59, 60, 61 Community Health Navigator, Referral and Case Management Programs $2 - $471 Sobriety Treatment and Recovery Teams (for parents with substance use disorders as alternative to traditional child welfare programs $2.2272 (savings identified are within the foster care system)) Screening, Brief Intervention and Referral to Treatment (for Substance $3.81 - $5.6073, 74 Misuse) Alcohol Pricing: a 10 percent increase in the price of alcoholic beverages is shown to reduce consumption by 7.7 percent.75, 76 Alcohol tax revenue generated around $9.8 billion for communities across the country in 2016.77 ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS (ASTHO) PRESIDENT’S CHALLENGE 2017 A conceptual framework of public health approaches to preventing substance misuse Key strategies to prevent substance and addictions 78 misuse and addictions: Reduce stigma and change social norms Increase protective factors and reduce risk factors in communities Strengthen multi-sectoral collaboration Improve prevention infrastructure Optimize the use of cross-sector data for decisionmaking Source: ASTHO TFAH • WBT • PaininTheNation.org 13 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA) COMPREHENSIVE STRATEGY TO SUPPORT MENTAL AND BEHAVIORAL HEALTH l Health: overcoming or managing one’s family caretaking or creative endeavors, disease(s) as well as living in a physi- and the independence, income and re- cally and emotionally healthy way; sources to participate in society; and l Home: a stable and safe place to live; l Community: relationships and social networks that provide support, friend- l Purpose: meaningful daily activities, ship, love and hope.79 such as a job, school, volunteerism, 14 TFAH • WBT • PaininTheNation.org SECTI O N 1: Pain in the SECTION 1: PROJECTIONS: POSSIBLE FUTURES OF DRUG, ALCOHOL AND SUICIDE DEATHS Projections: Possible Futures of Drug, Alcohol and Suicide Deaths Nation: A new analysis conducted by the Berkeley Research Group on Public Health behalf of TFAH and WBT found that if alcohol-related, drug- Report related or suicide deaths continue to grow at current rates, they series could account for around 1.6 million fatalities in the next decade (between 2016 and 2025). This would be a 60 percent increase l U nder the best case scenario, the from this past decade when there were deaths would increase to 51 per 1 million deaths attributable to substance 100,000 in 2025; under the worst case misuse and suicide (2005 and 2015). scenario, they would increase to 62 per 100,000; and under the extreme worst l D eaths would increase from nearly 40 case pessimistic scenario, they would (39.7) per 100,000 as of 2015 to nearly increase to 83 per 100,000. 56 (55.9) per 100,000 by 2025 (in the baseline scenario). Note: From 1999-2015, there were 78,000 suicide deaths over the analyzed period l T he analysis also includes best case that were also drug- or alcohol-related, and worst case scenarios based on the analysis accounts for any potential the growth trends, which would yield double-counting. From 2006-2015, there around 1.5 million and 1.7 million were 52,000 suicide deaths over the deaths respectively. Under an extreme analyzed period that were also drug- or worst case scenario, which would alcohol-related, the analysis accounts be consistent with current reported for any potential double-counting. A trends in 2016, these deaths could full methodology for the analysis is reach 2 million by 2025 — effectively available in Appendix B. doubling the rates of the past decade. U.S. Drug, Alcohol, or Suicide-Related Deaths NOVEMBER 2017 U.S. Drug, Alcohol or Suicide-related Deaths per 100,000 Individuals PROJECTED ANNUAL GROWTH RATE SCENARIOS FOR NATIONAL DAS DEATHS PER 100,000 (2016-2025) DAS Metric Very Pessimistic Pessimistic Baseline Optimistic Drug-Induced Deaths 10.6% 6.4% 5.1% 4.0% Alcohol-Induced Deaths 7.1% 3.5% 2.3% 1.4% Suicide Deaths 2.4% 2.2% 1.8% 1.4% U.S. Drug, Alcohol or Suicide-related Deaths 60 56.0 55 50 45 39.7 Deaths per 100,000 40 35 30 28.4 25 23.1 20 16.3 16.5 15 13.1 13.8 10.3 10.5 10 7.0 6.9 5 0 1999 2015 2025 1999 2015 2025 1999 2015 2025 1999 2015 2025 Alcohol Deaths Drug Deaths Suicide Deaths Total ADS Deaths 16 TFAH • WBT • PaininTheNation.org U.S. Drug-Related Deaths U.S. Alcohol-Related Deaths U.S. Suicide-Related Deaths TFAH • WBT • PaininTheNation.org 17 Drug, Alcohol and 1999 Alcohol, Drug and Suicide Deaths Per 100,000 Suicide Deaths by State, WA 1999, 2015 and MT ND ME VT OR MN Projected for 2025 ID SD WI NY NH 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 <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 to ≤90 >90 to ≤100 >100 2005 Alcohol, Drug and Suicide Deaths Per 100,000 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 <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 to ≤90 >90 to ≤100 >100 18 TFAH • WBT • PaininTheNation.org 2015 Alcohol, Drug and Suicide Deaths Per 100,000 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 <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 to ≤90 >90 to ≤100 >100 2025 Alcohol, Drug and Suicide Deaths Per 100,000 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 <20 >20 to ≤30 TX LA >30 to ≤40 >40 to ≤50 FL AK >50 to ≤60 HI >60 to ≤70 >70 to ≤80 >80 to ≤90 >90 to ≤100 >100 TFAH • WBT • PaininTheNation.org 19 ALCOHOL, DRUG AND SUICIDE DEATH RATES PER 100,000 IN 1999 AND 2015 AND 2025 PROJECTIONS (CDC WONDER) Alcohol Deaths Drug Deaths 1999 2015 2025 Change 1999-2025 1999 2015 2025 Change 1999-2025 Alabama 5.6 6.5 8.2 46% 4.4 15.2 27.5 525% Alaska 15 21.8 27.5 83% 9.0 16.5 28.4 215% Arizona 9.3 18.7 23.6 154% 11.1 18.7 32.6 194% Arkansas 4.5 8.1 10.2 128% 4.6 13.2 23.5 411% California 9.8 13.2 16.6 69% 9.2 11.9 21.2 130% Colorado 11.1 15.7 19.8 78% 8.9 15.9 27.0 203% Connecticut 5.2 9.5 12.0 130% 9.7 22.3 38.0 291% Delaware 7.9 8.5 10.7 35% 7.1 20.9 36.2 411% D.C. 13.5 11.9 15.0 11% 9.6 18.6 31.9 232% Florida 8.1 12.3 15.5 91% 6.7 15.9 27.5 310% Georgia 5.9 7.1 9.0 52% 4.3 12.8 22.1 414% Hawaii 3.1 6.6 8.4 170% 6.9 11.8 20.2 192% Idaho 5.8 14.5 18.3 215% 5.2 13.2 22.3 329% Illinois 5.2 7.4 9.3 78% 7.1 14.3 24.0 238% Indiana 5.1 10.4 13.1 157% 4.2 18.8 32.6 677% Iowa 5.2 11.0 13.9 167% 2.0 9.9 17.5 776% Kansas 4.9 9.5 12.0 146% 3.7 11.3 19.8 434% Kentucky 5.9 10.5 13.3 125% 5.4 28.8 49.6 819% Louisiana 6.7 8.3 10.5 56% 5.5 18.4 31.8 478% Maine 8.4 14.6 18.4 119% 5.5 20.2 34.5 527% Maryland 6.0 5.0 6.3 5% 12.6 21.4 36.2 188% Massachusetts 5.6 9.3 11.7 110% 8.1 25.4 44.9 454% Michigan 6.3 9.9 12.5 99% 7.2 20.0 38.5 434% Minnesota 6.2 10.9 13.8 122% 3.5 10.6 19.6 460% Mississippi 5.5 5.8 7.4 34% 3.6 11.7 20.3 465% Missouri 7.2 8.4 10.6 47% 5.3 17.5 29.8 461% Montana 8.5 18.8 23.7 179% 5.3 13.4 24.3 358% Nebraska 5.3 10.5 13.2 150% 2.4 6.6 12.1 404% Nevada 13.1 15.0 18.9 44% 12.2 21.4 35.9 194% New Hampshire 7.3 13.0 16.4 125% 5.1 31.7 53.6 952% New Jersey 5.6 5.9 7.4 32% 9.1 16.2 27.7 205% New Mexico 16.2 31.5 39.7 145% 15.2 24.0 40.8 168% New York 6.6 7.5 9.4 43% 5.8 13.9 25.1 332% North Carolina 8.7 9.1 11.5 32% 5.0 15.6 26.9 437% North Dakota 8.1 12.7 16.0 97% 2.3 8.1 14.2 515% Ohio 4.9 8.8 11.1 128% 4.7 28.5 48.5 932% Oklahoma 7.1 13.6 17.1 141% 5.5 18.5 31.7 475% Oregon 9.0 22.2 28.0 212% 9.7 12.5 24.9 157% Pennsylvania 3.7 6.9 8.7 134% 8.6 25.5 43.5 405% Rhode Island 6.7 13.8 17.4 160% 5.9 29.4 49.6 741% South Carolina 10.8 10.1 12.7 18% 4.2 15.5 26.7 536% South Dakota 10.7 17.7 22.3 109% 2.7 7.6 13.8 412% Tennessee 7.0 9.7 12.2 74% 6.6 22.1 38.6 485% Texas 5.7 7.5 9.5 67% 6.1 9.4 16.4 169% Utah 5.8 8.9 11.2 93% 9.6 21.6 36.7 282% Vermont 6.1 15.3 19.3 217% 5.1 15.8 29.2 473% Virginia 4.8 7.8 9.9 105% 5.6 12.4 21.0 276% Washington 9.7 15.3 19.3 99% 10.2 15.3 27.3 168% West Virginia 6.5 10.5 13.2 103% 4.4 39.3 67.0 1424% Wisconsin 6.7 11.1 13.9 108% 4.4 15.2 25.5 480% Wyoming 12.2 25.9 32.7 168% 4.3 16.4 27.8 548% UNITED STATES 7.0 10.3 13.1 87% 6.9 16.3 28.4 311% Rates based on per 100,000, based on analysis of data from CDC’s Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). For full methodology see Appendix B on page 160. 20 TFAH • WBT • PaininTheNation.org Suicide Deaths Alcohol, Drug & Suicide Deaths 1999 2015 2025 Change 1999-2025 1999 2015 2025 Change 1999-2025 Change 2015-2025 Alabama 12.5 15.4 18.4 47% 21.2 36.8 51.9 145% 41% Alaska 15.4 27.2 32.5 111% 37.6 63.0 84.4 125% 34% Arizona 15.2 18.7 22.3 47% 34.0 55.0 75.8 123% 38% Arkansas 12.7 19.4 23.1 82% 20.4 39.5 54.2 166% 37% California 9.2 10.7 12.7 38% 27.2 35.4 48.9 80% 38% Colorado 13.6 20.0 23.9 76% 32.0 49.7 67.8 112% 36% Connecticut 8.1 10.7 12.8 58% 22.1 41.9 61.2 177% 46% Delaware 11.1 12.9 15.4 39% 24.9 41.9 60.4 143% 44% D.C. 5.3 5.1 6.0 14% 27.9 35.7 52.2 87% 46% Florida 12.9 15.8 18.9 46% 26.3 42.9 59.6 126% 39% Georgia 10.9 12.9 15.4 41% 19.9 31.9 44.6 124% 40% Hawaii 11.2 14.0 16.8 50% 20.0 31.2 43.3 116% 39% Idaho 14.2 21.7 25.9 82% 23.6 47.1 63.4 169% 34% Illinois 8.3 10.6 12.6 52% 19.6 31.3 44.4 127% 42% Indiana 10.4 14.5 17.3 66% 18.5 43.0 61.0 230% 42% Iowa 10.5 13.9 16.5 57% 16.6 33.9 46.0 177% 36% Kansas 11.2 16.4 19.5 75% 18.6 36.0 49.0 164% 36% Kentucky 11.7 17.5 20.9 79% 21.7 56.1 81.3 275% 45% Louisiana 11.6 15.5 18.4 59% 22.6 41.2 58.5 159% 42% Maine 13.8 17.7 21.1 53% 26.2 51.1 71.5 173% 40% Maryland 8.3 9.2 11.0 32% 25.9 35.1 52.2 102% 49% Massachusetts 6.8 9.5 11.3 66% 19.8 44.9 66.6 237% 48% Michigan 9.8 14.2 17.0 73% 22.2 45.8 65.9 197% 44% Minnesota 9 13.3 15.9 76% 17.7 34.5 47.3 168% 37% Mississippi 10.7 14.4 17.2 61% 18.6 30.9 42.8 130% 39% Missouri 12.6 17.3 20.6 64% 23.7 41.7 58.5 147% 40% Montana 18 26.3 31.4 75% 29.9 56.7 75.6 153% 33% Nebraska 10.4 11.8 14.0 35% 17.0 28.2 37.7 122% 34% Nevada 20.9 19.3 23.0 10% 43.9 53.8 75.0 71% 40% New Hampshire 11.2 17.1 20.4 83% 22.3 60.6 88.1 294% 45% New Jersey 6.7 8.8 10.5 57% 20.7 30.5 44.4 115% 46% New Mexico 17.6 24.0 28.6 63% 47.1 77.4 105.7 125% 37% New York 6.3 8.4 10.0 58% 18.1 30.0 43.3 140% 44% North Carolina 11.1 14.0 16.7 50% 23.6 37.7 53.1 124% 41% North Dakota 11.3 16.4 19.5 73% 20.5 35.7 47.4 131% 33% Ohio 9.7 14.2 17.0 75% 18.3 50.8 74.6 308% 47% Oklahoma 14.3 20.2 24.1 69% 25.4 50.5 70.0 176% 38% Oregon 14.1 18.9 22.6 60% 31.2 54.0 72.8 133% 35% Pennsylvania 10.5 14.8 17.6 68% 21.6 46.3 67.7 213% 46% Rhode Island 9.2 12.0 14.3 56% 20.8 54.5 79.7 284% 46% South Carolina 10.5 15.2 18.1 72% 24.4 39.7 55.4 127% 40% South Dakota 13.7 20.2 24.0 75% 25.6 43.8 57.4 124% 31% Tennessee 12.9 16.2 19.3 50% 25.1 47.3 67.8 170% 43% Texas 9.8 12.4 14.8 51% 20.5 28.4 38.9 90% 37% Utah 12.8 21.0 25.1 96% 26.8 49.7 70.0 161% 41% Vermont 10.4 16.5 19.6 89% 20.5 47.6 65.8 221% 38% Virginia 11.3 13.3 15.9 41% 20.4 32.3 44.9 120% 39% Washington 14 15.9 18.9 35% 32.3 45.9 63.3 96% 38% West Virginia 12.6 18.4 22.0 75% 22.1 67.4 99.6 350% 48% Wisconsin 11.1 15.2 18.1 63% 21.0 39.9 55.5 164% 39% Wyoming 19.9 26.8 32.0 61% 34.2 66.4 88.8 160% 34% UNITED STATES 10.5 13.8 16.5 57% 23.1 39.7 56.0 142% N/A TFAH • WBT • PaininTheNation.org 21 ALCOHOL, DRUG, AND SUICIDE DEATHS PER 100,000 IN 2015, 1999 AND PERCENT CHANGE 1999 - 2015 (CDC WONDER) Alcohol Deaths Drug Deaths Suicide Deaths 1999 2015 Change 1999 2015 Change 1999 2015 Change Overall 7.0 10.3 47% 6.9 16.3 136% 10.5 13.8 31% Female 3.2 5.6 75% 4.4 11.9 170% 4.0 6.3 58% Male 10.9 15.2 39% 9.4 20.1 114% 17.1 21.5 26% Black 7.8 6.5 -17% 8.6 11.6 35% 5.4 5.6 4% Asian 1.3 2.0 54% 1.3 2.9 123% 5.8 6.6 14% White 7.0 11.4 63% 6.9 18.3 165% 11.5 15.8 37% Hispanic 6.4 7.9 23% 5.8 7.8 34% 5.0 5.8 16% 0-17 <0.1 <0.1 -- 0.3 0.5 67% 1.4 2.6 86% 18-34 1.1 2.1 89% 7.2 22.0 206% 12.3 15.2 24% 35-54 12.0 15.4 28% 14.4 30.8 114% 14.1 18.7 32% 55-74 17.5 24.6 41% 4.1 17.2 322% 12.7 17.4 37% 75+ 9.3 9.5 2% 4.1 4.7 16% 18.4 18.4 0% Northeast 5.6 7.9 41% 7.4 19.7 166% 7.9 10.8 37% Midwest 5.8 9.5 64% 5.1 17.4 241% 10.0 14.0 40% South 6.7 8.9 33% 6 15.4 157% 11.3 14.3 27% West 9.8 15.1 54% 9.5 14.3 51% 11.8 14.9 26% Metro 6.2 10.1 63% 6.8 15.5 128% 10.1 13.0 29% Non-Metro 7.2 11.7 63% 4.4 17.0 286% 12.6 18.2 44% 22 TFAH • WBT • PaininTheNation.org LOWERED LIFE EXPECTANCY IN THE UNITED STATES CDC announced that life expectancy in in life expectancy in recent years have the United States decreased in 2015 been increases in mortality rates among — the first decline after decades of White men and women ages 45 to 54, increases in longevity. 80 who have experienced a 10 percent increase in deaths in the past 15 years While mortality rates remain highest (2000-2014).81, 82 among Black men, the biggest changes Whites – by Increase in Causes of Deaths (2000-2014) Age Range Drug Overdoses and Other Chronic Liver Disease Suicides Unintentional Injury Deaths (many related to alcohol) 25-34 63.3% 36.3% N/A 35-44 41.5% 30.2% N/A 45-54 73.5% 57.5% 31% Age-specific death rates for unintentional injuries, suicide, and chronic liver disease and cirrhosis for the White population: United States, 2000-201483 Source: CDC NOTES: UI is unintentional injuries, S is suicide, and CL is chronic liver disease and cirrhosis. Death rates for chronic liver disease and cirrhosis for ages 25–34 and 35–44 are not shown due to very small death rates (ages 25–34) and no statistical change over time (ages 35–44). SOURCE: NCHS, National Vital Statistics System, Mortality.  TFAH • WBT • PaininTheNation.org 23 Additional studies have found differences were 30 percent higher than Blacks.85 in these trends as they are related to Researchers suggest that “the increases education and region. in deaths of despair are accompanied by a measurable deterioration in economic l R esearchers Anne Case and Angus and social well-being, which has become Deaton found rates for Whites ages more pronounced for each successive 45-54 with no more than a college birth cohort. Marriage rates and labor education increased by 134 deaths per force participation rates fall between 100,000 between 1999 and 2013, with successive birth cohorts, while reports overdoses death rates rising four-fold of physical pain, and poor health and and chronic liver diseases and cirrhosis mental health rise.” by 50 percent (while rates decreased among those with a college degree by l T he Commonwealth Fund found 57 per 100,000). 84 A follow-up study significant regional variation in mortality found that death among the cohort trends, with Southern states with the of Whites with no more than a high highest rates of poverty among Whites school degree was around 30 percent seeing some of the worst trends lower than Blacks (of all education (West Virginia, Mississippi, Tennessee, levels) in 1999, but by 2015, they Kentucky, Alabama and Arkansas).86 The “Mortality Gap” for Middle-Aged Whites was Particularly Large in Parts of the South Source: CDC 24 TFAH • WBT • PaininTheNation.org “Deaths of despair” for White non-Hispanics, 2000 and 2014 Ages 45-54, by county Source: CDC White non-Hispanic Midlife Mortality from “Deaths of Despair” in the U.S. by Education Ages 50-54, deaths by drugs, alcohol, and suicide Source: “Mortality and morbidity in the 21st century” by Anne Case and Angus Deaton, Brookings Papers on Economic Activity, Spring 2017 U.S. Average Life Expectancy: 78.8 Years (2014)87, 88 Women: 81.2 Men: 76.3 White Black Latino 78.8 75.2 81.8 Women Men Women Men Women Men 81.1 76.5 78.1 72.0 84.0 79.2 TFAH • WBT • PaininTheNation.org 25 S EC T I ON 2 : Pain in the SECTION 2: HEALTHCARE COSTS ASSOCIATED WITH DRUG, ALCOHOL & SUICIDE-RISK DIAGNOSES Healthcare Costs Associated Nation: With Drug, Alcohol and Public Health Suicide-Risk Diagnoses Report BRG, TFAH and WBT also reviewed the total healthcare costs for series patients with drug, alcohol or suicide-risk diagnoses. Annual total spending for patients with these three diagnoses was $249 billion, which is roughly 9.5 percent of total U.S. health expenditures. These costs represent a significant portion of the population, with 3.8 percent of Americans having one of the diagnoses — their costs averaged 2.5 times higher than average patients ($20,113 compared to $8,045). DAS Average Healthcare Spend vs. Overall Healthcare Spend DAS Diagnosis Prevalence Note: The analysis is based on two data sources: Medical Expenditure Survey (MEPS) data and the Agency for Healthcare Research and Quality (AHRQ), who identified those with an alcohol, drug or sui- cide diagnosis code. This data was used to calculate healthcare costs for those with these diagno- NOVEMBER 2017 ses. In addition, per capita National Health Expenditure (NHE) data from the Office of the Actuaries (OACT) from the Centers for Medicare and Medicaid Services (CMS) were used for overall and per capita healthcare spending. A full methodology of the analysis is available in Appendix D. STATE PER CAPITA HEALTH Estimated Average 2014 Cost Per Person with Alcohol, Drug, or Suicide-Related EXPENSES Diagnosis Estimated Average FY 2014 Cost Per Person with WA DAS Diagnosis MT ME Alabama $7,281 $18,203 ND VT Alaska $11,064 $27,660 OR MN ID NH Arizona $6,452 $16,130 SD WI NY MA Arkansas $7,408 $18,520 WY MI CT RI California $7,549 $18,873 NE IA PA NJ Colorado $6,804 $17,010 NV OH DE UT IL IN Connecticut $9,859 $24,648 CA MD CO WV VA Delaware $10,254 $25,635 KS MO DC KY D.C. $11,944 $29,860 NC Florida $8,076 $20,190 AZ TN OK Georgia $6,587 $16,468 NM AR SC Hawaii $7,299 $18,248 MS AL GA Idaho $6,927 $17,318 TX LA Illinois $8,262 $20,655 Indiana $8,300 $20,750 FL Iowa $8,200 $20,500 AK Kansas $7,651 $19,128 HI Kentucky $8,004 $20,010 Louisiana $7,815 $19,538 <$18,000 ≥$18,000 and <$21,000 Maine $9,531 $23,828 ≥$21,000 and<$24,000 ≥$24,000 Maryland $8,602 $21,505 Massachusetts $10,559 $26,398 Michigan $8,055 $20,138 Minnesota $8,871 $22,178 Mississippi $7,646 $19,115 Missouri $8,107 $20,268 Montana $8,221 $20,553 Nebraska $8,412 $21,030 Nevada $6,714 $16,785 New Hampshire $9,589 $23,973 New Jersey $8,859 $22,148 New Mexico $7,214 $18,035 New York $9,778 $24,445 North Carolina $7,264 $18,160 North Dakota $9,851 $24,628 Ohio $8,712 $21,780 Oklahoma $7,627 $19,068 Oregon $8,044 $20,110 Pennsylvania $9,258 $23,145 Rhode Island $9,551 $23,878 South Carolina $7,311 $18,278 South Dakota $8,933 $22,333 Tennessee $7,372 $18,430 Texas $6,998 $17,495 Utah $5,982 $14,955 Vermont $10,190 $25,475 Virginia $7,556 $18,890 Washington $7,913 $19,783 West Virginia $9,462 $23,655 Wisconsin $8,702 $21,755 Wyoming $8,320 $20,800 United States $8,045 $20,113 Estimated Total Cost for Those $243,694,476,474 with DAS Diagnosis TFAH • WBT • PaininTheNation.org 27 S EC T I ON 3 : Pain in the SECTION 3: REVIEW OF KEY POLICIES THAT SUPPORT WELL-BEING Review of Key Policies that Nation: Support Well-Being Public Health A range of key strategies can help reduce the urgent epidemics Report of substance misuse and suicide and can be effective in addressing the underlying factors that contribute to these crises series to support better well-being for millions of Americans. Experts from National Institutes of focusing on children and at-risk families Health (NIH), CDC, SAMHSA, Office of — not only have shown results in National Drug Control Policy (ONDCP), reducing the risk for substance misuse Food & Drug Administration (FDA), and suicidal thoughts and attempts, Administration for Children and Families they also reduce the chances for: (ACF), CMS, the U.S. Department of poor school performance, behavioral Health and Human Services (HHS), problems in school, dropping out U.S. Department of Education, state and of high school, the need for special local government agencies, academic education and child welfare services, researchers, philanthropies, health behavioral health issues like depression systems and other organizations develop and anxiety, chronic illnesses, shorter and advance key policies and programs and less healthy lives, obesity and eating that communities around the country disorders, difficulty in maintaining can use to address these epidemics and healthy relationships, teen pregnancy, improve behavioral health. sexually transmitted diseases (STDs), aggression and violence, domestic abuse This review is intended to help advance and rape, not acquiring key parenting the specific policies — to provide an skills or support for when people have overview of existing efforts — to help children themselves and difficulty in inform building to a more concerted securing and maintaining a job.89, 90, 91, 92 and comprehensive effort. While these actions are important — they are not The following sections provide an currently supported or sufficiently overview of effective policies and coordinated at the level needed to turn approaches — to support the goal of the tide on the crises or the underlying expanding efforts to benefit communities factors that contribute to the problems. across the country and inform the development of a comprehensive While these efforts may require National Resilience Strategy: additional investments, they can also provide strong returns in reduced A. Reducing Drug and Alcohol Misuse healthcare and social service costs and Suicide NOVEMBER 2017 and improved health, education and B. Improving Behavioral Health Services productivity outcomes. — To Support “Whole Health” A majority of policies and programs C. Prioritizing Prevention — Supporting featured in the report focus on effective, Healthier Communities and Raising research-based approaches to prevent a Mentally and Physically Healthier and reduce problems in the first place. Generation of Kids Investments in prevention — especially EVIDENCE-BASED AND RESEARCH AND DEVELOPMENT OF PROMISING POLICIES AND PROGRAMS More than four decades of research Center for the Study and Prevention into the most effective policies and of Violence’s Blueprints for Healthy programs are available from a range Youth Development; the Coalition for of resource centers, including: Evidence-based Policy; the Institute NIH/National Institute on Drug Abuse’s of Education Sciences’ What Works (NIDA) review of NIDA-supported Clearinghouse; Communities That Care; substance misuse prevention Washington State Institute for Public programs; CDC’s Community Guide Policy; and the National Institute of to Preventive Services; CDC’s Health Justice’s Crimesolutions.gov, among Education Curriculum Analysis Tool others. These resources can be used (HECAT); CDC’s Preventing Suicide: to help communities, school districts, A Technical Package of Policy, policymakers and philanthropies Programs and Practices; SAMHSA’s identify which of the range of evidence- National Registry of Evidence-based based approaches best match their Programs and Practices (NREPP); the needs.93, 94, 95, 96, 97, 98, 99, 100, 101, 102 A. REDUCING DRUG AND ALCOHOL MISUSE AND SUICIDE The National Institutes of Health, Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention and leading experts around the country have identified numerous evidence- based policies, programs and practices that effectively help prevent and reduce drug and alcohol misuse and suicide. This section focuses on many of the targeted strategies to address the acute aspects of substance misuse and suicide prevention. They are important approaches that should be scaled and invested in across the country — but also must be combined with improving and expanding the availability of behavioral health services and focusing more on upstream prevention to achieve a comprehensive strategy. TFAH • WBT • PaininTheNation.org 29 Effective Approaches for Preventing and Reducing Opioid and Other Drug Misuse There have been numerous reviews Currently, three times the amount of about the growth of the opioid opioids are prescribed compared to the epidemic — tracking a paradigm amount in 1999 (which is down after change in perspectives on pain, the peaking at more than four times that rapid rise in the types of prescription level in 2010).108 In 2015, the amount of opioids that came to market, marketing opioids prescribed (around 200 million of opioids and increased prescribing prescriptions) could medicate every rates for these medications.103, 104 American around the clock for three weeks.109, 110, 111, 112 Millions of Americans suffer from Prevalence of prescription opioid pain and the rapid increase in the use Around 21 to 29 percent of patients misuse and opioid disorder of prescription opioids was related prescribed opioids for chronic pain Patients who misuse opioids prescribed for to finding effective ways to alleviate misuse them.113 And between 8 and chronic pain and manage pain.105 A recent report 12 percent of individuals who use released by the National Academies of prescription opioids develop an opioid 21% to 29% Science, Engineering and Medicine use disorder.114, 115, 116 8% to (NASEM), Pain Management and the 12% The epidemic has become even more Opioid Epidemic: Balancing Societal and complicated, starting in around 2009, Individual Benefits and Risks of Prescription Individuals who with the marked rise in the use of use prescription Opioid Use identified that “the ongoing opioids and illicit opioids, which are often less develop an opioid opioid crisis lies at the intersection of expensive and easier to obtain in many use disorder two public health challenges: reducing communities. This is particularly the burden of suffering from pain and true of heroin that is being cut with containing the rising toll of the harms cheaper and more potent forms of that can arise from the use of opioid synthetic opioids, such as fentanyl medications. Chronic pain and opioid (50 to 100 times more potent than Source: CDC use disorder both represent complex heroin) and carfentanil (100 times human conditions affecting millions of more potent than fentanyl). An Americans and causing untold disability estimated 4 to 6 percent of those who and loss of function.”106 misuse prescription opioids transition Starting in the late 1990s, there was a to heroin — and around 80 percent of rapid growth in the use of prescription people who use heroin first misused opioids.107 Some of the major uses of prescription opioids. 117, 118, 119 prescribed opioids are to help alleviate Its scale and prevalence presents a major and/or reduce suffering from cancer challenge for reducing opioid misuse pain, end-of-life care, chronic pain and addiction, which has intensified the syndromes (arthritis, fibromyalgia, back need to find additional, effective ways to pain), dentistry and muscular-skeletal treat and manage pain and the factors issues, fractures, sprains, contusions and that contribute to pain. other related concerns. 30 TFAH • WBT • PaininTheNation.org TRENDS IN OPIOID AND OTHER DRUG MISUSE l D rug Deaths. 52,404 people died from Age-adjusted rate of drug overdose deaths by state, 2015, CDC WONDER drug overdose/poisoning in 2015 and 433,900 died over the last decade (2006-2015).120 In 2015 alone, almost 48 million Americans reported illicit drug use or prescription drug misuse.121 l O pioid Deaths. Opioid deaths tripled from 2000 to 2015 — to 34,000 deaths in one year, which translates to 94 deaths per day, about four every hour, and one every 15 minutes.122 • The increase in opioid overdoses between 2000 and 2015 (increasing by 7.4 deaths per 100,000) is higher than the overdose rate for all drugs in 2000 (6.2 deaths per 100,000).123 Opioid Deaths, 2015, CDC WONDER 20.0 18.5 • pioid deaths are highest among men O 18.0 (14.1 deaths per 100,000), Whites 16.0 15.6 14.1 Deaths per 100,000 (12.2 deaths per 100,000), younger 13.7 14.0 12.2 12.2 adults ages 25-34 years old (19.7 12.0 10.6 10.7 9.9 9.4 10.0 deaths per 100,000) and those who 10.0 8.0 8.0 7.2 live in the Northeast and Midwest 6.5 6.0 4.6 (13.7 and 12.2 deaths per 100,000, 4.0 respectively).124 2.0 1.2 1.3 0.3 0.0 • oth sexes, all races, nearly all age B e e n es -17 es 34 k es ic h t n- ro l Hi ite es 54 Ag -74 rth + M ast So t ro al es s al al ia ac ut No 75 Ag an No et we et er Ag 18- h m M As Ag 35- groups and every state saw large W Ag 5 e 55 Bl M W M sp Ov Fe id es increases in opioid-related death rates between 2000 and 2015, with women Source: TFAH analysis of CDC data (324 percent increase), Asians (300 percent increase), 55-74 year-old individuals (640 percent increase) and those living in the Midwest (408 involving heroin, as of 2016.126 A total of percent increase) having the largest 11.5 million Americans report misused proportional increases. 125 prescription pain relievers in 2016.127 l O pioid Misuse. More than 1.75 million l P rescription Opioid Deaths. Around Americans had a substance use disorder 22,000 overdoses in 2015 were from related to prescription pain relievers and prescription opioid (pain relievers), 62 626,000 had a substance use disorder per day.128 TFAH • WBT • PaininTheNation.org 31 l R ise of Heroin and Fentanyl Deaths. looking at synthetic opioid deaths in in particular areas.137 For example, Between 2010 and 2015, heroin death 14 states found a doubling of fentanyl in Southeastern Massachusetts, the Annual Surveillance Report of Drug-Related Risks and Outcomes | United States CDC National Center rates dramatically increased by four-fold deaths between 2014 and 2015, proportion of opioid-related deaths (from 1.0 to 4.0 per 100,000). Between while other synthetic opioids slightly involving fentanyl increased from about 2013 and 2015, synthetic opioid (like declined. CDC also estimates 135 one-third in 2013 and 2014 to about about half of the increase in heroin rates of drug overdose deaths , by drug In June 2016, year — Age-adjusted three-quarters in 2016.138 or drug class and a b fentanyl) deaths tripled in just two years FIGURE 2B from 1.0 to 3.0 per 100,000. Heroin deaths between 2013 United States, 1999–2015 during a six-hour period in New Haven, and 2015 accounted for 34 percent of opioid had co-involvement of fentanyl. This Connecticut, one community experienced deaths and synthetics for 25 percent, The rate of drug overdose deaths involving natural andoverdoses from andopioids |in illustrates the particularly high potency Annual Surveillance Report of Drug-Related Risks and Outcomes | United States an outbreak of 12 semi-synthetic CDC National Center for Injury Prevention Control 2 during the same period. 129 100,000 population in 1999 to 3.9 of fentanyl and the inherent difficulties in 2015 (p<0.05); cocaine; some patients heroin, th fentanyl-laced for those involving • Three out of four new heroin users re- percreating fentanyl-laced products with (p<0.05); for40 times as much ofsynthetic opioids of 100,000 in 1999 to 4.1 in 2015 needed those involving the rescue ported that they misused prescription rate increased nonlethal doses.from 0.3 per 100,000 in 1999 to 3.1 in 2015 (p<0.05); and for those 136 drug, naloxone, as the usual initial Age-adjustedwitha abuse overdoseCenter for Injuryor drug class and year — |100,000one1999 to 1.8 in 20 f Drug-Related Risks and Outcomes130 United States rates of drug potential, the by drug Prevention and Control 2017 in hundred deathsb, rate increased dosage.139 per from 0.2 Approximately opioids before heroin. |2B FIGURE CDC National • ocal reports around the country also L United States, 1999–2015 • CDC analysis of 2011-2013 National A overdose deaths involving(50 to show increases in illicit fentanyl methadone declined from 1.8 per 100,000 pounds of fentanyl was seized from a in 2006 to Surveys on Drug Use and Health average decrease ofthan heroin) 100 times more potent 7% per year; and for those involving cocaine, increased from house outside of San Diego, California The rateaof drug overdose deathsb, byandin or drug (p<0.05), an average increase opioids increased of thousands ofoverdose drug overdose deaths involving(100 times more potent natural and semi-syntheticinof 9% per year. Rates for drug June 2017, and tens from 1.0 per omes United States surveyrates ofCDC National Age-adjusted data found for Injury2015 class and year — | 2017 2.1 carfentanil drug URE |2B (NSDUH) States, 1999–2015 that in Center toand in Prevention and Controlover the United 100,000 population 1999 3.9 semi-synthetic opioids remained stablewere discovered increased from 0.7 than fentanyl) (p<0.05); for those involvingpills from 2010 to 2015 (p>0.05); while in 2015 overdose deaths heroin, the rate in Tempe, Arizona individuals with a prescription opioid per 100,000 in 1999 to 4.1 in 2015 (p<0.05); especially concentrated syntheticAugust 2017.140, 141 were largest from 201 for those involving otherin opioids other than methadone, the deaths involving synthetic opioids past few years, than methadone dependence were 40 times more rate increased from 131 per 100,000 in 1999 toon average by 81% per year. Heroininvolving psychostimulants 31 0.3 rate increasingopioids2015 (p<0.05); and for those rates increased on average 3.1 in esa of drug overdose with abuse potential, the and semi-synthetic 0.2 per increased from 1.0 per in 2015 (p<0.05). Rates of drug e of drug overdoseto develop adrug or drug class and year — deaths involving natural likely deathsb, by heroin addiction. rate increased fromand death 100,000 of psychostimulants in 1999 to 1.8 0 population in 1999 to 3.9 in 2015 (p<0.05); for those involving heroin, the ratesincreased from 0.7 with abuse potential increas 99–2015 Moreover, 68 percent of heroin users 2015 (p<0.05), rate overdose deaths involving methadone declined from 1.8 per 100,000 in 2006 to or in 2015 (p<0.05), an from 2008 ratesa of drug overdose deathsb, by drug 1.0 Age-adjusted to 2015 (p<0.05). 0,000 in 1999 to 4.1 in 2015 (p<0.05); forin misused prescription pain relievers those involving synthetic opioids other than methadone, the drug class and year average decrease of 7% per — United States, 1999–2015 cocaine, increased from 1.3 per 100,000 in 2010 to year; and for those involving creased from 0.3 per 100,000 in 1999 to 3.1 in 2015 (p<0.05); and for those involving psychostimulants s involving the past year (641,000 out of 948,000 average increase of 9% per year. Rates for drug overdose deaths involving natural natural and in 2015 (p<0.05), an 2.1 semi-synthetic opioids increased from 1.0 per buse2015 (p<0.05);132 those involving heroin, the rate increased from 0.7 9 in potential, the rate increased from 0.2 per 100,000 in 1999 to 1.8 in 2015 (p<0.05). Rates of drug in 2016). for semi-synthetic opioids remained stable from 2010 to 2015 (p>0.05); while increases in drug overdose and se deaths involving methadone declined from 1.8 per than methadone, the in 2015 (p<0.05), an I those involving synthetic opioids other 100,000 in 2006 to 1.0 5 (p<0.05); for • n 2015, the Drug Enforcement Agency deaths involving synthetic opioids other than methadone were largest from 2013 to 2015 (p<0.05), with the e decrease (DEA) issuedyear; and for those involving cocaine,psychostimulants per 100,000 in 2010 to 00 in 1999 to 7% in rate increasing on average byinvolving year. Heroin rates increased on average 31% per year from 2010 to of 3.1 per a nationwide alert for those 2015 (p<0.05); and increased from 1.3 81% per 015 (p<0.05), anper 100,000 in 100 of to 1.8 inyear. Rates for drug overdose deaths involving natural average increase times per 2015 (p<0.05). Rates of drug 9% reased from 0.2 that fentanyl is 1999 death rates of psychostimulants with abuse potential increased on average 23% per year warning 2015 (p<0.05), and mi-synthetic opioids remained stable in 2006 to 1.0 2015 (p>0.05); while increases in drug overdose more from 1.8 per 100,000 from 2010 to in 2015 (p<0.05), an adone declined powerful than morphine and from 2008 to 2015 (p<0.05). involving synthetic opioids otherincreased from 1.3were100,000 from 2013 to 2015 (p<0.05), with the and for those involving cocaine, than methadone per largest in 2010 to 30-50 times more than heroin.133 creasing on9% per year.81% per year. Heroin rates increased on average 31% per year from 2010 to ncrease of average by heroin and fentanyl drug • An increase in Rates for drug overdose deaths involving natural p<0.05), andfrom 2010 to 2015 (p>0.05); while increases in drug overdose on average 23% per year ined stableseizures reported to the DEA mirrored with abuse potential increased death rates of psychostimulants 008 to 2015 (p<0.05). in deaths. largest from ds other than methadone were The Northeast 2013 to 2015 (p<0.05), with the the increase % per year. and Midwest saw steady increases in Heroin rates increased on average 31% per year from 2010 to f psychostimulants with abuse potential and heroin drug reports between 2006 increased on average 23% per year 2015. The increases in the South and West of the United States were evident starting in 2010. All regions have had large increases in fentanyl drug reports since 2013, after staying level between 2006 and 2012.134 Source: National Vital Statistics System, Mortality File, CDC WONDER. a Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage year popul • llicit fentanyl is the primary driver of I might involve more than one drug, some deaths are included in more than one category. Specification on de synthetic opioid deaths, as well as Source: CDC142 over time. In 2015, approximately 17% of drug overdose deaths did not include information on deaths varies boosting heroin deaths. One study Some of these deaths may have involved opioids or stimulants. b Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), and Y10–Y14 (undetermin c Drug overdose deaths, as defined, that involve natural and semi-synthetic opioids (T40.2). Source: National Vital Statistics System, Mortalityoverdose deaths, as defined, that involve heroin (T40.1). d Drug File, CDC WONDER. a Rate per 100,000 population age-adjusted to the 2000 U.S. standard population using the vintage opioids other than the data year. Because deaths e Drug overdose deaths, as defined, that involve synthetic year population of methadone (T40.4). 32 TFAH • WBT •might involve more than one drug, someDrug overdose deaths, as defined, one category. Specification on death certificates of drugs involved with PaininTheNation.org f deaths are included in more than that involve cocaine (T40.5). deaths varies over time. In 2015, approximatelyoverdose deaths, as defined, that involve psychostimulantson the specific type of(T43.6). involved. g Drug 17% of drug overdose deaths did not include information with abuse potential drug(s) Some of these deaths may have involved Drug overdose deaths, as defined, that involve methadone (T40.3). h opioids or stimulants. l H IV and Hepatitis C. The increase of l O verdose-related Hospitalizations. heroin and fentanyl also means more Opioid-related hospitalizations totaled individuals and new populations are 1.27 million in 2014. Inpatient stays injecting drugs and may be exposed to increased by 64 percent from 2005 to infectious diseases, like hepatitis C, hep- 2014 (225 per 100,000) and emergency atitis B and HIV through shared unsterile department visits nearly doubled during needles or other injection equipment. 143 this time (to 178 per 100,000).148, 149, 150 • ,400 (6 percent) HIV diagnoses were at- 2 l N eonatal Abstinence Syndrome tributed to injection drug use in 2015.144 (Prenatal Exposure to Opioids). • epatitis C diagnoses nearly tripled, H Around 21,000 pregnant women (ages from 850 new cases in 2010 to 2,400 15-44) used opioids non-medically new cases in 2015, in tandem with the between 2007 and 2012.151 Another increases in heroin and fentanyl use review found there was a 383 percent and overdoses. The highest rates of increase in the number of infants new diagnoses were among 20 to 29 born with neonatal opioid withdrawal year olds who inject drugs, and in Appa- syndrome due to in utero exposure lachia and rural areas of the Midwest from 2000 to 2012, across 28 and New England. Most new cases are states.152 In 2012 and 2013, three of not diagnosed since symptoms often the 28 states had rates above 30 per develop as people age, likely represent- 1,000 hospital births: Maine (30.4), ing an increase of tens of thousands of Virginia (33.3) and West Virginia cases of undiagnosed hepatitis C.145, 146 (33.4). Other notable rates included: Kentucky (15), Maryland (11.4) and l T reatment Gap. Only roughly one in Massachusetts (12.5). Remaining 10 individuals with a substance use states were below 10 per 1,000 births. disorder (drug and/or alcohol) receives recommended professional treatment.147 Past month opioid misuse among women aged 15 to 44, by pregnancy status and age: 2007 to 2012 Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2007 to 2012. TFAH • WBT • PaininTheNation.org 33 l O pioid Prescribing. While the overwhelming majority of individuals prescribed an opioid do not become addicted, the large growth in use and availability of opioids means many are placed at risk.153 Opioid prescriptions were three times higher in 2015 than they were in 1999 (from 180 to 640 morphine milligram equivalents (MME) per person).154, 155 • Prescribing rates have decreased some from their peak level in 2010 (780 MME), declining 13 percent from 2012 to 2015.156 • ates vary by state and region, with R some high-prescribing counties citing six and 2015 and the average length of l E conomic Burden. CDC estimated that times the number of prescriptions per prescriptions continued to increase the economic cost of prescription opioid person than low-prescribing counties.157 steadily through 2015 (from 13.3 days overdose, misuse and dependence • ecreases in prescribed opioids have D in 2006 to 17.7 in 2015). 158, 159 Some was $78.5 billion in 2013 alone.160 not occurred consistently across the data suggests fewer patients may be The National Drug Intelligence Center country — only about half of counties initiating prescription opioid use, but estimated that illicit drug use cost the actually saw a reduction in the amount patients already prescribed opioids United States $193 billion in health, prescribed per person between 2010 may be continuing longer-term use. crime and lost productivity in 2011.161 U.S. County Prescribing Rates, 2016 SOURCE: CDC 34 TFAH • WBT • PaininTheNation.org Prescription Behavior Surveillance System (PBSS) CDC National Center for Injury Prevention and Control | July 2017 EXAMPLES: RISING FENTANYL DEATHS Brandeis University While final national data is not available beyond 2015, more recent provisional examples of state data suggest that the FENTANYL: Overdoses On The Rise Fentanyl is a synthetic opioid approved for treating severe pain, such as advanced cancer pain. 2013-2015 trends in fentanyl deaths Illicitly manufactured fentanyl is the main driver of recent increases in synthetic opioid deaths. have continued to grow at an alarming SYNTHETIC OPIOID DEATHS ACROSS THE U.S. rate in 2016 and 2017: 10,000 50-100 73% MORPHINE FENTANYL 7,500 l National: Provisional data from the INCREASE FROM 2014 TO 2015 CDC for February 2016-January 2017 X 264% 5,000 INCREASE FROM show that total drug deaths continue MORE POTENT 2012 TO 2015 THAN MORPHINE 2,500 to increase (to 64,000 deaths) with 2012 2013 2014 2015 deaths involving synthetic opioids more Ohio Drug Submissions Testing Positive for Illicitly Manufactured Fentanyl than doubling to 20,000 deaths.162 4,000 ILLICITLY MANUFACTURED FENTANYL l Maryland: Fentanyl overdose deaths 3,000 Although prescription rates have OFTEN MIXED WITH reached 372 in the first quarter of 2,000 196% INCREASE FROM fallen, overdoses associated with fentanyl have risen dramatically, HEROIN 2014 TO 2015 contributing to a sharp spike in OR COCAINE 2017, compared with 157 deaths in 1,000 synthetic opioid deaths. WITH OR WITHOUT USER KNOWLEDGE the first quarter of 2016.163 2012 2013 2014 2015 l N ew Hampshire: Between 2011 and 2013, New Hampshire averaged 14 deaths from fentanyl per year. at this time, from 225 in 2014 to 866 l W est Virginia: Fentanyl-related Every year since, the number has in 2015. The state also reported 164 overdoses grew to Rise in Overdose States See Sharp 324 in 2016, an PBSS STATES climbed dramatically: 108 in 2014, a rise in carfentanil use in the state, Death Rates Involving Synthetic 80 percent increase (180 deaths) over 239 in 2015, and 314 in 2016. with 73 carfentanil-related deaths from Opioids other than Methadone 2015 and a 604 percent increase over Correspondingly, the number of fentanyl January to May 2017. 165 2014 (46 rate of synthetic opioid overdose The national deaths).166 deaths was at or below 1 per 100,000 from 2010 shipments intercepted also increased through 2013, then more than tripled from 2013 to 2015, reaching 3.1 per 100,000.1 This rapid rise is reflected in similar increases in synthetic opioid overdose death rates in several PBSS states located PBSS STATE in the East, Midwest, and Appalachian regions of NON-PBSS STATE the country, including West Virginia, Ohio, Maine, and Virginia. However, in one western state, Washington, a much lower and more stable rate FENTANYL OVERDOES IN OHIO IN JANUARY/FEBRUARY 2017 of synthetic opioid overdose deaths was observed during this same time period (Figure 1). A CDC study looking at the kind of drugs Within the fentanyl deaths, the study rural/non-Appalachian counties (heroin involved in overdose deaths in 24 counties found high numbers of acryl fentanyl (48 was involved in less than 4 percent of 2 in Ohio in the first two months of 2017, percent of all deaths) and furanyl fentanyl overdoses). Additional data found that found that almost all of the overdoses (31 percent) deaths, two drugs often half of all carfentanil deaths were in one involved fentanyl or an analog, and many found on online illicit cryptomarkets. county (Montgomery County), and that included multiple kinds of fentanyl. it was involved in half of the overdose When looking at geographic breakdowns, deaths in the county. Other drugs often Specifically, 92 percent of overdose heroin-related deaths represented a found included: alcohol (20 percent); deaths included fentanyl or an analog, much higher proportion in Appalachian benzodiazepines (27 percent); cocaine 23 percent included prescription opioids, counties (26 percent of overdose (31 percent); and marijuana (35 percent). and 6 percent included heroin. deaths) than in urban, suburban or TFAH • WBT • PaininTheNation.org 35 RURAL COMMUNITIES — OPIOID AND SUICIDE CRISES Rural communities have been particularly Deaths in rural/ 2015 death rates for Death trends in rural/suburban impacted by the opioid and suicide crises suburban areas rural/suburban vs. metro areas 2000-2015 2005-2015 areas over the past 15 years.167, 168, 169 All drugs – Three-fold increase All drugs – 64,700 All drugs – 2 percent lower (5.0 to 17.0 per 100,000) deaths Before 2000, rates of drug overdoses in Drugs Prescription opioids – Seven- rural communities had been lower than Prescription opioids Prescription opioids – 4 fold increase (1.0 to 7.3 per – 28,000 deaths percent higher in metro areas of the country. Rural 100,000180) communities were the first to see the Alcohol 60 percent increase (7.3 to 44,700 deaths 16 percent higher 11.7 per 100,000) rapid increases in opioid misuse and 44 percent increase (12.6 to deaths — including concentrated rates of Suicide 18.2 per 100,000) 73,300 deaths 40 percent higher deaths and injuries in a number of states Source: CDC data. Note: Rural/suburban is used for “non-metro” classifications. with large rural populations (Kentucky, West Virginia, Alaska and Oklahoma).170 Suicide rates* by level of county urbanization† — United States, 1999-2015 Rural opioid-related overdose deaths increased more than seven-fold between 2000 and 2015. Rural/non-metro overdose death rates surpassed metro areas in 2003 and remained higher until 2015, when rates in metro areas caught up.171 The National Academy for State Health Policy (NASHP) suggests that socioeconomic realities in rural areas have exacerbated the opioid problem: “More than 25 percent of rural workers over age 25 earn less than the federal poverty rate, and 23 percent of rural counties are identified as ‘persistent-poverty’ counties. Geographic isolation and limited public and Source: CDC181 private transportation create tremendous barriers to healthcare for this population. Additionally, social stigma (particularly approved to provide buprenorphine number of factors including access to lethal in regions with small populations) may treatment (a type of medication-assisted means, social isolation, financial hardship discourage individuals living with substance treatment) have practices in rural areas.175 and access to mental healthcare. The use disorders from seeking treatment.” 172 There are around 39.8 physicians per acceleration of suicide rates in rural areas 100,000 people in rural areas compared may also reflect the influence of the 2007- A shortage of healthcare providers, to 53.3 per 100,000 in urban areas. 176 2009 economic recession and the opioid including mental health and substance overdose epidemic. Rural areas took longer use disorder treatment options in rural Suicide rates have also increased by 38 to recover from the recession and the areas, creates a barrier for those seeking percent in rural areas during this time opioid epidemic (associated with increased treatment and complicates efforts to period — and are 40 percent higher than risk for suicide) also disproportionately combat opioid misuse.173, 174 For example, in metro areas. Experts believe the rates affected these areas.177, 178, 179 only 1.3 percent of physicians who are may be higher due to the influence of a 36 TFAH • WBT • PaininTheNation.org RESPONSES TO THE OPIOID EPIDEMIC l n 2017, President Donald J. Trump I • AMHSA programs and grants to S • ood and Drug Administration F declared the opioid epidemic to states, including the State Targeted commissioned a comprehensive review be a public health emergency and Response to the Opioid Crisis Grant by the National Academics of Sciences, appointed the President’s Commission program, Substance Abuse Prevention Engineering and Medicine about on Combating Drug Addiction and the and Treatment (SAPT) Block Grants, the state of the science regarding Opioid Epidemic. 182 HHS released a the Partnership for Success Program, prescription opioid misuse and is using 2017 updated multi-pronged strategy, Drug-Free Communities, Project AWARE, evidence-based recommendations and federal agencies have developed a Project LAUNCH and other efforts. to update drug approval and renewal number of interagency task force efforts. decision-making within a population • Centers for Disease Control and health benefit-risk framework.184 l ngoing federal efforts to address the O Prevention leads epidemic surveillance The agency has also supported epidemic include: efforts, as well as research and development of tamper-resistant • ffice of National Drug Control Policy O development of effective state-level medicines and removed one opioid, leads coordinated efforts across the response strategies. CDC works Opana, from the market in 2017.185 federal government to:183 with states to track the opioid overdose epidemic and changes • .S. Department of Justice (DOJ) U • etter understand epidemic trends, B in trends (such as the emergence and DEA, working with local law and expand community-based drug and growth of heroin and fentanyl enforcement agencies, have launched prevention efforts and recovery use in communities). In March efforts to crack down on the supply support services; 2016, CDC developed and published and distribution of illegal opioids and, • ecrease the excess prescription D the CDC Guideline for Prescribing in August 2017, DEA proposed a 20 opioid drug supply in circulation; Opioids for Chronic Pain to provide percent reduction in the amount of • ducate patients and prescribers on the E recommendations for the prescribing prescription opioids and some other risks involved with opioid prescribing; of opioid pain medication for patients controlled substances that could be • rain healthcare providers to identify T 18 and older in primary care settings. manufactured in 2018.186 early signs of an opioid use disorder; The opioid prescribing guideline is • he Surgeon General issued a 2016 T intended to improve the way opioids • xpand prescription drug monitoring E comprehensive report, Facing Addiction are prescribed through clinical practice programs and other tools to detect in America: The Surgeon General’s guidelines that ensure patients misuse and diversion; Report on Alcohol, Drugs and Health, have access to safer, more effective • xpand access to evidence-based E which looks at the scope of substance chronic pain treatment while reducing treatment for those with opioid use misuse, consequences, risk and the number of people who misuse, disorders, including those in the protective factors and strategies to develop a dependency or overdose criminal justice system; support prevention and treatment.187 from these drugs. • ddress the healthcare needs A l he Comprehensive Addiction and T • ational Institute on Drug Abuse N of those affected by opioid use Recovery Act (CARA) and 21st Century supports research into effective disorders, including people who Cures Act, passed in 2016, created treatment and prevention strategies inject, pregnant women and infants the State Targeted Response to the and how they can be disseminated exposed during pregnancy; and Opioid Crisis Grant program, expanding and implemented with fidelity as well • isrupt the supply chain of heroin, D support for evidence-based treatment as monitoring trends and providing fentanyl and other illegal drugs, approaches and authorized around $1 information to health providers, including from outside of the billion in funding for opioid programs. policymakers and the public. United States. TFAH • WBT • PaininTheNation.org 37 l ational Governors Association’s 2016 N collaboration, strengthening prevention l he National Association of Counties T Solutions to the Prescription Opioid and infrastructure and optimizing cross- (NACo) and the National League of Cit- Heroin Crisis: A Road Map for States is a sector data for decision-making. 194 ies (NLC) joined forces in 2016 to form tool to help states respond to the growing State and local health officials and the National City-County Task Force on crisis of opioid misuse and overdose departments around the country are the Opioid Epidemic and published A by assessing their current capacity to developing and implementing prevention Prescription for Action: Local Leadership address the problem, selecting evidence- and response strategies, including with in Ending the Opioid Crisis examining based and promising strategies, and support from the Safe States Alliance. how cities and counties can strengthen evaluating their work — and more than collaboration with each other and state, l very state has created a Prescription E 40 governors have signed a 2016 federal, private-sector and nonprofit Drug Monitoring Program (PDMP) to help compact agreement to fight opioid partners to tackle the opioid crisis, and support responsible prescribing practices. addiction.188, 189 Six states have declared featured policy recommendations and The scope and impact of the programs states of emergency in response to the best practices.197 can vary significantly, and they are funded opioid epidemic.190 At least 37 state and operational at differing levels. l he U.S. Conference of Mayors developed T attorneys general and governments an Action Plan to Address Substance Use have asked insurers to develop financial l aw enforcement agencies are putting L Disorders in America’s Cities toolkit to incentivizes for health systems to in place a public health response provide resources, recommendations, promote non-opioid pain treatment to connect individuals in need with policies and program solutions to help options for non-cancer patients.191 effective treatment and support, mayors respond locally to the impact of including via the High Intensity Drug l tate Alcohol and Drug Authority S the national opioid crisis.198 Trafficking Areas (HIDTA) program.195 Directors manage many state-level They are supporting “take back” days l ealthcare providers and systems are H efforts — including publicly funded or locations, where unused medications supporting education, training and re- substance misuse prevention, treatment can be safely returned and disposed. sponse strategies. For instance, the and recovery systems in states — In addition, law enforcement, American Medical Association’s (AMA) that support more than 1.5 million emergency responders and emergency Task Force to Reduce Opioid Abuse Americans receiving treatment annually, department professionals are and the American Society of Addiction more than 18.6 million receiving receiving training in responding to Medicine (ASAM) support participation grant-funded prevention services and opioid overdoses, including through in PDMPs and provider education and 500 million people benefitting from the expanded availability of overdose training for prescribing, as well as iden- population-level programs.192 rescue drugs. Communities across tification and treatment of substance l tate Mental Health Program Directors S the country are also developing law misuse.199, 200 The American Hospital are responsible for the $37 billion public enforcement strategies to limit illegal Association (AHA), Catholic Health Associ- mental health service delivery systems distribution of prescription opioids and ation, America’s Essential Hospitals, the serving 7.2 million people annually in contain the surge in illegal opioids, and Children’s Hospital Association and other states around the country.193 support liability limitations for helping groups have developed patient education during overdoses. tools and resources to help hospitals and l he Association of State and Territorial T emergency departments to set policies Health Officials President’s Challenge l he National Conference of State T and practices to respond to the crisis and for 2017 promotes public health Legislatures tracks state laws that support mental health.201, 202, 203, 204 approaches to prevent substance address opioid and other drug misuse, misuse and has issued a prevention including those related to PDMPs, l n September 2017, the Pharmaceutical I framework of leading strategies and rescue drugs, provider training and pain Research and Manufacturers of America policy approaches, including reducing clinics. In 2016 alone, states enacted (PhRMA) announced support for policies stigma, supporting protective factors approximately 150 new laws targeting limiting the supply of opioids to seven and reducing risk factors, multi-sector prescription drug misuse. 196 days for acute pain treatment.205 38 TFAH • WBT • PaininTheNation.org PRESIDENT’S COMMISSION ON COMBATING DRUG ADDICTION AND THE OPIOID CRISIS206 In March 2017, President Trump signed an l stablishing drug courts in all 93 federal E programs. Prevention is most successful executive order to create a Commission on districts to treat those who need it and when messages are consistent, culturally-ap- Combating Drug Addiction and the Opioid lower the prison population; propriate, repeated at home, reinforced in Crisis, chaired by New Jersey Governor schools, workplaces, and community orga- l ocusing on opioid addiction treatment, over- F Chris Christie, to “study the scope and nizations, and delivered by influential adults dose reversal and recovery – improving and effectiveness of the federal response and peers…. Risk and protective factors expanding screening and treatment options; to drug addiction and the opioid crisis are influential at different times during de- removing reimbursement barriers (includ- and to make recommendations to the velopment, and they relate to changes that ing patient and treatment modality limits); president for improving that response.” occur over the course of development. Risk expanding use of recovery coaches and ser- The commission issued a final report on factors can interrupt developmental patterns vices; recruiting more treatment providers November 1, 2017 that included more than and it is therefore important to implement and expanding types of providers; support- 50 recommendations, including: 207 programs designed for early developmental ing availability and ability and protections periods by building on the strengths of the l lock grant federal funding for opioid- B for administering naloxone; support for in- child or caregiver. Intervening early in child- related and substance use disorder-related terventions and practices to keep impacted hood can alter the life course trajectory in a activities to states, and establish systems families together and provide support, when positive direction.”208 Highlighted examples to track efforts and accountability; it can be done safely; and support employ- of effective universal programs (that if widely ment opportunities and workplace support l ollaboration between the U.S. C used can have a positive impact across a for addiction and treatment services; and Department of Education and states to population) include: Good Behavior Game; deploy Screening, Brief Intervention and l esearch and development efforts R Nurse Family Partnership; Life Skills Training Referral to Treatment (SBIRT) in middle for pain management and addiction (LST); Strengthening Families Program 10-14; school, high school and college levels to research; develop and test alternative and Communities That Care. Examples of identify and support at-risk youth; medications for pain and substance use highlighted effective selective interventions disorder treatment; and post-market (delivered to particular communities, families, l esign and implement a public-private D surveillance of opioids and alternatives. or children who, due to their exposure to risk national multi-platform media campaign; factors, are at increased risk of substance The report also features information about evi- l upport for prescribing guidelines, S misuse problems) include Coping Power and dence-based prevention programs, noting that: regulations and education; Focus on Families; and examples of effective “When evidence-based programs are selected indicated interventions (directed to those l nhance Prescription Drug Monitoring E for specific populations and implemented who are already involved in a risky behavior, Programs, including mandatory use, data with fidelity, they can be effective. Prevention such as substance misuse, or are beginning sharing and integration and electronic programs need to be tested for scalability, to have problems, but who have not yet de- prescribing; fidelity, and sustainability after research veloped an SUD) include: Project Toward No l trategies to reduce the supply of licit S champions are no longer present to drive Drug Abuse; BASICS; and Keepin’ it Real. and illicit opioids along with enhanced enforcement strategies, such as through increased Take Back efforts, removing U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OPIOID pain questions from patient satisfaction STRATEGY (5 PRIORITIES):209 surveys, modifying CMS rate-setting policies that discourage other pain l trengthening prevention and public S l mproving access to treatment and I treatment, enhancing federal penalties health surveillance recovery service for fentanyl and related drug trafficking, l upporting cutting-edge research S l dvancing the practice of pain A expanded domestic and international management anti-trafficking efforts and fentanyl safety l argeting the availability and distribution T recommendations for first responders; of overdose-reversing drugs TFAH • WBT • PaininTheNation.org 39 COMPREHENSIVE ADDICTION AND RECOVERY ACT AND THE 21ST CENTURY CURES ACT In 2016, two laws were passed to a grant for a residential program for help combat the opioid epidemic: the pregnant and post-partum women and Comprehensive Addiction and Recovery their children; and Act and the 21st Century Cures Act l eterans Treatment Courts and other V (Cures Act).210, 211 programs targeting veterans, such as The Comprehensive Addiction and peer-to-peer mentoring, to increase Recovery Act (CARA), 212 signed in July opioid safety practices and treatment 2016, authorized up to $181 million for options for veterans struggling with programs designed to reduce addiction opioid addiction.214 215 216 and promote recovery. It did not, however, The 21st Century Cures Act,217 signed appropriate any funds for these programs, into law in December 2016, authorized and in the FY 2017 budget process $158 more than $6 billion in healthcare million of the authorized $181 million was spending and included $1 billion to target appropriated to CARA initiatives.213 CARA the opioid crisis to be distributed over promotes a number of strategies, including: the subsequent two years. Additionally, l revention and education initiatives, P several provisions were designed to such as community-based drug improve access to mental health care. education programs, PDMPs, outreach Congress appropriated the first $500 to teen athletes, drug take-back million of Cures Act funding in December programs and research into the causes 2016, and the President’s FY 2018 and cures of opioid addiction; budget requests another $500 million for Cures Act programs.218 The Cures Act l ccess to Medication-Assisted Treatment A supports several initiatives to combat the (MAT) by authorizing, for the first time, opioid epidemic, including: nurse practitioners and physician assistants to prescribe and administer l ederal leadership and accountability F buprenorphine and by expanding access for substance misuse and mental to buprenorphine for many populations, health issues by, for example, creating including inmates in correctional facilities; an Assistant Secretary for Mental Health Substance Abuse to coordinate l ccess to overdose treatment by A federal mental health programs and a supporting programs to expand naloxone National Mental Health and Substance access and training for first responders Use Policy Lab to guide grants awarded and community members; by SAMHSA; l iversion programs to steer those with D l ntegration of care between primary I dependence towards treatment instead and behavioral health systems by, for of jail; example, making it a condition for l revention of relapses by supporting P state-level grant dollars and creating a Building Communities of Recovery; technical assistance center to support integration efforts; l reatment for mothers and children who T are dependent on opioids by authorizing 40 TFAH • WBT • PaininTheNation.org l vidence-based prevention and E treatment practices, including workforce training for prevention, treatment and recovery support for workforces, improvements to PDMPs, opioid treatment programs and other public health activities through block grants to the states; l ecriminalizing behavioral health D issues by, for example, researching the effectiveness of diversion programs for certain individuals with mental illness and creating a federal Drug and Mental Health Court pilot program; l mproving law enforcement responses I to behavioral health situations, including grants for Crisis Intervention Team (CIT) interpretation of the Medicaid statute to programs and de-escalation training prohibit reimbursement for mental health for law enforcement and other first and primary care services provided to an responders; individual on the same day; l uicide prevention by, for example, S l arity enforcement, by requiring HHS to P revising and reauthorizing suicide issue new compliance guidance to health hotlines and other suicide prevention plans and to create an action plan for programs, including creation of a College improved federal and state coordination Campus Task Force at HHS; and related to parity enforcement; l orkforce development to encourage, W l ccess to mental health and substance A for example, medical residents and use disorder records to provide better fellows to practice psychiatry and continuity of care by requiring HHS to addiction medicine in underserved and issue final regulations within one year rural areas, and the establishment of a clarifying under the HIPAA circumstances minority fellowship program for mental by which a healthcare provider may health and substance use disorder share protected health information; and professionals.219 l reventive services for children P The Cures Act also contains measures receiving inpatient mental health care to support mental health care programs, by specifying that youth under 21, who including existing SAMHSA programs such as are receiving Medicaid-covered inpatient suicide prevention and mental health training. psychiatric hospital services, are also Additional mental health provisions include: eligible for the full range of early and l ame-day billing for mental health S periodic screening, diagnostic and and primary care, rejecting a previous treatment (EPSDT) services. TFAH • WBT • PaininTheNation.org 41 Key Policies Many of the current policy strategies to pain; new, innovative medications and policy groups, consumers, payers address the epidemic focus on the acute technologies to treat opioid use disorders; and the private sector, and other priorities of reducing the availability of and improved overdose prevention and provider and patient organizations, prescription and illicit opioids available reversal interventions to save lives and recognize there are twin epidemics for misuse and reducing the harms and support recovery. of pain and opioid misuse. They risks of misuse, addiction and overdoses. have issued policy recommendations Another key component is to support for ensuring the needs of pain Due to the urgent nature of the crisis, better training for informed and patients — both adults and children much of the response has focused on responsible prescribing practices. CDC — are appropriately recognized emergency services for responding has developed guidelines for prescription in the process of creating best to overdoses and trying to increase opioid use for chronic pain with input practice guidelines for providers to the availability of effective treatment from patient and medical groups. ensure the needs of these patients of opioid use disorder when there is l Provider Education and Informed are appropriately met. Around 11 a shortage of services, providers and Practices. Education for practitioners percent of adults (25.3 million) and issues around coverage and systems is a critical component to reducing between 5 and 38 percent of children for treatment (see Section B: Improving incidences of prescription drug misuse experience chronic pain.222, 223 Behavioral Health Services for more discussion — including support for continuing on treatment). There are also a number • n 2016, CDC issued Guidelines for I education support, particularly as the of efforts to support community-based Prescribing Opioids for Chronic Pain, field and guidance may change over programs that focus on trying to prevent and more than 60 medical schools time.220 Recommended subject matter misuse in the first place. committed to including it in their include: treating pain in a holistic curricula. 224, 225 CDC recommends that The following section examines key manner, appropriate prescribing, critical clinicians consider pain management approaches being used to address thinking skills, use of state PDMPs and regimens that do not involve opioid the opioid epidemic. They are being addiction identification and referral therapy, and states that non-opioid implemented and funded at varying to treatment. Many medical, dental, therapy is preferred for managing levels around the country. A broad pharmacy and other health professional “chronic pain outside of active cancer, recommendation would be to ensure schools provide only limited training on palliative and end-of-life care.”226 the strategies can be effectively substance misuse and pain treatment. Non-opioid pain management scaled and supported to benefit every • number of states have enacted A therapies include physical therapy, community where opioids are an issue. or adopted training requirements exercise, cognitive behavioral therapy for certain prescribers, including and non-opioid medications, such Pain Treatment and Management — through licensing requirements as acetaminophen or ibuprofen and Changing Prescribing Practices. for treatment in pain clinics. In or steroid injections. There are A top priority is to find additional and 2016, the National Conference of no corresponding guidelines for effective ways to treat and manage pain State Legislatures (NCSL) began prescribing for acute pain. and to provide training to all health tracking provider training on pain providers who may prescribe opioids, as • CMS issued a set of best practices for management, and at least 11 laws well as continuing to support research and opioid prescribing and treatment, have been enacted in nine states.221 development into innovative approaches including supporting more opioid for addressing pain. A number of • he Pain Action Alliance to T prescribing education and training health organizations, provider groups, Implement a National Strategy for prescribers, and FDA is expected pharmaceutical companies and NIH (PAINS) consortium of leaders to update its Risk Evaluation and are working to develop: safe, effective, working in professional societies, Mitigation Strategy in 2017 requiring non-addictive strategies to manage patient advocacy organizations, manufacturers to offer voluntary 42 TFAH • WBT • PaininTheNation.org opioid training programs to U.S. licensed prescribers.227, 228, 229 FDA’s prescriber education initiative, Search and Rescue, helps connect REDUCE OVERDOSE. prescribers with resources on the latest prescribing guidelines, PRESCRIBE RESPONSIBLY. screening tools and PDMP best OVERPRESCRIBING LEADS TO MORE ABUSE AND MORE OVERDOSE DEATHS. 4x practices to help identify at-risk patients, prescribe responsibly and guide patients in need to increase in sales of prescription opioids appropriate care.230 since 1999. • number of medical professional A In that same organizations and schools are time more than 165,000 expanding efforts to provide opioid- related education and training. According to AMA, more than 118,000 physicians completed people have died training in opioid prescribing, pain from overdose related to management, addiction and other prescription opioids. related issues in 2015 and 2016.231 In April 2017, the Federation of State Medical Boards updated its model policy for medical and osteopathic boards on assessing a clinician’s management of pain — whether opioid use is both medically REFER TO THE CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN FOR RESPONSIBLE PRESCRIBING OF THESE DRUGS1. appropriate and in compliance with applicable state and federal 1 USE NONOPIOID THERAPIES Don’t use opioids routinely 2 START LOW AND GO SLOW When opioids are used, start 3 FOLLOW-UP Regularly assess whether laws and regulations.232 At least 74 for chronic pain. Use with the lowest effective opioids are improving pain nonopioid therapies alone or in dosage and short-acting and function without causing schools of medicine have signed combination with opioids. Only opioids instead of extended­ harm. If benefits do not consider opioid therapy if you release/long-acting opioids. outweigh harms, optimize onto an Association of American expect benefits for pain and other therapies and work with Medical Colleges statement.233 function to outweigh risks. patients to taper opioids. The American Board of Medical 1 Recommendations do not apply to pain management in the context of active cancer treatment, palliative care, and end-of-life care Specialties recognized addiction medicine as a subspecialty in March GUIDELINE FOR PRESCRIBING 2016, and has focused on supporting OPIOIDS FOR CHRONIC PAIN addiction medicine fellowships to train physicians in preventing, LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html identifying and treating addiction and related physical and psychiatric conditions. In 2017, they offered 40 fellowships and aim to have 65 by 2020 and 125 by 2025.234, 235 TFAH • WBT • PaininTheNation.org 43 l Prescription Drug Monitoring Programs. to be “locked-in” to using a single • ake use mandatory for all M PDMPs are a database tool that track pharmacy to monitor and coordinate prescribers, require timely dispensed controlled substances in the safety of their prescriptions.238 reporting of data and link PDMPs a state. They allow doctors, dentists, Some patients continue to circumvent to Electronic Health Records. pharmacists, other health providers, lock-in policies by paying out-of-pocket Some recommended practices public health and law enforcement to for their medicines.239 are to mandate prescribers use access information about individual the databases before prescribing Every state and Washington, D.C. and population prescribing patterns.236 opioids and benzodiazepines; currently have some level of PDMP, PDMPs can help support safe and allowing “authorized delegates” but they vary significantly in the level effective prescribing and dispensing within healthcare offices to be of funding, support and use they practices — informing clinical able to use the systems to support receive. CDC, the Prescription Drug decision-making, enhancing care prescribers;245 ensuring timely Monitoring Program Training and and reducing risks of overprescribing entry of prescriptions/data; linking Technical Assistance Center (PDMP and identifying when a patients’ PDMPs to Electronic Health Records TTAC) at Brandeis University, National pain is not being well managed or according to protocols that protect Alliance for Model State Drug Laws may be suffering from pain or a patient privacy laws; and interstate (both receiving support from DOJ), drug dependence (if integrated with interoperability/data-sharing. It and Shatterproof have proposed Electronic Health Records). They is also important for states to work a number of best practices for can help identify possible provider with state and local public health, PDMPs.240, 241, 242, 243 CDC encourages overprescribing (intentional and including local health departments, universal use, real-time reporting, unintentional) and areas with higher to disseminate analyses of prescribing active management and easy use and than expected rates of prescribing. and overdose trends. Improving data access for providers.244 Some key They help identify providers who may collection and analysis around opioid recommendations for improving and be overprescribing (“bad actors” or misuse, dependency and overdose expanding the use of PDMPs include: “pill mills”) and “doctor shopping” helps the state and local public individuals. A number of reviews • rovide sufficient funding for P health to identify concerns and target have called for increased research PDMPs. States use various prevention and reduction strategies.246 into PDMPs and best practices, and to mechanisms to fund their PDMPs, • At least 37 states have some provide “insight into how variations including: grants (private, mandatory PDMP use requirement among PDMPs modify program philanthropic or from the federal — where 23 states and Guam effectiveness, to suggest potential government); general revenue funds; require querying the PDMP means of better utilizing PDMP and controlled licensing fees; regulatory before prescribing or dispensing to limit possible unintended negative board funds; legal settlements; opioids, and 14 additional states outcomes.”237 PDMP licensing fees; and/or health require querying the PDMP insurance licensing fees. Some Some related practices to using before prescribing and dispensing states do not allow general treasury PDMPs include requiring patient opioids.247 Some studies have funds to be used to support PDMPs, identification prior to dispensing shown the effectiveness of and some programs are supported opioids, prohibiting dispensing of mandatory use.  For instance, in only by time-limited grants. Federal certain medication in the office setting Kentucky, requirements increased support for PDMPs comes from (requiring pick up at a separate use five-fold; multiple prescriptions SAMHSA, CDC’s Prevention for pharmacy) and for patients with high were reduced by more than States and the DOJ’s Harold Rogers patterns of receiving prescriptions half; and opioid prescribing was PDMP Grant Program. from multiple providers to be required reduced by around 12 percent.248 44 TFAH • WBT • PaininTheNation.org In Tennessee, PDMP use increased by more than 400 percent; PDMP Mandatory Query by Prescribers and Dispensers (Listing of the specific conditions for mandatory query) opioid prescribing decreased VT by 7 percent within one year; PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC ME TTAC PDMP TTAC PDMP TTAC PDMP WA NH and patients being able to fill MT ND MA MN PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC multiple overlapping prescriptions OR WI NY RI SD CT PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC decreased by 31 percent.249 A ID WY MI PA NJ IA best practices guidance memo NE OH DE PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC IL IN NV WV VA UT from CMS identified a strategy CO PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMPDC PDMP TTAC PDMP TTAC KS KY TTAC MD CA *MO NC where state Medicaid programs TN OK PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC SC AZ NM AR can consider including language GA PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC MS AL PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC in provider agreements and LA AK TX managed care contracts to require PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC FL that providers access their state PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP as a condition of provider PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC Prescribers and Dispensers (14) agreement and payment, along HI PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC Prescribers Only (24) PDMP TTAC PDMP TTAC PDMP TTAC with mandatory electronic GU prescribing.250 PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTAC PDMP TTACNo Mandatory Query (14) PDMP TTAC PDMP TTAC PDMP TTAC Research is current as of August 24, 2017 *Missouri does not have a state-wide PDMP • orty-two states and Washington, F D.C. require pharmacies to submit data daily; one state (Oklahoma) had real-time reporting; three had Frequency of Data Reporting Authorized by Bill/Statute/Rule/Ordinance* (exceptions for veterinarians or others may apply; effective dates may vary) 72 hours requirements; and four states had 7-8 day requirements (as WA NH ME of October 2017).  Oklahoma’s real- MT ND VT OR MN time reporting is credited with being ID SD WI NY MA a contributing factor to a tripling of WY MI RI PA CT PDMP use among prescribers (from NE IA NJ NV OH IN DE 24 percent to 86 percent).251 UT CO IL WV CA KS VA MD MO KY DC • haring PDMP information S TN NC AZ OK between states, particularly NM AR SC Real time (1) MS AL GA bordering states, is important given No later than daily/ TX that patients may go to doctors LA 24 hours/1 business AK day (40 + D.C.) or pharmacies across state lines.  FL 3 business days/ Forty-four states and Washington, HI 72 hours (1 + RI for non-opioids) D.C. are sharing data — either 8 days (1) PDMPs share data with other Weekly/7 days Michigan requires daily reporting for online reporting of dispensing information and PDMPs or allow authorized users weekly for mail-in submission of data. (6 + St. Louis County ) to set up accounts with different Rhode Island’s daily reporting requirement applies to opioid prescriptions. Data for non-opioid prescriptions must be reported 3 business days/72 hours after dispensing. state programs; five states are * PLEASE NOTE: Preparation for implementation may result in a time difference between implementing data sharing (as of the enactment or effective date and the date of implementation of the reporting frequency. September 2017).252 Source: National Alliance for Model State Drug Laws TFAH • WBT • PaininTheNation.org 45 Community-based Strategies. There are numerous effective, evidence- and disposal of prescription drugs, efforts around prescription drug based programs that can support local including educating the public about use, including issuing publications communities to reduce drug misuse the benefits and risks of taking opioids, to provide community anti-drug and related problems — while also information about how individuals can coalitions with the research and tools promoting stronger well-being and develop dependencies and the risks to they need to implement effective community vitality. However, there is be alert to when taking opioids, as well prevention strategies and train currently insufficient infrastructure or as about the need to safely store drugs community anti-drug coalitions in resources to scale them and ensure they so they are only used by the prescribed effective community problem-solving benefit most local areas. patient and the safe disposal of any excess strategies using local data.254 medications when they are not needed. Most states and many local communities l Communities That Care255 was have created task force or coalition SAMHSA, CDC and ONDCP help developed by the Social Development efforts to deal with the opioid crisis. develop and evaluate best practice Research Group at the University of However, these vary widely in terms of policies and programs, and advise and Washington to provide a prevention- their scope and resources. provide assistance to support state and planning system and network of community activities to combat the expert support for the use of evidence- The most effective efforts include epidemic.253 In addition, a number based approaches that promote the multi-sector engagement — leveraging of organizations — including the positive development of children the expertise and assets from within a Community Anti-Drug Coalitions and youth and prevent problem community — bringing together major of America (CADCA), Partnership behaviors. Hundreds of U.S. and institutions (across sectors), like hospitals for Drug-Free Kids, Communities international communities have used and healthcare systems, universities That Care, Community Catalyst and this evidence-based approach, which and schools, businesses, community numerous other initiatives around the involves all parts of a community to organizations and faith-based groups country — have led the way in providing target predictors of problems, rather (see Section III-C for recommendations for support for community-based efforts to than waiting for problems to occur. It creating systems to scale and support Multi- prevent and reduce drug misuse. (See is grounded in research from public Sector Community Health Improvement and Section III-D for more discussion on school- health, psychology, education, social Well-being Partnerships). Drug misuse is community prevention programs). work, criminology, medicine and having a negative impact on families and organizational development. communities throughout the country — For instance, groups like CADCA, including acutely impacting emergency Communities That Care and the A randomized controlled test of and healthcare services, the workforce, PROSPER project provide support Communities That Care programs in child welfare and foster care and social and technical assistance to some of the 24 communities across seven states service systems. Solutions must involve leading efforts in the country. However, that followed 4,407 fifth grade youth the leaders, institutions and members of the number of communities receiving found that by the spring of eighth communities themselves — leveraging support and funding are very limited in grade, significantly fewer students resources, expertise and community scale, where nearly every community in from participating communities had engagement. The most effective, the country would benefit from this type health and behavior problems and long-term efforts have a sustained of effort. For instance: were 25 percent less likely to have management structure, a financial initiated delinquent behavior; 32 l CADCA is the largest national agent, and expert and technical percent less likely to have initiated membership organization that assistance support. alcohol use; and 33 percent less likely works to strengthen the capacity of to have initiated cigarette use.256 The Many prevention initiatives also support community coalitions to create and results were sustained through 10th public education about the risks and maintain drug-free communities. and 12th grades — with 25 percent use of opioids (for instance CDC’s Rx CADCA has engaged in ongoing lower odds of engaging in violent Awareness Campaign) and safe storage educational and communications 46 TFAH • WBT • PaininTheNation.org behavior. A cost-benefit analysis parenting and youth skills outcomes found a $4.23 benefit for every dollar and reduces negative peer influences. Total federal spending to invested in the Communities That support prevention in states There are limited sets of federal Care operating system.257 government grants to support is less than 1 percent of the l The PROSPER project (PROmoting community prevention efforts. Total School/community-university federal spending to support prevention economic costs of prescription Partnerships to Enhance in states is less than 1 percent of the opioid overdoses and misuse. Resilience),258, 259, 260 developed by economic costs of prescription opioid the Partnerships in Prevention overdoses and misuse (less than $1.5 Science Institute and the cooperative billion in prevention grants in FY 2016 Total State Substance Abuse extension, is an evidence-based vs. $78.5 billion on prescription opioid Prevention Expenditures, $536 million, State FY 2014 delivery system for supporting misuse and overdose in 2013).264 Some sustained, community-based larger initiatives include: Local/ State implementation of scientifically- 19.48% Other l SAMHSA supports prevention focused 0.39% proven programs that reduce Other activities in communities — where Federal adolescent substance misuse or other 11.82% states are required to direct at least 20 problem behaviors and promote SAPT percent of funds from the Substance Block youth competence. The PROSPER Abuse Prevention and Treatment Medicaid Grant delivery system has been shown 0.01% 68.30% Block Grant (funded at $1.85 billion to reduce a number of negative in FY 2016) to support primary behavioral outcomes, including prevention efforts. These funds Source: NASDAD drunkenness, smoking, marijuana use, make up 68 percent of all funding use of other substances and conduct for primary prevention in states.265 behavior problems, with higher-risk Funding for SAPT has decreased youth benefiting the most.261, 262, 263 by 26 percent over the past decade PROSPER also demonstrates positive (adjusting for inflation). effects on family strengthening, SAMHSA’S STRATEGIC PREVENTION FRAMEWORK (SPF) FOR COMMUNITIES266 The steps of the SPF include: l tep 1: Assess Needs: What is the S problem, and how can I learn more? l tep 2: Build Capacity: What do I have S to work with? l tep 3: Plan: What should I do and S how should I do it? l tep 4: Implement: How can I put my S plan into action? l tep 5: Evaluate: Is my plan succeeding? S Source: SAMHSA TFAH • WBT • PaininTheNation.org 47 l Drug-Free Community (DFC) grants • For middle school youth living in Percentage Change in Past 30-Day support community-based coalitions DFC-funded communities, data from Alcohol, Tobacco, Marijuana, and that work to prevent youth substance the DFC National Evaluation found: Prescription Drug Prevalence of Use: misuse, and federal funds require a a 24.4 percent reduction in alcohol Significant Long-term Change Among local-support match.267 The program, use, 29.4 percent reduction in FY 2013 DFC Grantees managed by ONDCP and SAMHSA’s tobacco use, 15.1 percent reduction Center for Substance Abuse in marijuana use, and a 21.4 percent Prevention, has funded more than reduction in prescription drug 2,000 coalitions and mobilizes nearly misuse. Additionally, high school- 9,000 community volunteers annually. aged youth have reduced their use In FY 2016, $85.9 million funded 92 of alcohol by 15.5 percent, tobacco new DFC grants, 585 continuation by 23.7 percent, marijuana by 4.9 grants, three new DFC Mentoring percent and prescription drug (DFC-M) grants and 18 continuation misuse by 14.5 percent in DFC- DFC-M grants.268, 269 funded communities. Source: Drug-Free Communities 48 TFAH • WBT • PaininTheNation.org l CDC — there is increased funding for opioids in the FY 2017 Omnibus Appropriations bill — supporting a total of 45 states and Washington, D.C. through its Overdose Prevention in States (OPIS) effort, including: • revention for States (PfS). CDC P provided competitive grant funds to 29 states to execute and evaluate prevention strategies for safe prescribing practices and to prevent misuse, dependency and overdoses. Through 2019, CDC plans to give states within the program $750,000 to $1 million to advance: PDMPs, community and/or health system interventions, policy evaluations and rapid hotspot response efforts. For example, the CDC-supported Injury Center supported five state health departments (Kentucky, • Data-Driven Prevention Initiative overdoses. Funds will be used by Oklahoma, Tennessee, Utah and (DDPI) — $4.6 million in additional states to implement innovative West Virginia) with funding and funds will go to 12 states and surveillance activities and to scientific assistance following the Washington, D.C. in program support comprehensive toxicology initial identification of the opioid expansion supplemental awards. testing within medical examiner epidemic in their communities. and coroner offices. Many of the 32 • States are actively working to: • tates are actively working to: S states with these grants overlap with • Improve data collection and PfS and DDPI states. • nhance and maximize PDMPs; E analysis around opioid misuse, • mplement community or insurer I dependency and overdose; • State activities include: mechanisms or health systems • evelop strategies that impact D • Establishing an early warning interventions; behaviors driving prescription system to detect sharp increases • valuate the impact of E opioid misuse and dependence; or decreases in non-fatal opioid prescription drug-related state and overdoses; policies; and • Engage communities to develop • Collecting information on the • evelop Rapid Response Projects D more comprehensive opioid number and rate of opioid that give states flexibility in overdose prevention programs. overdose deaths; quickly responding to changing • Analyzing information from • Enhanced State Opioid Overdose circumstances in communities. toxicology tests and death scene Surveillance (ESOOS) — $4.7 investigations; and • mong the 29 states receiving grant A million in additional funds will funds, 27 states will receive an additional go to 32 states and Washington, • Providing information on key $19.3 million in supplemental funding D.C. to better track and prevent risk factors contributing to opioid for program expansion. opioid-involved non-fatal and fatal overdose deaths. TFAH • WBT • PaininTheNation.org 49 Surveillance. Safe Storage. and production of tamper-resistant Understanding the scope of the problem Disposal and Take Back Programs. prescription opioids and the FDA has is essential to helping solve it. CDC, These strategies help to ensure only issued guidance for the industry on SAMHSA, state and local public health intended patients access opioid the evaluation and labeling of tamper- departments and State Alcohol and medications and reduce the number deterrent opioids.274 In 2017, FDA Drug Abuse Directors often have a of unused medications that may be requested the removal of one opioid, primary responsibility for tracking health available in homes and institutions. Opana, from the market in response problems and related contributing A majority (53 percent) of people to reports of misuse and diversion.275 factors within communities. Strong who misuse prescription drugs get FDA is taking greater action to take surveillance is essential to understanding them from friends and family.271 Of cost-benefit concerns and expand pre- public health issues within specific areas individuals who are more likely to and post-market studies of opioids. and developing effective strategies to overdose, 27 percent get opioids from Many have expressed concern that address and evaluate them. Key national their own prescriptions, 26 percent tamper-resistant formulations may have systems that state and local agencies work receive free from friends or family, 23 had the unintended consequence of with in collaboration include: Web-based percent buy from friends or family and contributing to the use of heroin and Injury Statistics Query and Reporting 15 percent buy from a drug dealer.272 other illicit opioids.276 System (WISQARS), Wide-ranging Controlling the amount of opioids ONline Data for Epidemiologic Research prescribed is important to avoid having Stopping the Supply of Heroin, (CDC WONDER), National Violent excess supply. Important efforts also Fentanyl and Carfentanil. Death Reporting System (NVDRS), seek to ensure unused drugs are either The rising use of illicit opioids — due Youth Risk Behavior Surveillance System taken out of circulation or properly to lower cost and increased availability (YRBSS), National Survey on Drug Use disposed of. Many communities — has become a top priority for federal, and Health and Monitoring the Future sponsor “Take Back” programs, where state and local agencies.277 Significant (MTF). Each are essential tools for people can turn in unused prescription portions of the supply are coming tracking and understanding the rise in drugs, and an increasing number of from outside of the United States — alcohol, drug and suicide deaths and police and fire stations and pharmacies including by mail — and there have contributing factors, and ultimately have standing Take Back centers. CDC, been increasing trends of traffickers inform more effective strategies. For state and local public health agencies, mixing the lower-cost and more potent instance, recent reports have tracked law enforcement agencies and drugs fentanyl and carfentanil with patterns in the rising and shifting use pharmacies often sponsor Take Back heroin to maximize their profits. of heroin and fentanyl, and reductions days and public education campaigns. Individuals are then often unknowingly in prescription opioid prescribing Another emerging strategy is providers using drugs that are even more potent while at the same time identifying areas and pharmacies supplying patients with than expected, leading to increases in where prescribing rates are still higher safety bags along with their medications overdoses (fentanyl can be 50 to 100 than the norm. They also have been where they can seal unused medicines. times more powerful than heroin, and instrumental in assessing hepatitis C and The bags contain a neutralizing agent carfentanil is 100 times more powerful HIV growth rates in areas of the country that deactivate the drugs so they than fentanyl). The Customs and related to the increased use of injection can then be disposed of in regular Border Patrol seized approximately 8 drugs. The President’s Commission on garbage.273 pounds of fentanyl in 2014 and nearly Combating Drug Addiction and Opioid 200 pounds of the drug in 2015.278 Crisis interim report identified two key Tamper-Resistant Formulations. l Target heroin and fentanyl imports. prevention efforts: the need to develop While FDA notes that it is impossible to Heroin and synthetic opioids are a “national prevention strategy using make drugs completely tamper-proof primarily being imported into the ‘big data analytics’ to devise targeted and instructions for tampering can United States, with heroin most often prevention messages that employ be found on the internet, there has coming from Columbia and fentanyl cutting-edge methods of marketing and been an increase in the development from Canada, Mexico and China.279, 280 communication.”270 50 TFAH • WBT • PaininTheNation.org China did not regulate the manufacture Illicit Fentanyl and Fentanyl Precursor Flow Originating in China or sale of fentanyl until 2017, when it added additional synthetic opioid formulations to its list of controlled substances after requests from the United States.281, 282 Continuing to work with these countries to limit trafficking into the United States is important — as well as supporting and adequately funding law enforcement efforts to stop large criminal organizations who are most responsible for the overall supply of illegal drugs, like the DOJ’s Organized Crime Drug Enforcement Task Forces (OCDETF).283 l Support domestic anti-drug trafficking programs. Initiatives such as the High Intensity Drug Trafficking Areas program, run by ONDCP, provide grants and other support Source: DEA to federal, state, local and tribal prevention and treatment, ONDCP agencies by directing resources to estimates that each $1 of HIDTA “hot spots” for drug production and funding in 2016 yielded a return on trafficking.284 There are currently 28 investment of $75.34.287 In 2016, HIDTAs covering 49 states, as well as HIDTA-supported programs: Washington, D.C., Puerto Rico, the • isrupted or dismantled 2,668 D U.S. Virgin Islands and the Warm drug trafficking or money Springs Indian Reservation, and 752 laundering organizations; initiatives specific to each geographic area.285 In addition, 20 states and • eized 5.2 tons of heroin and 1 ton S eight HIDTAs are now coordinating of prescription opioids; efforts to address the spike in heroin • rovided training for 77,913 P use and fatalities as part of the HIDTA criminal justice professionals; Heroin Response Strategy. • pprehended 50,923 fugitives A • he HIDTA program is designed T involved with drug trafficking, to be flexible, drawing on data violent crime and gangs as well as from dozens of intelligence and other major crimes; and investigative support centers to • eized $547 million in illegally- S bring together information, identify gained cash from drug trafficking trends and assess threats.286 Every and money laundering HIDTA sponsors initiatives focused organizations to be equitably on prevention, coordination and shared with tribal, local, state and support for local law enforcement federal government agencies.288 strategies. Excluding funding for TFAH • WBT • PaininTheNation.org 51 Reducing Harm and Preventing and Enforcement Assisted Diversion individuals who may be at high risk Reducing Risks of Misuse, Addiction (LEAD), which is a pre-booking for overdose, and are changing laws and Overdoses diversion program that establishes to limit liability for individuals seeking There are also a number of important protocols where police divert people or providing medical assistance for strategies to help reduce the harm away from traditional criminal an overdose, called overdose Good and impact of substance use disorders. justice processes into health-based Samaritan laws. The risk for overdose, vein damage intensive case management where the According to the AMA, more than and contracting infections like individual receives support services, 32,000 prescriptions were written for HIV and hepatitis C have serious including for drug treatment and naloxone in the first two months of life-and-death and other health mental health along with needed 2017, compared to 4,291 in the entire consequences. The legal and social supports such as housing.290 second quarter of 2015 — and the policies around substance misuse have l Expanding Naloxone Access and Good number of prescriptions increased by major implications for individuals and Samaritan Laws. One important area almost 500 percent for the first two communities. Public health approaches of focus is to respond effectively to months of 2017 compared to the first focus on: providing support and overdoses. An emergency prescription two months of 2016.293 connections to treatment and recovery medication called naloxone can to individuals; reducing the supply Significant barriers remain to be used to reverse the effects of an of drugs and supporting responsible broader use of naloxone, including: opioid overdose if used promptly.291 and appropriate use of prescription 1) the prescription requirement (a The practice of providing naloxone medicines; and treating addiction as change that a number of experts started with harm reduction programs, a public health and not a criminal have recommended and the FDA has especially syringe exchange programs. concern and avoiding compounding indicated it is reviewing)294, 295 and 2) Expanding naloxone access has the negative impact for families, or cost.296, 297 In recent years, the cost of gained support over the past decade advancing high-cost and ineffective naloxone has increased dramatically, as the opioid epidemic escalated, with approaches within the justice system. in some instances by more than 1000 support from the U.S. Conference percent.298 Some local governments l Treat Substance Misuse as a Health of Mayors (2008 Resolution), AMA and overdose treatment clinics are Issue. One key priority is focusing (2012 Resolution), the American struggling to afford enough of the drug on substance use disorders as public Public Health Association (APHA) to meet their need, and local lawmakers health issues and getting treatment (2012) and a number of other have proposed rationing dosages.299 and care for individuals to provide organizations.292 support. Moreover, it must also be l State Naloxone Laws. As of July 2017, Most state governments, as well as viewed as a top strategy for reducing all 50 states and Washington, D.C. have local and federal programs, have additional misuse. Treating substance modified their laws to increase access expanded the availability and support use disorders as a public health issue is to naloxone by providing immunity to for naloxone. This includes ensuring important to reducing stigmas around medical professionals who prescribe or first responders have it available disorders and seeking help. Evidence dispense naloxone or individuals who when responding to emergencies. supports that arrests and severity of possess or administer naloxone, and In addition, many public places criminal punishment for drug-related 48 states and Washington, D.C. allow and institutions are starting to have offenses have not reduced demand third party prescribing (all but Kansas naloxone on their premises (libraries, of sales.289 Some communities have and Minnesota).300  Some laws provide community centers, schools and adopted different approaches that, civil, criminal or disciplinary immunity universities) and are providing while still criminalizing addiction, are for prescribers, dispensers, laypersons training to some staff to be able to less focused on being “punitive.” For or all three.  Other laws permit administer it. Also, many providers instance, some strategies for deterring organizations that are not otherwise and states are supporting policies use include use of drug courts, where permitted to dispense naloxone, and practices to prescribe naloxone individuals are connected with care such as nonprofits and syringe access to individuals or the families of and services, and programs like Law programs to distribute the medication.  52 TFAH • WBT • PaininTheNation.org • orty-five states and Washington, F D.C. provide civil, criminal and/or Status of Relevant Laws as of May 15, 2017 disciplinary immunity to prescribers; 43 states and Washington, D.C. WA MT ME provide civil, criminal and/or ND VT OR MN disciplinary immunity to dispensers; NH ID SD WI and 46 states and Washington, NY MA WY MI CT RI D.C. provide civil and/or criminal IA PA NJ NV NE immunity to lay administrators.301  OH DE UT IL IN CA MD CO WV KS MO VA DC • orty-six states’ laws allow third-party F KY prescriptions via standing order of TN NC AZ OK naloxone to a family member, friend NM AR SC or other person in a position to assist MS AL GA a person at risk of experiencing an TX LA overdose.302  FL AK • ifteen states allow laypersons to possess F HI the drug without a prescription.303, 304  States with nalaxone access and Good Samaritan laws • n 2016, CMS highlighted steps I States with nalaxone laws only different Medicaid programs are taking to improve naloxone access, Source: Network for Public Health Law including:305 expanding community- based naloxone distribution programs; including naloxone on the possession of a controlled substance.  state’s Medicaid Preferred Drug List; However, 21 states, including Alaska, making naloxone available without North Carolina and Virginia, do not a prescription; increasing trainings protect such individuals from being on opioid overdose risks and how to charged.  Vermont, Hawaii and Nevada respond; and passing laws to assuage have the broadest version of the law, liability concerns associated with providing protection from protective the prescription, distribution, or or restraining orders, probation or administration of naloxone. parole violations and civil forfeiture, l State Good Samaritan Laws.  Forty as well as laws providing that reporting states and Washington, D.C. have an overdose can be a mitigating factor some form of Good Samaritan law that in sentencing for crimes for which reduces legal penalties for an individual immunity is not provided.  Some states seeking help for themselves or others have more limited laws where people experiencing an overdose (as of May assisting an overdosing individual 2017).306  These laws, however, vary receive protection but the individual significantly from state to state.  Thirty themselves may not be protected from states’ and Washington D.C.’s Good legal action.  Utah requires, and Indiana Samaritan laws prevent an individual permits, courts to take the fact that a who seeks medical assistance for Good Samaritan summoned medical someone experiencing a drug-related assistance into account at sentencing.  overdose from being prosecuted for TFAH • WBT • PaininTheNation.org 53 Sterile Syringe Access. Numerous studies have shown that Increase in new cases of acute The increase of heroin and opioids syringe access programs are one of the hepatitis C infections reported from that are often injected, in areas where most effective and scientifically-based 2010 to 2013 non-evidence-based laws and policies methods for reducing the spread of HIV make it difficult to access sterile and hepatitis — and do not contribute syringes, has also contributed to a to increased drug use. Needle exchange dramatic rise in HIV and hepatitis C programs have been endorsed by leading virus (HCV) infections in a number of scientific organizations and individuals, 151.5% communities and has contributed to including NAM; the World Health many policymakers reexamining syringe Organization; the American Academy exchange policies as an effective strategy of Pediatrics (AAP); AMA; the American for helping to reduce rates. Nurses Association; and the APHA.315, 316, 317 These programs also provide important l N ew acute hepatitis C infections have points for individuals seeking help and increased by 151.5 percent in reported connections to treatment and other cases from 2010 to 2013 (increases are social services.318 Many law enforcement attributed to both real incidence and officials also support them as an effective heightened detection efforts).307 Of harm reduction strategy to limit the the 39 states that reported data in both adverse effects associated with drug use 2010 and 2013, 28 states had an increase to individuals and communities and to in persons newly infected with HCV. limit the exposure of police, emergency According to CDC, the increase has workers, healthcare providers and others predominantly been among young adults in the community to contaminated (under 30 years old) who are White, live needles.319 The symptoms of HIV in non-urban areas, particularly in the and HCV may not appear for years, so East and Midwest, and have a history of individuals may continue to spread the injection drug use and previously used diseases to others without even knowing prescription opioids.308, 309 they are infected. These programs, l I n Kentucky, Tennessee, Virginia and however, have been at the center of West Virginia, acute HCV infections political debates, many of which are increased by 364 percent from 2006 based on some long-held misperceptions, to 2012 — a majority of those infected creating a challenge for the medical have been White adolescents and community and policymakers. adults under 30 who inject drugs.310 In December 2015, Congress partially l I n May 2015, there were 135 confirmed lifted restrictions on the use of cases of HIV in rural Scott County, federal funds to support syringe Indiana — and 85 percent of the exchange programs, allowing states patients were co-diagnosed with HCV, and communities to use federal funds leading then-Governor Mike Pence to to pay for operational costs at syringe declare a State of Emergency.311, 312 exchange programs.320 l I n 2016, CDC issued a report Many communities around the country identifying 220 counties in 26 states have safe needle exchange programs, at high risk for spread of HIV and however, 30 states do not provide access HCV infections based on analysis of to a needle exchange program or pharmacy sales of prescription opioids, provide limited access at only one or two overdose deaths and unemployment locations (as of April 2017).321 rates, among other factors.313, 314 54 TFAH • WBT • PaininTheNation.org l A t least 24 states and Washington, D.C. injection sites, especially in urban have laws supporting syringe exchange locations. Public health officials in programs. This includes a number other countries also promote the use of states that have changed their laws of safe injection facilities, or safe drug in recent years related to the opioid consumption sites.329 Staff do not epidemic, including: in 2015, Colorado, administer drugs, but they are available Illinois, Indiana and Kentucky; in 2016, to provide clean needles as well as Florida, North Carolina and Utah; and counseling, monitoring and treatment in 2017, Montana, New Hampshire for overdoses, and connections with and Virginia.322, 323, 324, 325, 326, 327 This social services. Studies suggest that safe does not reflect other states that may injection facilities help prevent overdose have removed legal barriers to syringe deaths, do not increase illicit drug use programs but do not directly authorize and help connect users to services and them. treatment.330 331 There are currently facilities operating in Canada, Germany l E ven without legislative authorization, and Denmark. In 2017, there have been many states and localities operate syringe proposals to open facilities in a few exchange programs. According to the locations in the United States, including North American Syringe Exchange San Francisco, New York, Philadelphia, Network, as of May 2015, there are 228 Massachusetts and Seattle.332, 333, 334 AMA syringe exchange programs in 35 states has endorsed trying supervised injection and Washington, D.C.328 facilities because they can lead to fewer Some public health officials are overdose deaths, lower transmission of calling for exploring the use of safe disease and promote treatment. TFAH • WBT • PaininTheNation.org 55 EXAMPLES: COMMUNITY AND STATE OPIOID INITIATIVES Intermountain Healthcare The Franklin County Opioid Community Communities That Care Collaborate is a Coalition (Massachusetts) provides a comprehensive community successful collaborative example involving collaborative launched by a nonprofit healthcare and community partners healthcare system that aims to creating measurable, positive changes decrease the burden of prescription in community health. The coalition drug misuse and overdose throughout brings together youth, parents, schools, Utah. The hospital uses its community hospitals, community agencies and local benefit dollars to support the coalition, government to promote youth well-being which is based on the Communities and reduce youth substance misuse — That Care model. Intermountain including serving as the prevention arm invested $3.5 million dollars over the of the local Opioid Task Force, promoting course of three years to support the evidence-based universal education in coalition’s efforts to promote public schools, ensuring family connections awareness messaging and improve through mini-grants to schools and treatment. The collaborative works local communities, increasing the use through a multi-pronged approach and of screenings, offering intervention includes stakeholders from criminal and referral to treatment in schools justice, health centers, local and state and emergency rooms, educating the behavioral health authorities, prevention community about teen substance coordinating councils, pharmacies, use disorders and improving clinician police departments, the University prescribing practices. This region- of Utah, and the Utah Department of wide approach is co-led by Community Health, among others. The coalition Action of the Franklin, Hampshire and educates providers on the danger of North Quabbin Regions and the Franklin prescription opioids, supports public Regional Council of Governments’ awareness messaging, identifies Partnership for Youth and operates within and treats at-risk individuals, offers a network of other local coalitions in order chronic disease management courses to deepen prevention efforts. Between and provides MAT. The coalition also 2003 and 2015, a notable number of the offers training to other organizations. coalitions’ priority risk factors (laws and They have 21 community drop boxes norms favorable to substance misuse, available for medications across the parent attitudes favorable to substance state that have collected over 11,000 misuse and poor family management) pounds of medications for disposal. decreased by 17-26 percent. 56 TFAH • WBT • PaininTheNation.org EXAMPLES: COMMUNITY AND STATE OPIOID INITIATIVES North Carolina’s Comprehensive Approach to Preventing and Reversing Drug Overdoses Early in 2000, Project Lazarus, established in 2007 l N aloxone, the opioid overdose rescue state public health — a public health community-based medication; surveillance identified a surge of deaths model based on the premise that l P roject Pill Drop, a community-based in North Carolina. CDC conducted an overdose deaths are preventable and medication disposal program; investigation into the increase, finding that all communities are responsible l L azarus Recovery Services, a peer- the main driver was unintentional drug for their own health — was one of the guided recovery support program; overdoses from prescription drugs. first initiatives designed to respond to the extremely high overdose l L ocal and state data on overdose and In 2003, the Governor created the poisoning rates; and mortality rates in Wilkes County, Task Force to Prevent Deaths from North Carolina. The program sought l L ocal and state funding sources for Unintentional Drug Overdoses, which to integrate community awareness overdose prevention work. helped establish the North Carolina and coalition-building activities with Controlled Substances Reporting evidence-based overdose prevention System — the state’s PDMP. strategies. Through collaboration Since then, North Carolina has with the hospital, criminal justice Community Provider Education Education implemented a variety of measures system, first responders, behavioral to prevent overdoses. With increased health providers, primary care and access to data from the PDMP and more specialty providers and pharmacists, Addiction Hospital ED Treatment Public Awareness Policies attention to the issue, public health individual communities have developed Coalition Action Data & Evaluation continued to collect data, finding in 2007 a sustainable infrastructure and select that Wilkes County, in the northwest part interventions that resonated with, Harm Diversion of the state, had the third highest drug and were appropriate for, those who Reduction Control overdose death rate in the country. are most affected by the misuse of Pain Patient Support prescription pain medication. This The Child Fatality Task Force (CFTF) model is conceptualized as a wheel is a standing committee of the general with a hub and seven spokes with the The University of North Carolina Injury assembly that is composed of 10 hub representing community-based Prevention Research Center (UNC legislators and numerous technical bottom-up activities and the spokes IPRC) is a key partner in addressing advisors and serves as a policy component representing top-down approaches the overdose epidemic. UNC IPRC of the state’s child death review system. that communities can choose to provides evaluation, research, training CFTF provides a unique opportunity employ, such as evidence-based best and technical assistance to partners for the public health community to practices for mitigating the unintended and programs working to combat the present data and bring in outside consequences of using opioids. opioid epidemic. experts, including law enforcement l C oalition formation, capacity building UNC IPRC evaluated Project Lazarus and subject matter and harm reduction and sustainability practices; and found an initial drop in the experts to develop consensus on policy l C hronic pain management; overdose death rate of 40 percent, recommendations. Since 2010, most which grew to a 69 percent decline in bills addressing the overdose epidemic l S afe prescribing practices for providers; 2011, and has saved the health system have originated from CFTF, including l O pioid overdose education, awareness more than $1 million. The program has revisions to the reporting system and and safe medication usage materials; since been scaled statewide. better naloxone access laws. TFAH • WBT • PaininTheNation.org 57 Drug Take Backs: Operation Medicine extensive evaluation of CSRS, concluding the state to offer naloxone without a Drop is a statewide drug take back that further funding and improvements prescription under the state health initiative, started by Safe Kids North of CSRS should be included in the state director’s standing order, became law. Carolina in 2009. It operates within budget bill of 2015. The Standing Order Law was developed the Office of the Chief Fire Marshall in response to requests from the retail In 2017, the STOP Act, the most and works with the State Bureau of pharmacy industry, which wanted to comprehensive bill in the state to Investigation and a diverse group of easily offer naloxone in their pharmacy address the opioid epidemic, became partners. Since its establishment, outlets across the state. DHHS law and mandated use of CSRS, Operation Medicine Drop has collected developed a resource website with UNC placed limits on prescribing opioids and safely disposed of 89.2 million IPRC that contains technical resources consistent with cautionary thresholds pills at more than 2,000 events and on how to use the standing order. Nearly described in CDC’s Prescribing established a network of permanent 1,400 pharmacies in the state offer Guidelines and expanded naloxone drop boxes that serve most counties naloxone under the standing order law. distribution among other provisions to in the state. address the opioid epidemic. North Carolina became the first state in The state health agency noted that the South to legalize syringe exchanges To develop the Act and identify drug Take Back programs are a great with passage of House Bill 972. Years evidence-based strategies, NC way to get the community involved of collaborative efforts focused on harm DHHS worked with UNC IPRC, CDC’s and raise public awareness of the reduction broke down the historical Prevention for States Program and issue, giving everyone a stake in resistance to syringe exchanges national experts, including Corey Davis the challenge when they realize that and resulted in the decriminalization at the Network for Public Health Law. items in their medicine cabinet could of needles. Advocates performed be fueling the drug epidemic. This 911 Good Samaritan Law/Naloxone demonstration projects and worked with process helped move the conversation Access is another important part of law enforcement early on to identify upstream to ensuring people knew of North Carolina’s strategy to address the legislation that the law enforcement the problems and the steps they could overdose epidemic and was a founding community would find helpful and take to prevent people from developing principle of Project Lazarus. The North support. In addition, advocates made a substance use disorder. Carolina Harm Reduction Coalition the case that needle exchanges could (NC HRC) has worked with the law save the state money by reducing the North Carolina’s Department of Health enforcement community to gain their number of hepatitis C cases in the and Human Services has worked support for enactment of a series of future. DHHS noted that Medicaid to improve the state’s Controlled naloxone laws since 2013. charges for hepatitis C treatment Substances Reporting System, and increased from $3.8 million in 2011 PDMP has proven to be a valuable Since the successful passage of naloxone- to $85 million in 2016. Following the way for prescribers and dispensers to related legislation, NC HRC distributed legalization of the syringe exchanges, better manage pain and appropriate more than 41,000 overdose rescue kits DHHS developed the Safer Syringe prescribing. In 2012, the Child Fatality and confirmed 7,408 overdose reversals Initiative and registered 22 syringe Task Force convened a study group that in North Carolina. Additionally, working programs in the first year of the law, resulted in a revision to the CSRS Law in with law enforcement agencies to develop reaching 19 counties. When the STOP 2013. They added delegate accounts, naloxone programs has resulted in 164 Act passed, it included provisions that shortened the time to report and law enforcement agencies with officers only prohibited the use of “State Funds,” enabled proactive reporting from CSRS carrying naloxone and 403 reported law enabling local health departments and to licensing boards and prescribers. enforcement reversals by naloxone. other governmental units to use local In 2014, the Program Evaluation Division In 2016, the Naloxone Standing Order funds to do needle exchange. of the General Assembly conducted an Law, which enables any pharmacy in 58 TFAH • WBT • PaininTheNation.org EXAMPLES: PUBLIC HEALTH DRUG DIVERSION APPROACHES Bexar County Jail over an eight-year period. Recognizing Diversion Program in the gap in care within the juvenile system, Bexar County, Texas the county expanded the model to include is using an innovative services for county youth to prevent entry approach from the into the criminal justice system. They also criminal justice system to expand mental created Bexar CARES (Coordinated Access health interventions among youth. Bexar to Resources Equals Success), a program County created a model for aligning its that works in collaboration with police, criminal justice system, hospital, mental healthcare providers and community health services and community partners stakeholders to proactively screen children to transform the mental health system within the child welfare and public school into one focused on diverting people with system for behavioral health conditions serious mental illness away from jail and using a pediatric symptom checklist. toward treatment. This effort successfully This program has reached 741 children diverted over 100,000 adults from jails in the county and continues to create an and emergency departments and resulted environment promoting early intervention in a cost savings of nearly $100 million of mental illness. Clayton County Systems of more supportive clinical services and Care in Georgia was created lower healthcare costs for this group. to respond to high numbers of They developed an umbrella services youth involved in the Clayton organization within a coordinating agency County Juvenile Court system. An to oversee and align services agency assessment found that around 65 to coordinate and align services. They percent of youth who were detained in focused on identifying students in-need the youth system were readmitted within and likely not to complete school, and three years of release, and that secure they developed and provided appropriate facilities cost $91,000 per year per youth supports and services. For instance, compared to around $29,000 for non- “chronically-disruptive” students are secure facilities. The county saw this referred to a nonprofit where they as an opportunity to change outcomes assess and address the family’s risk and decrease costs. They implemented factors. This approach has led to an 87 five evidence-based programs and percent decrease in disciplinary referrals changed incarceration penalties for in schools, a 71 percent decrease in youth who commit misdemeanors. The juvenile crime rates, a 83 percent decline juvenile justice system partnered with in probationers, a 62 percent increase schools to reduce suspensions and in school attendance and significant arrests and implement restorative justice improvements in grades and graduation practices. The changes have led to the rates. The county has saved more than ability to close three facilities and reap $4 million over a four-year period. The savings to reinvest in evidence-based, Georgia Assembly has modeled a new supportive youth programs. In 2010, a legal code for youth for the state based system of care was developed to provide on the Clayton County approach. TFAH • WBT • PaininTheNation.org 59 Effective Approaches for Reducing Excessive Alcohol Use According to the National Institute l A cute alcohol use is associated on Alcohol Abuse and Alcoholism with around 23 percent of suicides (NIAAA), drinking too much alcohol and around 40 percent of suicide can “take a heavy toll” on a person’s attempts.337, 338 family and interpersonal relationships l D runk driving fatalities average and on work or school performance — around one death every 51 minutes.339 and puts individuals and their families at greater risk for “social harms,” such l A lcohol use contributes to more than as family disruption, issues in the 50 acute and chronic diseases and workplace and financial problems.335 causes of death.340 Excessive alcohol use — which is often l C hildren whose parents misused defined as binge drinking or heavy alcohol and other drugs were three drinking — can be associated with times more likely to be abused and many negative outcomes, including more than four times more likely to risk for developing an alcohol use be neglected than children from non- disorder, risk of injury, violence, motor misusing families.341 Additionally, vehicle crashes and suicide. While an increased risk factors for alcohol estimated nine out of 10 individuals who misuse include family influences, excessively drinks do not develop an such as lack of positive parent-child alcohol dependency, there are around relationship, family relationship with 15.7 million adults who do have an alcohol problems, lack of parent-child alcohol use disorder, which increases communication and bonding and risk for long-term health conditions ineffective family management. such as liver and heart disease and can l M ilitary personnel ages 18 to 35 have be co-related to mental health disorders. rates of heavy drinking about 60 l A pproximately two in five violent deaths percent higher than civilians in those and one in four emergency department age groups.342 visits for violence-related injuries are due to excessive alcohol use.336 60 TFAH • WBT • PaininTheNation.org ALCOHOL TRENDS Alcohol Deaths Reach a 35-year High l A lcohol-Induced Deaths. 33,200 people Deaths from alcohol-induced causes (excluding homicides, drunken driving and other accidents indirectly related to alcohol), 1979-2014, per 100,000 people. in the United States died from alcohol 10 in 2015 and 267,000 died over the last decade (2006-2015, based on those recorded directly as “alcohol-induced deaths.”).343 This equated to 10.3 8 deaths per 100,000 Americans in 2015, 91 per day, 3.8 per hour, and one death every 16 minutes. 6 • ne study found that when factoring in O alcohol-related injuries and motor vehicle crashes, alcohol can be attributed to 4 roughly 88,000 deaths annually,344 which would make alcohol-related deaths the fourth leading preventable cause 2 of death in the United States (alcohol- impaired driving fatalities accounted for 9,967 deaths, or around one-third of all 0 motor vehicle-related deaths in 2014).345 1980 1985 1990 1995 2000 2005 2010 • lcohol-induced deaths increased by 47 A Source: CDC percent from 2000 to 2015 (7.0 to 10.3 per 100,000), with increases across Percentage change in alcohol-related death rate sexes, regions and nearly all states. 120 • ates are highest among men (15.2 R 90 White deaths per 100,000), 45-74 year olds +130% 60 (23.4 per 100,000), Whites (11.4 per Hispanic 100,000) and those who live in the 30 +27% West (15.2 deaths per 100,000). 0 Black -12% • he largest proportional increases T -30 1999 2015 were among women (75 percent Source: CDC increase), Whites (61 percent increase) and those living in the Midwest (64 percent increase). • ates grew by more than one-third R • ates remained stable among 15- to R among Whites and Asians between 24-year olds, 34- to 55-year olds and 2000 and 2015. Death rates among individuals aged 75 or older — but Blacks decreased slightly during this grew among 25- to 34-year olds, 45- to time period. As of 2001, rates were 74-year olds and, the most, among 55- similar for Whites (7.2 per 100,000) to 64-year olds (increasing from 19.9 and Blacks (7.3 per 100,000), but per 100,000 in 2007 to 28.2 in 2015). have since diverged. TFAH • WBT • PaininTheNation.org 61 • he alcohol death rate among T Alcohol Deaths in 2015 (CDC WONDER) American Indians/Alaska Natives is 26 24.6 2.6 times higher than for the overall 24 population (27 vs. 10.3 deaths per 22 100,000). Deaths for this population 20 Deaths per 100,000 have increased by 50 percent from 18 16 15.2 15.4 15.1 18 per 100,000 in 2000 to 27 per 14 100,000 in 2015.346 11.4 11.7 12 10.3 9.5 9.5 10.1 l A lcohol Use Disorders. More than 6 10 8.9 7.9 7.9 percent of American adults have an 8 6.5 6 5.6 alcohol use disorder — including 9.8 4 million men and 5.3 million women.347 2 2.1 2 <0.1 More than a quarter of adults report binge 0 drinking in the past month (four drinks for l e e k n Hi te es ic es 17 es -34 es 54 Ag -74 rth + M ast So t h M t n- ro ro al s es ac al al ia ut No 75 Ag an we hi No et et er Ag 5- Ag 35- m M As e W Ag 18 55 Bl W a woman, five for a man) and more than 7 M sp Ov id es Fe percent binge drink on five or more days. Source: TFAH analysis of CDC data • ore than 10 percent of U.S. M children live with a parent with alcohol problems.348 million college students driving under liver damage and disease (including the influence annually. fatty liver disease), alcoholic hepatitis, • bout 1.2 million adults received A cirrhosis, hypertensions, heart disease, treatment for alcohol use disorder at a • wo percent of 12-17 year olds T stroke, some forms of cancer (mouth, specialized facility in 2016 (7.7 percent (488,000 people) have an alcohol use esophagus, pharynx, liver and breast), of adults who needed treatment).349  disorder.353 NIDA reports that alcohol depression and anxiety.358, 359 In 2013, This included 777,000 men (8.1 played a role in the death of 4,000 about a third of liver transplants were percent of men who needed treatment) people under 21 and emergency room related to alcohol.360 and 382,000 women (6.9 percent of care for another 190,000 people women who needed treatment). under 21 with injuries.354 l F etal Alcohol Spectrum Disorders (FASD). FASD include Fetal Alcohol l U nderage Drinking. Around one in three • n estimated 48,000 adolescents A Syndrome (FAS) as well as a spectrum high school students report consuming (26,000 males and 22,000 of less severe diseases associated with alcohol in the past month with more females) received treatment for an alcohol exposure during pregnancy.361 than half of those binge drinking and alcohol problem in a specialized While the number of individuals with two in five reported consuming eight or facility in 2016.355 FASD is unknown, a 2010 CDC study more drinks in a single occasion.350 An l I mpact of Excessive Alcohol looking at 7- to 9-year olds in several estimated 90 percent of adolescent Consumption and Alcohol Use states found 0.3 cases per 1,000 drinking is via binge drinking. 351 Disorders. Alcohol misuse increases children.362 FAS is a leading cause • ore than 1,800 college students M the risk of social problems, including of mental retardation and other birth die from alcohol-related injuries each lost productivity, family problems and defects, and is irreversible. year. 352 Alcohol use increases the risk unemployment. 356 It also increases l C ollective Economic Burden. Estimates for motor vehicle crashes, injuries, risk for fatal and non-fatal injuries and suggest alcohol misuse costs the United unsafe sexual practices, sexual assault violence (including homicide, suicide, States $249 billion every year (including and other forms of violence — and is sexual assault and intimate partner medical, criminal justice and lost life related to 696,000 student assaults, violence).357 It increases risk for a range expectancy costs).363 599,000 unintentional injuries and 2.7 of long-term health problems, including 62 TFAH • WBT • PaininTheNation.org Key Policies Reviews by public health experts, the Community Preventive Services Task Force and the Surgeon General’s Office have identified the most effective prevention strategies for reducing excessive alcohol consumption. These strategies have been shown to help reduce excessive consumption — and it is important to note this is distinct from being evaluated for the impact of lowering the number of individuals who develop an alcohol use disorder. Many of these same strategies are also effective for reducing suicides. As roughly State Spirits Excise Tax Rates (Dollars per Gallon), as of January 2017 23 percent of suicides are related to WA alcohol, reducing drinking also reduces $31.48 NH ME #1 MT ND $5.86 risk for suicide. These include pricing, $9.84 $4.66 VT #24 OR #12 #33 MN $7.75 access and availability (density of bars, $22.78 #2 ID $8.80 #13 #16 NY $10.98 SD WI $6.44 restaurants and stores selling alcohol and #10 $4.68 #32 $3.25 #41 MI #21 WY $11.97 limiting times of sale) and enforcement NV NE IA $12.52 #9 PA $7.27 #18 $3.60 $3.75 #8 OH MA ■ of underage drinking and accessibility CA #39 UT #37 IL IN $9.90 $8.55 $2.68 #11 WV $4.05 #35 $3.30 $13.11 CO #14 #44 VA RI ■ laws (including commercial and host #40 #6 $2.28 KS $2.50 MO $5.05 $19.90 $5.40 #28 #47 $2.00 KY #30 #3 #45 CT ■ providing of alcohol to minors).364, 365, 366 #48 $7.74 #17 NC $5.40 #28 AZ OK $4.46 $14.66 #5 NJ ■ TN #34 $3.00 NM $5.56 AR SC $5.50 #26 Top strategies for reducing excessive #43 $6.06 #25 $6.88 $5.42 DE ■ #22 #19 MS GA #27 $3.75 #37 alcohol consumption include: AL $7.98 $18.25 $3.79 #15 #27 MD ■ TX #4 $4.85 #31 $2.40 LA l ricing Policies. The different types of P #46 $3.03 DC ■ #42 FL $5.69 #25 alcohol taxes include excise taxes and AK $6.50 $12.80 HI #20 sales taxes, which are implemented #7 $5.98 #23 primarily at the federal and state State Spirits Excise Tax Rate (Dollars per Gallon) levels and can be done so alone or in combination. Excise taxes are based on Lower Higher the volume of alcohol sold, while sales State Wine Excise Tax Rates (Dollars per Gallon), as of January 2017 taxes are assessed as a percentage of WA $0.87 NH the retail price of alcohol.367 Consistent #25 MT ME ND $0.60 evidence shows that higher alcohol prices $1.06 $1.06 VT #32 OR #18 #18 MN $0.55 $0.67 $1.21 #33 and alcohol taxes are associated with #31 ID SD #16 WI NY $0.45 $0.30 $1.29 $0.25 MI reductions in both alcohol misuse and #37 WY #14 #43 $0.51 #41 IA #35 related, subsequent harms.368 Multiple NV NE $1.75 PA MA ■ $0.70 $0.95 #4 OH IL IN $0.32 $0.55 #32 systematic reviews have found that higher CA #30 UT #23 $1.39 $0.47 #39 WV $0.20 CO #11 #36 VA RI ■ KS MO $1.00 $1.51 alcohol prices or taxes are associated with #44 $0.32 #39 $0.30 $0.42 #20 $1.40 #9 #41 KY #7 CT ■ #38 $3.17 #1 reduced consumption.369, 370 NC $0.72 #28 AZ OK $1.27 $1.00 #20 NJ ■ TN #15 $0.84 NM $0.75 AR SC $0.88 #24 • igher alcohol prices or taxes have H #26 $1.70 #5 #28 $1.35 $1.08 DE ■ #13 GA #17 $0.97 #22 AL $1.51 also been consistently related to MS $1.70 #7 MD ■ TX #5 $1.40 #9 reductions in motor vehicle crashes $0.20 LA $0.76 DC ■ #44 #27 $1.79 #4 and fatalities, alcohol-impaired driving, AK FL $2.25 $2.50 HI #3 mortality from liver cirrhosis and #2 $1.38 #12 unsafe sex practices that can increase State Wine Excise Tax Rate risk for sexually transmitted diseases (Dollars per Gallon) and unplanned pregnancies.371 Lower Higher Source: Tax Foundation TFAH • WBT • PaininTheNation.org 63 State Beer Excise Tax Rates (Dollars per Gallon), as of January 2016 WA $0.26 NH #24 $0.30 ME MT ND #21 $0.35 $0.14 $0.39 VT #17 OR #39 #16 MN $0.27 $0.08 $0.47 #22 #45 ID #11 NY $0.15 SD WI $0.14 #38 WY $0.27 $0.06 MI #39 $0.02 #22 #48 $0.20 #50 IA #28 PA NV NE $0.19 $0.08 #45 $0.16 $0.31 #31 OH MA ■ UT #20 IL IN $0.18 $0.11 #44 CA #35 $0.23 $0.12 #32 WV $0.20 $0.41 CO #26 #41 VA RI ■ #13 $0.08 KS MO $0.18 $0.26 $0.12 #41 #28 $0.18 #45 $0.06 KY #32 #24 #32 #48 CT ■ $0.84 #6 NC $0.23 #26 AZ OK $1.29 $0.62 #8 NJ ■ TN #1 $0.16 NM $0.40 AR SC $0.12 #41 #35 $0.41 #15 $0.35 $0.77 DE ■ #13 #17 MS GA #7 $0.16 #35 AL $0.43 $1.05 $1.01 #12 #4 MD ■ TX #4 $0.49 #9 $0.20 LA #28 $0.32 DC ■ #19 $0.64 #8 AK FL $1.07 HI $0.48 #2 $0.93 #10 #5 State Beer Excise Tax Rate (Dollars per Gallon) Lower Higher Source: Tax Foundation l ccess and Availability. Alcohol A associated with increases in alcohol density (the number of alcohol misuse and harms, while fewer days retailers in an area) and limits on the were associated with decreases.375, 376 days and hours when alcohol can be Seventeen states ban the sale of some sold have also been shown to reduce types of alcohol on Sundays. Liquor excessive alcohol consumption and bans are more common, but some related harms. states also ban wine or beer or both.377 Indiana is the only state that bans all • lcohol outlet density regulation A three on Sundays, with exceptions for involves reducing the number of restaurants and wineries. Minnesota outlets where alcohol is available lifted its ban on liquor sales effective for purchase or sale in an area July 2, 2017.378 Sunday bans in many and is often implemented through states occur at the local level and vary licensing or zoning processes.372 The from county to county.379 Community Preventive Services Task Force systematic review of 39 studies • voiding privatization of retail A found that regulating to lower density alcohol sales is another policy helped reduce excessive drinking strategy that has been shown to and related harms, including crime, be effective in reducing excessive violence and injuries.373, 374 alcohol consumption. A systematic review of studies done for the • educing days and hours of alcohol R Community Preventive Services Task sales have also been shown to reduce Force found that privatizing alcohol excessive alcohol use and related sales increased the per capita sales of harms. A range of studies have found the privatized beverage, which can be that policies (in bars, restaurants and used as a proxy for excessive drinking stores) that increase the number of by a median of 44 percent.380 days when alcohol could be sold was 64 TFAH • WBT • PaininTheNation.org Commercial Host Liability: An Evidence-Based Strategy Commercial host liability holds alcohol retailers legally responsible for injuries or harms caused by illegal service to intoxicated or underage customers. Commercial host liability Alcohol retailers Commercial host laws adopted without encouraged to comply liability laws improve major restrictions with liquor laws health & save lives Reduced rates of excessive alcohol Com consumption m (including binge S TAT E Liab ercial and underage ility Hos Law t drinking) Avoiding serving underage and intoxicated patrons Fewer motor vehicle crashes Considerations in Implementing Commercial Host Liability as a Public Health Strategy Lower rates of violence Alcohol retailers are Alcohol-related Alcohol retailers Injured parties are held to the same injuries and deaths are held financially compensated by liability standards are reduced when responsible for negligent alcohol as other retail retailers implement negligent practices retailers businesses best practices ChangeLab Solutions is a nonprofit organization that provides legal information on matters relating to public health. The legal information in www.changelabsolutions.org this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state. © 2017 ChangeLab Solutions l L imiting Underage and Intoxicated • hese laws often have not been T Customer Sales. Commercial host implemented consistently and/or liability laws (also known as dram have been changed over time. As of shop liability) hold the owner or January 1, 2015, 20 states had dram server of an establishment liable for shop liability laws with no major harms (including injuries or deaths) limitations; 25 states had these resulting from the illegal sale of laws but with major limitations alcohol to underage or intoxicated (e.g., restrictions on who this patrons.381, 382 While an underaged liability applied to and the evidence or intoxicated person could be required to determine liability); the first to be sued by the injured and six states have no dram shop party, dram laws allow the injured liability laws at all.384 to seek monetary damages from the establishment that served the individual, helping prevent illegal alcohol sales.383 TFAH • WBT • PaininTheNation.org 65 l educing Underage Drinking. Raising R the minimum legal drinking age Liability for Hosting Underage Drinking Parties as of January 1, 2016 to 21 has been shown to reduce alcohol-related harms, including drunk-driving motor vehicle crashes and deaths, violence and injuries.385 There is also evidence that the 21 minimum legal drinking age protects drinkers from suicide, homicide and future alcohol and other drug dependence.386 Youth who start drinking before age 15 years are six times more likely to develop alcohol dependence or excessively consume alcohol later in life than those who begin drinking at or after age 21 years.387 They are also more likely to experience problems in school, physical and sexual assault Source: APIS and have a higher risk for suicide and homicide.388 Tween (pre-teen), teen and young adult brains are still at least 71.6 percent of intended • Minimum legal drinking age developing critical judgment skills, audiences for alcohol ads to be at least compliance checks that initiate or like resisting peer pressure and 21 years old.390 According to a review by increase the frequency of monitoring determining their consumption limits, Sober Truth on Preventing Underage retailer compliance against sales to and drinking can cause problems Drinking (STOP) Act, one in four states any persons appearing to be under and other changes in young brain (25 percent) is implementing programs the age of 21, and which have been development that may be life-long. to measure and/or reduce youth shown to decrease underage sales by exposure to alcohol advertising and 42 percent.396, 397 In addition, NIAAA emphasizes that marketing.391 The Center on Alcohol increasing public awareness about the • enalties for hosting parties with P Marketing and Youth is working with problems associated with underage underage drinking, known as “social CDC to monitor and reduce youth drinking and countering social host liability laws,” where adults exposure to noncompliant alcohol acceptance/pressure are important who knowingly or unknowingly host advertising on cable TV.392 strategies for reducing underage underage parties on properties they drinking.389 This includes countering There are a number of the strong, own, lease or otherwise control, inaccurate perceptions of how much proven approaches to enforce the help prevent access to and alcohol minors think their peers may be drinking age limit and reduce underage use among minors, and reinforces drinking. The Surgeon General’s drinking. Many include policies, cultural norms. Thirty-two states and report and other expert sources also strategies and messages that limit adults Washington, D.C. have some form reinforce the importance of addressing enabling or condoning underage of social host liability laws, which can cultural norms and messages around drinking. Best practices focus on taking be either criminal (which usually underage drinking, excessive drinking a public health approach that identifies require intent) or civil offenses.398, 399 and drinking and driving — including youth at risk for misuse and excessive Criminal laws have been associated through peer, parental, school-based use and provides critical support, brief with declines in binge drinking (3 and community-based efforts, as well as intervention and counseling and/ percent), driving after drinking (1.7 not marketing alcohol to minors. The or treatment as indicated. Strategies percent) and alcohol-related traffic industry has voluntary codes requiring include:393, 394, 395 deaths (9 percent).400 66 TFAH • WBT • PaininTheNation.org POLICIES TO REDUCE DRINKING AND DRIVING: REDUCING HARM AND IDENTIFYING NEED FOR TREATMENT AND SUPPORT Drunk driving laws and penalties instituted Driving While Intoxicated (DWI) traffic fatalities each year.410 States are among the most effective public Courts as a model for accountability and are experimenting with a number of health laws in the United States. CDC long-term treatment. One study found responses to prevent driving under estimates that U.S. adults drove under 19 times lower rates of recidivism than the influence, including: increasing the influence around 112 million times use of regular courts. 404 the number of driver’s licenses (as of 2010). On average, there are suspended or revoked in response to l D runk Driving Laws. All 50 states and around 1.5 million drunk-driving arrests, DUI incidents; enacting zero tolerance Washington, D.C. currently have laws that and more than 10,000 drunk-driving laws for drivers under 21 who have make it illegal to operate a motor vehicle deaths each year (as of 2015). 401 consumed alcohol; mandating special at or above a .08 percent BAC level.405 Alcohol-related crashes decreased license plates for drunk driving significantly in the 1980s and 1990s, l M andatory Ignition Interlocks. Twenty- offenders; and enhancing penalties if a when the first waves of drunk-driving four percent of alcohol-impaired drivers child is in the car, if the driver causes laws went into effect. An analysis of in fatal crashes in 2013 had had their an injury or fatality or if the driver has fatal-crash data from 1982 to 2005 licenses suspended or revoked within an excessively high blood alcohol estimated that alcohol safety laws — the previous three years for alcohol- content (0.15 percent or higher).411 blood alcohol content (BAC) limits (from and non-alcohol-related offenses.406 l Z ero tolerance underage drunk driving .10 to .08), license revocation and zero Ignition interlocks devices test a laws. These policies are for violations tolerance laws — accounted for 44 driver’s blood alcohol content through a that result in the minor’s license being percent of the reduction in fatal crashes device similar to a Breathalyzer before suspended or revoked have been shown (the other percentage being attributable allowing the car to be operated. All to have a strong impact in reducing to demographic factors).402, 403 50 states and Washington, D.C. have alcohol-related vehicle crashes, injuries ignition interlock laws, and 26 states These laws and penalties help discourage and deaths. Studies have found and Washington, D.C. have made not only drunk driving, but excessive states with these laws have 20 to 30 interlocks mandatory for all alcohol- drinking as well. percent fewer alcohol-related traffic related offenses.407 crashes — and they save 159 lives Public health and law enforcement officials l I ncrease use of “sobriety” checkpoints. per year.412, 413 Some states also have are also increasingly viewing violations as After reviewing 11 high-quality use/lose laws, where they authorize important opportunities to identify teens, studies, CDC determined that sobriety suspension or revocation of driving youth and adults at risk for alcohol misuse checkpoints reduce alcohol-related privileges as a penalty for underage and addiction as a time to do screening, fatalities, injuries and property damage purchase, possession or consumption intervention and connections to support crashes by about 20 percent. 408 of alcohol.414 Drunk driving and/or and treatment as appropriate. Thirty-eight states and Washington, penalties for overconsumption For instance, CDC has recommended D.C. authorize the use of sobriety among minors can also be used as that health professionals should checkpoints, but few states regularly an opportunity to help identify teens routinely screen patients with risky implement them. 409 In addition, 10 and youth at risk for alcohol misuse driving behaviors and, at a minimum, states have outlawed these checkpoints. and problems and provide screening, provide a 10- to 15-minute counseling early intervention and connections to l T ighten DUI penalties. Alcohol is a session for patients who screen positive. services and support as appropriate. factor in more than 30 percent of all And many states and localities have TFAH • WBT • PaininTheNation.org 67 EXAMPLE: COMMUNITY-BASED UNDERAGE DRINKING INITIATIVE Healthy Communities college parties and local bars. In That Care of Livingston collaboration with local law enforcement County New York partners, stronger compliance checks, (2015 CADCA Coalition fake ID details and party patrols were in Focus awardee) works to reduce implemented. A successful county-wide underage drinking. A great strength of media campaign was also launched this coalition is its use of qualitative to educate adults about the risks and data to enhance understanding of consequences associated with providing the local issues contributing to youth alcohol to minors and not monitoring alcohol access. “What has made our alcohol stored in their home. Between coalition so effective is our long-term 2010 and 2014, the community saw a collaborations with key members. Our 44 percent reduction in the number of strong relationship with our schools and parents that report they know teens that the nearby SUNY Geneseo College has are obtaining alcohol at parties hosted enabled us to conduct focus groups in by parents. Compliance check failures the high schools with over 400 youth have also been reduced by 42 percent each year,” explained Rachel Pena, since 2010. Today, fewer youth report the coalition’s Project Director. Driven that alcohol is easy to get and youth by the data, the coalition worked who reported drinking in the past month to address youth alcohol access at has been reduced by 45 percent. 68 TFAH • WBT • PaininTheNation.org Effective Approaches for Preventing Suicides Suicide is the 10th leading cause There is no single determining Rates of suicide are highest among cause for suicide. There are a range males ages 35 to 64 and males ages 75 of death in the U.S. Each year of influences — social, emotional, and older, so it is important to focus 44,193 Americans die by suicide. psychological, physical, interpersonal heightened attention for risk and and community factors.415 programs for support on these age groups. Other groups identified at According to CDC, key risk factors heightened risk include: veterans and include: family history of suicide, service members and military families, family history of child maltreatment, young adult males, Native Americans, previous suicide attempt(s), history of LGBTQ individuals, middle-aged women, mental disorders (particularly clinical homeless individuals, those of have depression), history of alcohol and experienced foster care, women who substance misuse or use disorders, are post-partum, transition-aged youth feelings of hopelessness, impulsive (e.g., moving between schools), ethnic or aggressive tendencies, cultural minorities experiencing health and and religious beliefs (e.g. belief that Suicide Death by Method, 2015 behavioral health disparities and women suicide is a noble resolution of a who experience partner violence. personal dilemma), local epidemics 7.9% of suicide, isolation (feeling of being Key strategies to reduce suicide and cut off from other people), barriers to suicidal thoughts focus on: Other accessing mental health treatment, loss l R educing problems that lead to suicide (relational, social, work or financial), risk in the first place (e.g. hopelessness, Suffocation 26.8% physical illness, easy access to lethal 49.8% Firearm social isolation, thoughts of suicide, means and unwillingness to seek unemployment, mental health help because of the stigma attached programs) by strengthening economic Poisoning to mental health and substance use supports (financial and housing disorders or suicidal thoughts.416 stability and security) and supporting 15.4% Suicidal thoughts and risk can be positive relationships, community exacerbated by trauma, “triggering” connections and safe environments Source: CDC events and major life disruptions, within organizations and systems; such as experiencing: abuse; housing l C hanging social messages and norms insecurity (including inability to around suicide, including avoiding afford stable housing, frequent moves, sensationalized or romanticized eviction and foreclosure or risk of coverage of suicide that can lead losing housing); financial insecurity; vulnerable people to consider suicide; loss of a job or being at risk for losing a job; changing schools, jobs or homes; l P romoting connectedness through emotional distress; divorce or other community engagement strategies and relationship issues; and death of a peer norm programs; family member, friend or partner; l T eaching effective life-coping, problem- and/or injury or illness — which can solving and parenting skills and social- overwhelm regular coping mechanisms, emotional development to help people leading to heightened despair and a reduce and cope with adversity; sense of hopelessness. TFAH • WBT • PaininTheNation.org 69 l I mproving systems of care and excessive alcohol use and access to the training professionals (e.g., healthcare lethal means for suicides, such as safe providers, social service providers) storage of medications and firearms and laypeople (e.g., teacher, coaches) among those at risk; and to identify and support individuals l E nsuring access and coverage of who may be at risk; sufficient and effective mental health l S upporting people at risk and services and care after a suicide providing crisis intervention; attempt, including addressing workforce provider shortages in l A ddressing factors that contribute underserved areas and providing care to exacerbating and/or acting on to those at risk for suicide and those suicidal thoughts, including limiting who have attempted suicide. CDC’s 2017 technical package of policy, programs and practices highlighted strategies based on the best available evidence to help focus on activities with the greatest potential to prevent suicide.417 Strategy Approach • trengthen household financial security S Strengthen Economic Supports • ousing stabilization policies H • overage of mental health conditions in health C Strengthen Access and Delivery of insurance policies Suicide Care • educe provider shortages in underserved areas R • afer suicide care through systems change S • educe access to lethal means among persons at R risk of suicide Create Protective Environments • rganizational policies and culture O • ommunity-based policies to reduce excessive C alcohol use • eer norm programs P Promote Connectedness • ommunity engagement activities C • ocial-emotional learning programs S Teach Coping and Problem-Solving Skills • arenting skill and family relationship programs P • G atekeeper training • C risis intervention Identify and Support People At Risk • T reatment for people at risk of suicide • T reatment to prevent re-attempts • Postvention Lessen Harms and Prevent Future Risk • afe reporting and messaging about suicide S 70 TFAH • WBT • PaininTheNation.org SUICIDE TRENDS Suicide Deaths in 2015 (CDC WONDER) l S uicides. Suicide is the 10th leading 22 21.5 cause of death in the United States 20 18.7 18.4 18.2 18 17.4 and the second leading cause of death 15.8 Deaths per 100,000 16 15.2 14.9 among 15- to 35-year olds.418, 419, 420 13.8 14 14.3 14 13 It is the third leading cause of death 12 10.8 among 10-14 year olds. Suicide rates 10 among 10-14 year olds have more than 8 6.3 6.6 5.6 5.8 doubled since 2007. 6 4 2.6 • In 2015, 44,193 Americans died from 2 suicide, a rate of 13.8 suicides per 0 100,000 people. This averages to k Fe ll e e n Hi te e ic es -17 es 34 es -54 Ag -74 rth + M ast st h t n- o ro es ac a al al ia ut No etr No 75 Ag an we hi et er Ag 18- m M As e W Bl So Ag s 5 Ag 35 55 W M M sp Ov id es 120 per day, five per hour, and one death by suicide every 12 minutes.421 Source: TFAH analysis of CDC data. • ale suicide rates are more than three M times higher than among females (20.7 vs. 5.8 per 100,000), but more than three • ortheasterners by 38 percent, N significantly compared to 2009, where times as many women attempt suicide. Southerners by 26 percent, 14 percent seriously considered suicide, • uicide rates are highest among American S Midwesterners by 40 percent, 11 percent made a suicide plan, and Indian/Alaska Natives (20 per 100,000). Westerners by 30 percent; and 7.3 percent attempted suicide.426 • Suicide rates among Whites (18.1 per • etro residents by 31 percent and M l E conomic Costs. Suicide costs are 100,000) are more than 2.5 times those non-metro residents by 38 percent. estimated to total $93.5 billion in of Asians/Pacific Islanders (7.0), Latinos lifetime costs (health expenditures and l R eported Self-Harm Injuries. In (6.8) and Blacks (6.5 per 100,000). income loss) per year.427 2015 alone, more than a half-million l S uicide Increases. Between 2000 and Americans went to emergency l A lcohol and Suicide. Alcohol use 2015, suicide deaths increased nearly one- departments for self-harm injuries.424 is associated with 23 percent of third (32 percent) from 29,350 to 44,193 suicides and around 40 percent of l S uicidal Thoughts and Attempts — per year (10.4 to 13.8 per 100,000).422 suicide attempts.428, 429 Patients are at Adults. Nearly 10 million Americans • ates have increased among American R (9.8 million, 4 percent of the population) increased risk for attempting suicide Indian/Alaska Natives (more than ages 18 and older seriously considered within a 24-hour period of drinking 26 percent) and Whites (more than suicide, 2.8 million made a suicide plan alcohol or using opioids.430 20 percent) between 1999-2007 and 1.3 million made non-fatal attempts l M ental Health and Suicide. 90 percent and 2008-2015.423 During this time at suicide, in 2016.425 of those who die by suicide have an period, rates have increased among: l S uicidal Thoughts and Attempts — underlying mental illness.431 Nearly one- • omen by 57 percent and men by W third (28 percent) of adults who had a Youth. 18 percent of high school 26 percent; major depressive episode in the past students seriously considered suicide, • Blacks by 4 percent, Whites by 38 15 percent made a suicide plan and year had suicidal thoughts, 9 percent percent, Asians by 26 percent, American 8.6 percent attempted suicide, in made a suicide plan and 4.2 percent Indian/Alaska Natives by 26 percent; 2015. These trends have increased made non-fatal suicide attempts.432 TFAH • WBT • PaininTheNation.org 71 Age-adjusted suicide rates, by sex: United States, Suicide rates for females, by age: United States, 1999–2014434 1999 and 2014435 Source: CDC Source: CDC HIGHER RISK GROUPS FOR SUICIDE Some populations have higher suicide attempt and/or for lesbian/bisexual women is twice that of heterosexual completion rates than the general public, including: women.439, 440 Suicide rates among the LGBT population is not easy to define as death reports do not include information l M ilitary Veterans. The 2014 suicide rate was 21 percent on sexual orientation or gender identity. One study found 13 higher among veterans when compared with U.S. civilian percent of youth classified as sexual minority youth (SMY). adults — including 18 percent higher among male veterans Significantly more SMY than heterosexual youth reported and 2.4 times higher among female veterans, respectively.436 suicidal ideation (27.95 percent vs. 13.64 percent), a suicide Eighteen percent of suicide deaths were among veterans, plan (22.78 percent vs. 12.36 percent) and at least one suicide while they make up just 8.5 percent of the population. attempt (29.92 percent vs. 12.43 percent) in the past year.441 Sixty-seven percent of all veteran deaths by suicide were the result of firearm injuries. Sixty-five percent of veteran l P hysicians. Female physicians were more than 250 percent suicides are individuals over the age of 50. Twenty veterans, more likely to die by suicide than other women, and male on average, die each day from suicide. physicians were 70 percent more likely than other men, according to the most recently available review (2005).442 l I ncarcerated Individuals. Suicide is a leading cause of death in jails and prisons, with more than 800 inmates and l A dolescent and Young Adult American Indians (AI) and Alaska prisoners dying of suicide in 2014. It is particularly high in Natives (AN). Suicides among AI/AN 18- to 24-year olds is local jails, where inmates died at a rate 50 per 100,000, 66 percent higher than the overall suicide rate for the age which is more than three times the general population. 437 438 group, with males dying at rate of 35.5 per 100,000.443 This population has a particularly high rate of suicide by suffocation l L GBT Individuals. Studies suggest LGBT youth are 2-7 times (hanging), which has a high fatality rate. Other studies estimate as likely to attempt suicide. The lifetime suicide attempt that 14 to 27 percent of AI and AN adolescents attempt suicide risk for gay/bisexual men is estimated at four times that in their lifetimes.444 of heterosexual men and the lifetime suicide attempt risk 72 TFAH • WBT • PaininTheNation.org Key Policies Experts have identified a number of strategies that have been shown to be successful in preventing suicides. The Surgeon General’s Office, CDC, SAMHSA and other groups including the National Action Alliance for Suicide Prevention, the American Foundation for Suicide Prevention and the Suicide Prevention Action Network have summarized goals and policies, programs and practices for preventing suicide based on the best available research.445, 446, 447 Many of these support policies, programs and practices that focus on overall well-being and supports, but there are additional actions that can directly help prevent suicides: l S upport statewide suicide prevention Source: CDC plans. These initiatives should address suicide prevention across all ages and be fully implemented and for connecting with at-risk youth and professionals (e.g., psychiatrists, evaluated. Community plans should individuals in rural communities.449, 450 psychologists, social workers, licensed involve healthcare providers, schools Plans should help support the counselors and psychiatric nurses) and colleges — but also a broader development of effective responses do not receive training in suicide risk range of community and faith groups. and protocols for “postventions” that management, assessing individuals They should also take into account support communities and families after for suicidal thoughts or treatment. As providing special focus on groups suicides or suicide attempts to respond of 2016, only five states (Kentucky, that are at highest risk. Plans should to emotional and mental health needs Nevada, New Hampshire, Utah include providing information and the and help limit any further attempts. and Washington) required health availability of training for individuals There are also strong evidence-based professionals to receive training in who are in a position to help identify school-based strategies that should be suicide assessment, treatment and and reach individuals — particularly an integral part of state and local suicide management, and another three states with the ability to connect with prevention policies (more information on encouraged training.452 The Clinical individuals who may be at risk but do approaches for school-aged children and youth Workforce Preparedness Task Force not receive routine medical care or is available in Section III-D). of the National Action Alliance for may not have access to supportive and Suicide Prevention has proposed l I ncrease and improve suicide risk positive relationships in their schools guidelines for clinician training that can and treatment training for health or workplaces, such as coaches, clergy serve as a model for other states and professionals. A recent study and local community leaders.448 Crisis localities.453 Emergency department found that 95 percent of people intervention training should also be personnel should be trained to support who committed suicide saw at least made available. Hotlines should be Brief Intervention with Follow-Up one health professional in the year supported and the use of technology Visits for Suicide Risk Interventions, before their death, with 64 percent and social media strategies should be which includes one-hour discharge seeking healthcare the month before included. Initial research has found information sessions that address committing suicide and more than web-based training can be effective, suicide ideation and attempts, distress, 38 percent seeking out care the week and online crisis intervention may be risk and protective factors, alternatives before.451 Yet a majority of health particularly promising approaches to self-harm and referrals. professionals, including mental health TFAH • WBT • PaininTheNation.org 73 l I mplement and enforce parity for much as 30 percent to 50 percent.455 mental health and access to affordable Nearly half of all suicide deaths are from mental health treatment. The firearms, one-quarter from suffocation need to improve behavioral health and around 14 percent from poisoning, services, including their availability including drugs.456 Eighty-five percent and coverage, cuts across all three of suicide attempts using a firearm result epidemics of drug, alcohol and suicide in death. Attempting suicide by drug and for supporting better well-being. overdose results in death in around 3 There are some particular aspects percent of cases.457 of improvement for providing care Studies suggest that the decision to kill and services for individuals at risk oneself is often quick and impulsive, for suicide or who have attempted with as few as 5 or 10 minutes between suicide, including being connected the decision and the attempted with and covered for evidence-based act.458, 459 Research also shows that care and treatment. Some research individuals contemplating suicide who suggests that active outreach, face-to- cannot access a highly lethal method face contact and telephone support for killing themselves typically do in the aftermath of a suicide within not substitute another highly lethal a community can reduce suicidal Percent of individuals who attempt method.460, 461 Steps to reduce access to ideation for those impacted.454 This another suicide within a year of the the edges of cliffs, bridges, train tracks, initial attempt includes support for the individual and high buildings and to encourage as well as for their friends, family the safe storage of prescription drugs, and impacted members of the potentially poisonous household community to help lessen feelings of chemicals, and firearms, have been guilt, depression and grief that may shown to reduce incidents of suicide.462 be experienced by survivors. Some Research also indicates that members effective approaches can include of the general public and the medical psychotherapy by licensed providers, community are not aware of the home visits, regular contact, check-in 12% to 25% and case management, particularly importance of method availability as a tool to reduce suicides.463, 464 approaches that emphasize adherence and continuity of care. Sustained care Safe storage (such as in locked is important after a suicide attempt cabinets) of medications, firearms and — 12 to 25 percent of individuals other household products can reduce may attempt another suicide within the risk of suicide.465 a year and 3 to 9 percent who have There are a number of policies attempted suicide die by suicide within that help promote firearm safety — one to five years of an initial attempt. that reduce the likelihood of use l L imit access to suicide “hotspots” and for suicide. Around 30 percent of “lethal means” for suicides. Data from American adults reported owning a other countries shows that restricting gun and another 11 percent report access to lethal and common suicide living with someone who owns methods can reduce suicide rates by as a gun, according to a 2017 Pew 74 TFAH • WBT • PaininTheNation.org Research Center report.466 More than a dozen empirical studies have shown an association between the presence of a firearm and the risk of suicide, with the degree of risk in houses having a firearm ranging from two-fold to 10-fold higher than in those houses without.467 A Harvard study found states with the highest levels of gun ownership had suicide rates twice as high as those with the lowest ownership rates — controlling for poverty, urbanization, unemployment, drug and alcohol use and mental illness removing guns from households including certain individuals who and was replicated in studies across during episodes when someone are seriously mentally ill — and time, age groups and cities.468, 469 is experiencing suicidal thoughts requires licensed gun dealers to do A recent study found that after are important suicide reduction a background check on prospective Connecticut enacted a permitting strategies.473 purchasers. However, missing requirement for handguns, recordings in the background check • he Emergency Department T suicides-by-firearm fell in the state; system and no background checks Counseling on Access to Lethal conversely, suicides-by-firearm rose on private sales remain gaps that Means (ED CALM) initiative trained in Missouri after it repealed its can perpetuate sales to high-risk psychiatric clinicians in children’s handgun permitting requirement. individuals. After the shooting at the hospitals to provide lethal means Newtown, Connecticut elementary Firearm availability is a particular counseling and safe storage boxes school in 2012, a number of states took risk factor for youth suicide and one to parents of patients under age 18 additional actions to improve their study estimated that 1.7 million U.S. receiving care for suicidal behavior. background check systems. Currently, children and teens live in a home The effort resulted in 76 percent of 46 states and Washington, D.C. submit with a loaded, unlocked gun.470 parents reporting all medications mental health records nationally (and Compared to other developed were locked up (compared to 10 four states use an in-state database) countries, the United States has twice percent before counseling) and 100 and, as of July 2017, there were nearly the suicide rate among young people percent reporting safe gun storage 5 million mental health records in the aged 5-14 overall, but the rate of (up from 67 percent).474 At least two national background check system, non-firearm suicides was the same.471 states, Minnesota and Montana, have up from 500,000 records in October More than 80 percent of suicides by laws limiting the ability of physicians 2007.477, 478, 479 One study estimated firearm among those 18 or younger to counsel patients on gun safety.475 that 40 percent of guns are sold by involved a firearm belonging to a Florida had passed a similar law unlicensed sellers.480 Thirteen states family member.472 that was struck down by the court in have additional requirements for significant part in 2017.476 Research has shown that storing private sales requiring background firearms in locked containers, Federal law prohibits sales of firearms checks for all firearm purchases, and keeping firearms unloaded and to individuals who pose a heightened six states require background check for separate from ammunition — and danger to society or themselves — all handgun purchases.481 TFAH • WBT • PaininTheNation.org 75 Some states have taken additional reduced suicides by 5 to 10 percent Connecticut and Indiana have steps to keep guns away from children, among those who had their guns laws allowing law enforcement youth and/or individuals at risk of seized.485, 486 California (in 2014) and suicide, including: Washington State (in 2016) passed officers to obtain court laws that allow family members to • afe storage laws at the federal level S orders restraining dangerous require dealers to provide a gun seek an order. individuals from purchasing or lock or secure storage with every l E xpand the National Violent Death handgun purchase, but owners are Reporting System to all states. possessing firearms. not required to use the gun lock. Currently there is funding to support Massachusetts is the only state to 42 states, Washington, D.C. and require all firearms to be locked Puerto Rico to participate in the when not being used; California, National Violent Death Reporting Connecticut and New York require System.487 According to CDC, locked guns in certain situations.482 “linking information about the ‘who, when, where and how’ from data on • hild Access Prevention laws hold C violent deaths [including suicides] gun owners accountable for the provide insights about ‘why’ they safe storage of firearms, imposing occurred” and informs strategies for liability if they do not take certain how to help prevent them. These measures and children have access to systems can help identify common their gun: 27 states and Washington, circumstances associated with violent D.C. have some version of these deaths of a specific type, such as laws with a wide range of scope and clusters or patterns of suicides; help liability among states. The strongest target prevention efforts at groups laws impose criminal liability for or individuals at risk; and support negligent storage when a child may evaluations of prevention activities. or is likely to gain access.483 l E ncourage responsible media • un Violence Protective Order G reporting about suicide. According laws aim to restrict gun access for to SAMHSA, media reports of individuals in crisis who appear to suicides often sensationalize or be an acute danger to themselves or even romanticize suicide, and that others — similar to domestic violence these types of reports have been protection orders. Currently, there shown to increase “contagion,” are only a few states with these laws. making it more likely that vulnerable Connecticut and Indiana have laws individuals will commit suicide. allowing law enforcement officers Conversely, reports about suicide to obtain court orders restraining that include messages of hope dangerous individuals from and resilience and links to helpful purchasing or possessing firearms.484 resources such as hotlines appear to A 2016 evaluation of the Connecticut reduce the number of suicides.488 law estimated that that the law 76 TFAH • WBT • PaininTheNation.org EXAMPLES: SUICIDE PREVENTION INITIATIVES AND EFFORTS The Injury Control Research Center for Suicide Prevention (ICRC-S), a partnership between the University of Rochester Medical Center and the Education Development Center, promotes a public health approach to suicide prevention at the state, regional and national level through research, outreach and education. The Center is enhancing access to data to inform planning prevention activities; addressing challenges to preventing suicide among middle-aged adults; and examining intimate partner violence, substance misuse and other factors that contribute to suicide. The Center conducts and provides pilot grants for suicide prevention research projects and connects researchers, practitioners and other key partners in suicide prevention through webinars, intensive training institutes and a virtual Community of Practice.489 The Colorado Department of Public Health & Environment, in collaboration with ICRC-S, how often have you felt little pleasure in other means of suicide from their homes is taking a public health, prevention- doing things? High scores lead to further and create personalized safety plans.489 oriented approach to suicide, including a questions about sleep disturbances, Health systems conduct real-time suicide website to engage men in help-seeking changes in appetite and/or thoughts of surveillance and, in response to suicides for suicide and mental health difficulties hurting oneself. Providers must indicate that do occur, analyze root causes to (http://mantherapy.org), education of on each patient’s medical record that they understand if and how similar suicides emergency department clinicians about completed the screening — and when could be prevented in the future.493 The working with caregivers after a youth they recognize a mental health problem, model, originally adopted by the Henry suicide attempt to reduce youths’ access assign patients to appropriate care, which Ford Health System’s Behavioral Health to lethal means and a school-based includes cognitive behavioral therapy, Services division in 2001, led to an 80 suicide prevention program. medication, group counseling or new care percent reduction in suicide among Henry The Zero Suicide Initiative is a models such as same-day psychiatric Ford HMO members (from 110.3 suicides comprehensive approach to improve evaluations, drop-in group therapy visits, per 100,000 members before the depression care in health systems, and hospitalization, if necessary.491, 492 program to an average of 36.21 suicides integrating suicide prevention into primary Hospital staff are trained to make sure per 100,000 after the program). This and behavioral health care.490 The that patients who need follow-up care reduction has been maintained for over a model requires primary care doctors to do not leave without an appointment decade, even as the overall suicide rate in screen every patient during every visit and they conduct follow-up telephone Michigan has increased. Implementation with two questions: How often have you calls. Providers partner with patients of this approach had no negative impact felt down in the past two weeks? And and families to limit access to guns or on the division’s financial health. TFAH • WBT • PaininTheNation.org 77 The approach has been adopted by more in suicide rates (33 percent), homicide work with high schools and universities than 200 healthcare organizations in (51 percent), accidental death (18 focuses on evaluating and strengthening the United States and is a key concept percent) and severe family violence mental health, substance misuse and within the National Strategy for Suicide (54 percent).500 Average suicide rates suicide prevention programming and Prevention. 488,494 SAMHSA provides grants continued to be significantly lower than systems through a comprehensive, public to implement the Zero Suicide model in pre-program rates through 2008. health approach based primarily on the health systems, with the fiscal year 2017 U.S. Air Force’s proven Suicide Prevention The Jed Foundation, a nonprofit funding opportunity awarding a total of Program. Their comprehensive evidence- focused on promoting emotional health $7.9 million across up to 13 awardees for based model has seven prongs for and preventing suicide among teens projects lasting up to five years.495 institutions to consider when thinking and young adult in the United States, about suicide prevention: promote social Together for Life — a multicomponent approaches their work through several connectedness; identify students at risk; program to prevent suicides among avenues: working with schools and increase help-seeking behavior; provide the Montreal Police Force — includes universities to improve their programs and substance misuse and mental health training of all units and supervisors on systems; directly reaching and supporting services; follow crisis management suicide risk and how to give support, young adults; and educating and providing procedures; restrict access to potentially a telephone helpline for police officers resources to families and communities lethal means; and develop life skills.501 and an information awareness campaign on when and how best to help. JED’s directed at officers. The program was associated with a 79 percent reduction in suicide rates over 12 years, while police in a comparison group experienced no statistically significant changes.496 U.S. Air Force Suicide Prevention Program (AFSPP), launched in 1997, encourages effective help-seeking behavior and early identification and treatment.497 AFSPP components include: using leaders as role models and agents of change, training personnel, enhancing confidentiality policies, reducing stigma and fear of negative career consequences for seeking mental health care, strengthening social support, addressing risk factors for suicide (such as family violence, alcohol and substance misuse and depression) and creating organizational accountability for implementing the program.498,499 Five years after program launch, this comprehensive approach was associated with substantial reductions Source: Jed Foundation 78 TFAH • WBT • PaininTheNation.org STATE REPORTS: STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE FROM THE SAFE STATES ALLIANCE502 Alaska: Data from suicides, especially in small villages problems and 43 percent were receiving the Alaska reporting where suicides may have family or mental health treatment. Twenty-five system shows that community patterns, to reduce risks of percent had experienced a crisis in the state has the suicidal behaviors or actions. the two weeks prior to death and one second highest rates of suicide in the in five had intimate partner problems. Oklahoma: The state’s nation, and from 2009 to 2013, it was The state created a Suicide Prevention age-adjusted suicide rate the leading cause of death among 15- to Subcommittee of the Rhode Island was 33 percent higher 44-year olds. The highest rates were Injury Community Planning Group, and than the national rate in 2013. Suicides among American Indian/Alaska Natives, built partnerships with the Samaritans, outnumber homicides by around three young male adults and persons living in American Foundation for Suicide to one. The surveillance data helped rural regions. Ninety-two percent had at Prevention, community health and identify that veteran suicides increased least one mental health problem and/or mental health centers, Bradley Children’s by 34 percent from 2005 to 2012, life stressor associated with suicide, 22 Hospital, Brown University, Coastline and suicide rates among veterans was percent had known alcohol or substance Employee Assistance Program and twice that of non-veterans. The state use disorders and 33 percent had the Rhode Island Student Assistance has five military bases, and veterans’ intimate partner problems. In addition, Program. They launched an Economic health issues impact more than 300,000 21 percent were current or former U.S. Impact of Depression and Suicide in Oklahomans. The data helped inform the military personnel, while only 15 percent the Workplace symposium to increase Oklahoma Strategy for Suicide Prevention, of the state’s population was military. awareness of depression and suicide including a collaboration with the This information helped inform strategies among working age adults and provided Veterans Administration. It focused on for the state’s Suicide Prevention Plan, integrated suicide prevention strategies circumstances associated with suicides including making mental health services into worksites. The effort included high- across the lifespan — such as mental more readily available to current and level managers and human resources and physical illnesses, depressed mood former military and using Applied Suicide representatives from two of the state’s and intimate partner problems, as well as Intervention Skills Training to better largest employers. The Coastal approaches for providing supports. equip caregivers and those who provide Employee Assistance Program integrated services for at-risk populations to be Rhode Island: Surveillance suicide prevention into its mission able to identify high-risk individuals and data found there were 731 statement and provides training in early provide them support and connection to suicides in the state from identification and referral of at-risk services. It also helped identify how to 2004 to 2010. More than half (52 employees to their clinical staff as well provide local “postvention” efforts after percent) had current mental health as to their clients. SAMHSA developed the National Suicide Prevention Lifeline 1-800-273-TALK (Lifeline) and http://www.suicidepreventionlifeline.org/(link is external) allowing the user to “Click to Chat” to connect to immediate help. The Lifeline is a nationwide network of crisis centers that provides help 24 hours a day, seven days a week for individuals in emotional distress or suicidal crisis. TFAH • WBT • PaininTheNation.org 79 B. MPROVING BEHAVIORAL HEALTH SERVICES — I FOCUSING ON “WHOLE HEALTH” A National Resilience Strategy must include a major modernization of the mental health care system. A “modern” approach will require making mental health an integral part of the healthcare system to effectively identify individuals with concerns and ensure they receive needed supports and have access to and coverage of evidence-based treatment. Access to mental health and substance effective treatments for most mental use disorder services have been wholly health issues and substance use inadequate, particularly given the disorders and that most Americans in scope of Americans impacted. The need are not being well served. needs were insufficient before the There have been long-standing rise of opioid use — with only around disconnects between physical and one person per 10 needing treatment mental healthcare, and another receiving it.503 The new crisis is disconnect between the healthcare exponentially driving the need for system and the various other services additional behavioral health services. and supports that individuals and A population health approach would families receive. One issue is that many support a system that focuses on better of the current systems reflect outdated “whole health” care that acknowledges views of mental health, substance misuse the research that shows the strong and suicide risk that have been rooted interconnections between physical and in the stigma and lack of understanding mental health, and how other factors about these issues. They often involved — such as having stable finances and ignoring or trying to hide problems housing and community connections — hoping they would get better, focused have a major influence on how healthy on “will power” or “moral failings,” and people are. This includes focusing on intervened only when major problems the whole health of individuals, families emerged or people hit “rock bottom.” and communities. In recent years, there have been In 2016, 44.7 million American significant policy changes that support adults experienced a mental health covering mental health and substance illness, 20.1 million experienced a use disorders in “parity” with physical substance use disorder and 8.2 million health concerns. However, there are experienced both — and these numbers still many systemic gaps and legacy are likely to be underestimated due to healthcare systems and practices, issues of stigma.504 The current system including shortages of services and is not at all equipped to provide the professionals, which must be addressed services and supports to address those to be able to achieve this goal — and go needs. Advances in brain research and beyond parity toward considering the effective prevention and treatment inter-relationships between physical and strategies have shown that there are behavioral health. 80 TFAH • WBT • PaininTheNation.org MENTAL ILLNESS AND SUBSTANCE USE DISORDERS IN AMERICA Mental Illness percent of prisoners and 44 percent of Substance Use Disorder An estimated 44.7 million adults in the inmates have been told in the past by In 2016, 20.1 million people ages 12 United States experienced a mental a mental health professional that they or older had a substance use disorder, illness in 2016, including nearly 10.4 have a mental health disorder.515 with 15.1 million having an alcohol use million American adults with a serious l n 2016, 35 million adults received I disorder and 7.4 million having a drug use mental illness that caused disability. 505 mental healthcare, including 43 disorder, including 2.3 million with both percent of those with any mental alcohol and drug use disorders.520 l omen, adults ages 18-50, Whites, W American-Indians and individuals with illness and 65 percent with serious l lcohol and drug use disorders are A substance use disorders have higher mental illness.516 markedly higher among young adults rates of mental illness.506, 507 l 2008 study estimated that serious A ages 18-25 compared with their younger mental illness leads to $193 billion and older counterparts. l nxiety, mood and personality disorders A are the most common mental illnesses in lost earnings in the United States • 0.7 percent of young adults have an 1 among adults.508, 509, 510 annually. 517 alcohol use disorder compared with 2 percent of 12- to 17-year-olds and 5.2 l he cause of mental illness is likely a T l .4 percent of all health spending in 7 percent of those 26 years old and older. confluence of genetics, environmental the United States is devoted to mental health treatment services.518 • or drug use disorders, 7 percent of F and lifestyle factors.511 young adults ages 18-25 are affected l s many as one in five children and A l tate spending for mental healthcare S compared with 3.2 percent of 12- to teens have had a serious debilitating decreased $4.35 billion from 2013 to 17-year-olds and 2 percent of those 26 mental disorder, with half of the 2015.519 years and older. mental health conditions starting by the age of 14, and three-quarters by the age of 24.512, 513 From 2005 to 2015, the number of people with heroin and prescription opioid addiction increased substantially l ore than 25 percent of teens are M impacted by at least mild symptoms of depression.514 Teens with untreated depression are at a higher risk to be aggressive, engage in risky behavior, die from suicide, misuse drugs or alcohol, do poorly in school or run away. l ccording to a 2017 DOJ report, A around one in seven state and federal prisoners and one in four jail inmates report experiences that meet the threshold for serious psychological distress — compared to one in 20 in the general population. Thirty-seven TFAH • WBT • PaininTheNation.org 81 Alcohol Use Disorder in the Past Year among People Aged 12 or Older, by Age Group: Percentages, 2002-2015 Source: SAMHSA, National Survey on Drug Use and Health l ates of alcohol use disorder among R past year, which is only 10.6 percent individuals ages 12 and older held of those who needed treatment. steady in the 2000s and have been Adolescents and young adults (ages 12- declining more recently (moving from 25) were substantially less likely to get 7.7 percent in 2002 to 5.6 percent in the treatment they needed compared 2016), with the greatest decreases seen with adults ages 26 and older. in adolescents and young adults. 521 l edicaid covered treatment for one M However, another study using a more in three individuals receiving opioid intensive survey found a contradictory use disorder treatment in 2015.523 An result, with alcohol use disorder among evaluation by the Surgeon General adults in the United States increasing notes that costs of treating a substance by 49 percent between 2001-2002 and use disorder are more than offset in 2012-2013 to 12.7 percent.522 reductions for future expected health l bout 2.2 million Americans received A costs.524 treatment for a substance use disorder l round 1 percent of all health spending A at a specialty facility (inpatient hospital is devoted to substance use disorder setting, drug or alcohol rehabilitation treatment.525 facility or mental health center) in the 82 TFAH • WBT • PaininTheNation.org Past Year Substance Use Disorder (SUD) and Mental Illness among Adults veterans and people with more general Aged 18 or Older: 2015 medical illnesses.”528 Mental and Physical Health l tudies show that individuals with S severe mental illness die 13-30 years earlier than their peers, mostly due to physical health reasons.529 l ndividuals with a drug or alcohol I use disorder are disproportionately more likely to also have other costly health conditions, including hepatitis, liver disease, coronary disease and hypertension. Substance misuse or use disorders complicates the treatment of these conditions and increases overall health costs.530 Source: SAMHSA, National Survey on Drug Use and Health Medicaid and Behavioral Health l edicaid accounted for 25 percent of all M Co-Occurring Mental Illness and a substance use disorder as someone mental health spending and 21 percent Substance Use Disorder without a mental illness. of substance use disorder spending in In 2016, 8.2 million adults in the United 2014.531 Nearly 30 percent of Medicaid l 8.7 percent of adults with mental 1 States had experienced both a mental beneficiaries have either a mental health disorders used prescription illness and substance use disorder in the disorder or substance use disorder, opioids compared to just 5 percent of last year.526 or both. Medicaid expansion has the general population.527 increased Medicaid support for mental l ore than 40 percent of adults with M l ix percent of teens have a co- S health and substance misuse treatment a substance use disorder in the past occurrence of mental health disorder for low-income persons by $4.5 billion, year also experienced mental illness and substance use disorder. Some according to an analysis by Richard compared with 16 percent among the individuals use “negative coping Frank of Harvard University and Sherry rest of the population, meaning an mechanisms” by using drugs or alcohol Glied of New York University.532 individual with a substance use disorder to respond to symptoms of anxiety, is 2.5 times as likely as someone l early half of all Medicaid spending N depressive moods, ADHD, trauma and without a substance use disorder to is on care for the 20 percent of physical, emotional and/or sexual abuse. have a mental illness. Medicaid beneficiaries who have a l ccording to the National Alliance on A behavioral health diagnosis (mental l 8.5 percent of adults with a mental 1 Mental Illness: “Men are more likely illness and/or substance misuse). illness also had a substance use to develop a co-occurring disorder Annual expenditures are nearly four disorder in the past year compared than women.” Other people who times higher for Medicaid patients with 5.4 percent among the rest of the have a particularly high risk of dual with a behavioral health diagnosis population, and individuals with a mental diagnosis include individuals of than without a diagnosis ($13,303 illness are three times as likely to have lower socioeconomic status, military versus $3,564).533 TFAH • WBT • PaininTheNation.org 83 There has been a dramatic increase in Recent developments that are of a “whole person” approach for substance use disorders as the opioid significant policy levers for modernizing improved results, including for reducing epidemic has grown — generating an behavioral healthcare include: depression and improving experience urgent need for more services. And the of care.536 A range of experts and l overage of behavioral health. Two C severe shortages of behavioral health organizations, including the Surgeon new federal laws set important providers and services in many areas of General’s office, the American College requirements for certain public and the country are driving the need to look of Physicians and the American Society private health coverage to cover for different models for providing and of Addiction Medicine recommend an behavioral health services that often had paying for services. Many of the steps integrated approach to physical and been missing otherwise. Specifically, in modernizing behavioral healthcare behavioral healthcare.537 The Surgeon the Affordable Care Act (ACA) added a are aimed at systemic change, including General noted the question is “no requirement that individual and small issues of coverage, availability, quality longer whether but how this much- group health insurance must cover and integration of behavioral and needed integration will occur,” and that behavioral health services starting in physical health services. the “net benefits of integrated treatment 2014 and the Paul Wellstone and Pete include improved health care outcomes This section examines a range of policy Domenici Mental Health Parity and and reduced health care costs, as well as and practice recommendations to move Addiction Equity Act of 2008 required reduced crime, improved child welfare, toward positive change in mental health behavioral health services to be covered and greater employment productivity… care and substance misuse treatment on parity with physical, medical and fewer interpersonal conflicts, greater services — sometimes referred to surgical care under individual, group workplace productivity, reduced together as behavioral healthcare. and Medicaid expansion plans.534 infectious disease transmission and Key areas of focus include: • owever, despite these requirements H fewer drug-related accidents, including around coverage, legacy systems overdoses and deaths.”538 Despite the l M odernize Behavioral Health Services and practices continue to make fact that 68 percent of patients with l M odernize Substance Use Disorder access and availability of services a mental health disorder also have a Treatment challenging. Additionally, public medical problem, traditionally, mental and private insurance policies still health and substance use disorders have l E xpand and Improve the Behavioral vary significantly, and covered been treated in separate systems — Health Workforce services may be insufficient to meet including often with separate coverage l P rioritize Needs in Underserved recommended standards of care. and payment policies than physical Communities, Including Low-Income For instance, a 2015 GAO report healthcare.539 and Rural Communities showed significant variation in the l A dvancements in treatment and types of behavioral health services l C onnect Healthcare and Behavioral care. There have been significant provided to Medicaid beneficiaries Health Services with Social Service advancements in understanding in different states.535 In addition, the Supports effective treatments, best practices parity law only applies to employers and standards of care for treating l P rioritize Early Identification and that provide mental health coverage mental health illnesses and substance Connection to Services and Support and have 50 or more employees. use disorders through therapy and l R educe Stigma l I ntegration with physical healthcare. pharmaceuticals — including that long- There is also a significant movement term, sustained care and recovery are toward more integrated approaches to most effective for many patients. There physical and mental health, focused on have also been advances in addressing evidence and practices showing strong stigma and other barriers that have interconnections and the effectiveness limited patients seeking care in the past. 84 TFAH • WBT • PaininTheNation.org PARITY LEGISLATION AND IMPLEMENTATION IN STATES A ParityTrack review by The Kennedy Forum and Scattergood Foundation found that parity laws and regulation vary significantly across the states.540 n promising n needs work n neutral Source: The Kennedy Forum and Scattergood Foundation Addiction Solutions Campaign The National Center on Addiction and l I nsufficient enforcement: Currently, Substance Abuse, the Legal Action enforcement of parity primarily Center (LAC), Partnership for Drug- depends on consumers raising Free Kids and the Treatment Research concerns about compliance, which Institute launched the Addiction Solutions requires a sophisticated understanding Campaign (ASC) in June 2017 — and of the Parity Act’s requirements and the group issued analyses reviewing substance use disorder services that Maryland and New York health coverage many consumers do not have and policies that found equitable coverage is should not need. still lacking primarily due to a reinforcing The groups recommend that states combination of a lack of transparency should require insurers to provide by health insurers and insufficient adequate details about what services enforcement structures of the Parity Act: their insurance policies cover to l L ack of transparency: The information easily identify deficits, as well as do provided by health insurers to more official analyses of Parity Act consumers and state insurance compliance. If insurance policies do not departments is often insufficient to meet the Parity Act standards, insurers determine what substance use disorder must adjust their policies before being services are covered and if there are allowed to sell them to consumers, and any interceding requirements for these detailed information should be available services (e.g., prior authorization). to the public for scrutiny as well.541 TFAH • WBT • PaininTheNation.org 85 Modernize Behavioral Health Services Solutions should include Priority policies for moving health develop payment and service models adequate funding for community insurance and healthcare systems to that prioritize whole health — viewing provide better behavioral and physical and supporting physical and behavioral mental health centers and “whole health” of individuals include: health together (such as Accountable school-based health services Care Organizations, Patient-Centered l C ontinue to improve health insurance that have the capacity to address Medical Homes, Primary Care Case coverage affordability of behavioral Management and Health Homes). behavioral and mental health health services and increase access to There must be consideration for care. Despite significant advances in prevention and treatment needs. accessibility and affordability of mental developing quality measures for substance use disorder treatment health services, coverage is often limited and/or risk adjustment methods for and does not match what is needed inclusion in these types of models. to provide effective and ongoing treatment. Insurance coverage can be l I mplement effective treatment and improved by expanding parity laws to recovery practices. All providers should include all employers; better enforcing adopt — and all payers should cover parity laws; covering a broader range — the latest evidence-based treatment of mental healthcare services and methods with demonstrated ability medications; reducing out-of-pocket for improved outcomes, including costs; and increasing transparency, cognitive behavioral therapy, peer and including publishing clinical criteria family support programs and targeted used to approve or deny care and approaches for high-intensity patients, accurate lists of mental health providers youth transitioning to adulthood and participating in insurance plans.542 partnerships between law enforcement There is a need to work with experts in and mental health services. Currently, the field to continue to define ideal and only limited numbers of states have all appropriate modern behavioral health of these policies. services, along with the corresponding l D evelop and evaluate the most need to update insurance policies and effective models and practices for practices to ensure these services and behavioral health integration. A practices are covered. number of groups have examined l P romote delivery and payment models approaches for integrating physical to increase mental and behavioral healthcare and behavioral health health services. Scaling up value-based services. Since they have traditionally care including payment models that been delivered separately, there are promote flexible, team-based care — issues about how to align care through including community-based supports — medical practices and services, can help expand services and integrate including care coordination and system with primary care.543 Solutions integration (data integration, coverage should include adequate funding for policies, payment/funding approaches, community mental health centers etc.).544 Models and approaches and school-based health services that must also consider how to coordinate have the capacity to address behavioral healthcare and behavioral health and mental health prevention and services with screening for addressing treatment needs. Advanced primary the broader needs of the patients care models that focus on improving — which relate to health — such as outcomes provide new opportunities to financial assistance and social services. 86 TFAH • WBT • PaininTheNation.org • he Eugene S. Farley, Jr. Health T Policy Center conducted a review of an Advancing Care Together (ACT) demonstration and evaluation study for advancing integrated care involving 11 diverse practices in Colorado and identified key recommendations for health systems including to: • rame integrated care as a necessary F paradigm shift to patient-centered, whole-person healthcare; • efine relationships and protocols up- D front, understanding they will evolve; • uild inclusive, empowered teams to B provide the foundation for integration; • evelop a change management D strategy of continuous evaluation and course-correction; and • se targeted data collection pertinent U to integrated care to drive improvement and impart accountability.545 • AMHSA and NIH have identified S frameworks for models, including: coordinated care — which concentrates on communication; co-located care — which focuses on physical proximity; and integrated care — which emphasizes practice changes.546 Some emerging approaches have included Patient- The Case for Integrating Behavioral Health and Primary Care Page | 9 Centered Medical Homes; Chronic Health Homes: hub-systems, where primary providers have a network and Services Administration (HRSA), Washington, D.C. covered some other of connected professionals to and is run by the National Council type of therapy, 14 states covered some refer patients needing care, case for Behavioral Health. The Center’s form of peer support for substance management and care coordination; Innovation Communities come use disorders, and nine states and and intense case management models together for mutual learning and Washington, D.C. covered some for complex case treatment. The planning to adopt best practices for version of supported employment Center for Integrated Health Solutions integration.548, 549 under state plan authority.550 (CHIS) provides training and technical assistance to community behavioral • Medicaid and CHIP Payment and A • rizona, Connecticut, Florida, A health programs, community health Access Commission (MACPAC) review Georgia, Idaho and Mississippi centers, and other primary care found that as of 2015, under their have used Medicaid authorities to organizations,547 and is funded jointly Medicaid plans, 24 states covered some support integrated physical and by SAMHSA and the Health Resources type of psychotherapy, 39 states and behavioral health. TFAH • WBT • PaininTheNation.org 87 • ASHP has reviewed approaches N home certification, HIT capacity, some states are using for integration, population health, care management including:551 and quality improvement). • nnovating to leverage current I • upporting the transition to integrated S Medicaid authorities to provide care by investing resources to provide enhanced payments to practitioners technical assistance; developing that adopt core components of new workforce capacity (such as integrated care, such as multi- Community Care Teams in Vermont to disciplinary teams, care coordination link providers to community services); and population health strategies, and aligning regulations across sectors. which are otherwise non- • unding development of data F reimbursable services (including infrastructure for behavioral 1115 demonstration waiver and other health providers, who have not State Plan Amendment options). generally benefited from the • aying providers and managed care P Health Information Technology organizations more for integrated for Economic and Clinical Health care, through Health Homes (in (HI-TECH) Act investments. 20 states and Washington, D.C.) State Innovation Model (SIM) and other mechanisms, to support and other funding have been infrastructure enhancement for leveraged to fill this gap in uptake integrated care (such as multi- of health information technology by disciplinary teams, medical behavioral health providers. 88 TFAH • WBT • PaininTheNation.org EXAMPLES: MODERNIZING AND/OR INTEGRATING BEHAVIORAL HEALTH SERVICES Sustaining Healthcare Across integrated Primary pediatric PCPs are enrolled in MCPAP with 63 percent of these care Efforts (SHAPE) is an innovative partnership physicians using their services in 2016. This translates to 7,302 with Collaborative Family Healthcare Association, the children served with 10,412 phone calls, 2,524 consultation Farley Health Policy Center at the University of Colorado School of visits and 4,701 referrals arranged. The cost to run this program Medicine and Rocky Mountain Health Plan (RMHP). It is a three is only about $2.33 per child per year. As a result of its success, year project, funded by the Colorado Health Foundation aiming to MCPAP launched a National Network of Child Psychiatry Access examine the effect of paying for the integration of behavioral health Programs to expand this work across the country. and primary care through a practice payment for behavioral health. The Genesee Health System’s Health Center and Results from an innovative integrated Medicaid and Medicare Hope Network, a community-based behavioral health plan in Western Colorado suggested that with appropriate health and human services agency serving payment mechanisms, primary care practices can integrate and a predominantly Medicaid and low-income sustain behavioral health to improve patient outcomes and reduce population in Michigan, are co-located on a shared campus. Hope the cost of care. The SHAPE project model focuses on payment Network connects patients with PCPs in the health center who reform at the system level that allows for easier replication and share patient medical information and develop treatment plans implementation on a larger scale. The idea of shifting practices collaboratively with Hope Network staff. The health center also and providers away from fee-for-service models that emphasize the provides pharmacy support, facilitating access to medication and volume of encounter toward a focus on quality and outcomes with educating patients about medication compliance. Hope Network the practice payment is key for achieving a sustainable model for employs Navigator Teams to monitor and support clients who integrating mental health services both in the primary care setting are receiving primary care at the health center, locates needed and beyond. Results of the pilot show that practices receiving specialty care that is not available through the health center and a payment for behavioral health from the health plan yielded a connects patients with community-based services and supports. 4.8 percent lower total cost of care for their public payer patient All needed services and supports are encompassed in a single population than in the comparison practices. Additionally, patients integrated care plan that is coordinated by the Navigator Teams. in practices receiving a payment for behavioral health were more Hope Network reports that, for the small cohort of clients who likely to be diagnosed with anxiety and depression after payment received Navigator Team services and for whom longitudinal data implementation than patients in the comparison practices. This were available, psychiatric inpatient admissions per person fell effort is part of a larger vision of an accountable community that from an average of 1.95 in the year prior to receipt of navigator features clinical integration, value-based payments, social equity, services to 0.48 after receiving navigator services for one year. patient engagement, coordinated care and meaningful use of HIT. Due to the program’s success and ability to achieve the Triple Colorado is using $65 million in SIM funding to Aim (improved outcomes, decreased cost, and enhanced patient provide “access to integrated primary care and experience), RMHP has expanded the payment model to other behavioral health services in coordinated community primary care and pediatric practices. systems, with value-based payment structures, for 80 percent of state residents by 2019.” Practices in the first cohort are The Massachusetts Child Psychiatry Access experimenting with integrating licensed behavioral health providers Project (MCPAP) seeks to boost the ability (BHPs) into their workflows, renovating their practices to make of primary care providers (PCPs) to handle space for additional BHPs, conducting tablet-based behavioral behavioral health issues by screening and managing the needs health screenings, training existing and new staff, establishing of youth with common mental health conditions such as ADHD, community and patient engagement programs, and seeking better depression, anxiety and substance use disorder. The program, coordination and referral to specialty mental health settings in funded by the Massachusetts Department of Mental Health, is their communities. In the first year, practices reported challenges free to providers and offers telephone consultation with a child in finding qualified BHPs, billing for BHPs and collecting behavioral psychiatrist or licensed therapist within 30 minutes of a request, health screening data in existing EHRs. Participating SIM practices face-to-face consultation, resources and referral to community- integrating BHPs have reported decreases in emergency room based behavioral health services and training and education for visits among patients seeing BHPs and increased willingness to PCPs and their staff. In Massachusetts, over 95 percent of the try therapy among patients diagnosed with depression.552 TFAH • WBT • PaininTheNation.org 89 Modernize Substance Use Disorder Treatment Any strategies to prevent and reduce workforce shortages and ongoing stigma • reatment approaches should reflect T substance misuse must focus on around substance use disorders and research that shows many patients providing sustained and ongoing misperceptions about how effective need multiple treatment attempts treatment and recovery support treatment can be and how it works. before long-term success, and — otherwise they are inherently that prior attempts do not reduce Government and healthcare system incomplete and ineffective. The likelihood of future positive outcomes. policies should promote expanding final component of developing a full- access to and quality of substance misuse l Q uality, affordable and comprehensive spectrum strategy is to have an effective, treatment — and aligning practices and health coverage that covers effective, funded and compassionate treatment coverage policies with evidence-based best practice informed treatment — system in place, over the long-term. research for what is most effective. not restricting time or duration — and The rapid rise in opioid misuse is has streamlined, simple enrollment Key principles experts highlight as dramatically increasing the need for processes. essential for appropriate coverage include: treatment. While there was a reported • dditional supports during recovery A more than five-fold increase in treatment l H igh-quality, effective and timely tailored to needs, like connecting admissions for opioids in the past substance misuse treatment for as long as individuals from treatment to decade, millions are still going untreated needed at a location appropriately suited recovery/safe places to stabilize or and undetected.553 Only around one in for the patient (including medications). programs that keep families together 10 persons with a substance use disorder • ccess to immediate care when A during treatment. Stable, safe housing receives recommended treatment.554 an individual is seeking treatment and financial stability are often cited as Substance use disorder is defined as a is important to being supportive key to longer-term recovery success. chronic, relapsing brain disease that is when an individual is in need and Some priority policy areas for characterized by compulsive drug seeking receptive to treatment. There should modernizing, expanding and improving and use, despite harmful consequences. be “no wrong door” (NWD) entry treatment, many of which are aligned Researchers have documented how system for being able to connect to with broader integrated behavioral some forms of drug use can change coverage, such as through emergency health approaches, include: the structure of the brain, with lasting departments, primary care impact. Recommended treatments physicians, other specialists, social l E xponentially expand the workforce. vary depending on the type of drug services, EMS, Fire Department Safe The behavioral health workforce must dependence. For opioid addition, the Houses and other systems. be expanded to support the needed treatment typically involves counseling availability of providers who can treat • atients should be able to seek P and building a stronger support network and provide services for substance the most effective treatment that of friends, families and services for use disorders — including supporting works for their conditions and an individual, but for most, effective different service delivery models, such circumstances. This may include a treatment also includes use of MAT to ease as expanding use of community health range of inpatient and outpatient or eliminate withdrawal symptoms and workers, paramedics, peer counselors therapy, counseling and medications, relieve cravings. Additional considerations and expanding/building on primary etc. Services should be provided in are needed for individuals who may be care. Some models for bolstering locations and facilities that do not dependent on multiple substances. workforce areas have included incentives create an unreasonable burden on and loan repayments for professionals. The treatment gap has been fueled by lack the patient, and that take into account of funding, limits on insurance coverage, proximity/accessibility and stigma. 90 TFAH • WBT • PaininTheNation.org l U pdate provider treatment guidelines and duration of the recommended — and public and private insurance treatment; integrated medical policies and practices to match and mental health professional recommended standards of care/best support; and full reimbursement for practices. There is an urgent need appropriate, recommended medicines to update and modernize insurance and therapeutic treatments. Currently, policies and provider practices to many insurance plans limit the ensure sufficient coverage for the most number of doctor visits and duration effective, evidence-based treatment of treatment at levels far below what is approaches, including: the full scope recommended to be effective. SUBSTANCE USE TREATMENT TASK FORCE As the opioid epidemic has grown over independent scientists, and have been the past decades, so has the need for accepted and endorsed by all six of the substance use disorder treatment. The federal agencies most responsible for availability and quality of treatment, addiction policy (SAMHSA, NIDA, NIAAA, however, remains uneven and often fails CDC, FDA and CMS): to meet evidence-based care standards. 1. niversal screening for substance U In early 2017, the Shatterpoof use disorders across medical care organization brought together a range of settings expert stakeholders — from advocates 2. ersonalized diagnosis, assessment P and government officials to health and treatment planning insurers and researchers — into a Substance Use Treatment Task Force 3. apid access to appropriate R to facilitate collaboration and provide substance use disorder care accountability in improving addiction 4. ngagement into continuing long-term E treatment in the United States. This care with monitoring and adjustments Treatment Task Force has several work to treatment phases planned; they recently finalized a national standard of care that follows 5. oncurrent, coordinated care for C the most recent evidence-base and are physical and mental illness working to get major health insurers 6. ccess to fully trained behavioral A to all agree to identify, promote and health professionals reward substance use disorder care that meets these standards.555 The 7. Access to FDA-approved medications national standard of care includes eight 8. ccess to non-medical recovery A principles that have been reviewed support services and approved for accuracy by over 300 TFAH • WBT • PaininTheNation.org 91 MEDICATION-ASSISTED TREATMENT While treatment should match individual disorder could access methadone or needs and circumstances, experts advise buprenorphine treatment.563 A Blue Cross that the best evidence-based treatment Blue Shield analysis found that between approaches for many individuals with 2010 and 2016 there was an increase opioid and alcohol dependency include in the number of opioid dependency pairing counseling with MAT when certain diagnoses of 493 percent, but only a 65 medications can ease or eliminate the percent increase in the number of insured withdrawal symptoms, relieve cravings and patients receiving MAT — an eight-fold gap support sustained recovery.556, 557 between diagnosis and treatment.564 MAT for opioid use disorders has been The American Society of Addiction endorsed by NAM, NAS, NIDA, HHS, CDC, Medicine, whose mission is to increase World Health Organization, the Center for access to and improve the quality of Substance Abuse Treatment and others.558, addiction treatment, recommends against 559 In addition, a systematic review of laws, regulations or health insurance the literature on the costs, cost savings practices that impose arbitrary limits on and cost-effectiveness of medications the number of patients who can be treated for treating alcohol dependence found by a physician or the number and variety of that pharmacotherapy treatment of medicines or therapies that can be used alcohol dependence produced marked for treatment.565 ASAM finds the current economic benefits.560 A 2015 study 100-patient prescribing limit per certified found that treatment with methadone and provider for buprenorphine to be a major buprenorphine treatment episodes was barrier to patient access to care. associated with $153 to $223 lower total l T here are shortages and restrictions healthcare expenditures per month than on the availability of MAT around the behavioral health treatment without MAT, country. According to SAMHSA, as of and that patients were 50 percent less likely 2014, 43 percent of counties in the to relapse when treatment involved MAT.561 United States did not have a doctor Public and private insurers have different licensed to prescribe buprenorphine.566 policies for covering MAT. Physicians l A s of July 2017, there were no opioid and other providers must receive special treatment programs in Wyoming, only one authorization under federal law to treat in South Dakota, three in Idaho and North addictions with controlled substances, as Dakota and just four in Alaska, Hawaii, a result the number of providers and the Mississippi, Montana and Nebraska.567 availability of medications is limited. Medical doctors with training and one year experience l T hirteen states have fewer than can treat up to 275 patients at a time.562 five physicians certified to provide buprenorphine.568 A 2017 study of 1,151 FDA has approved three medications to opioid-treatment centers found 35.4 help treat opioid addictions, prevent or percent did not accept Medicaid, and, relieve withdrawal symptoms and cravings moreover, that numerous counties have no and help reduce potential for relapse — access to opioid use disorder treatment methadone, buprenorphine and naltrexone. in programs for Medicaid enrollees with As of 2012, only 1.4 million of the the most notable gaps in coverage in the 2.3 million people with an opioid use Great Plains (Idaho, Montana, North and 92 TFAH • WBT • PaininTheNation.org South Dakota, Nebraska and Wyoming) 2017 Nurse Practitioner State Practice Environment and portions of the Southeast (Arkansas, Louisiana, Mississippi and Tennessee).569 WA MT ME ND CARA extended the ability to prescribe VT OR MN NH MAT to authorized nurse practitioners and ID SD WI NY MA physicians assistants through 2021.570 WY MI CT RI IA PA NJ However, at least 12 states still have NV NE OH DE UT IL IN restrictions on nurse practitioners providing CA CO MD WV KS MO VA DC MAT.571 In addition, a 2015 review by the KY ASAM found only 30 states and Washington, NC AZ TN OK D.C. provided Medicaid coverage for all three NM AR SC FDA-approved medications via Medicaid. And MS AL GA according to a SAMHSA review in 2014, 30 TX LA states and Washington, D.C. had Medicaid FL AK fee-for-service programs covering methadone HI maintenance treatment via outpatient narcotic treatment programs. MAT still has Full Practice Reduced Practice Restricted Practice a stigma among many healthcare providers, including among providers delivering care Source: American Association of Nurse Practitioners within the criminal justice system, according to a 2016 GAO review.572 RECOVERY-ORIENTED SYSTEMS OF CARE (ROSC) Definitions of recovery differ. It SAMHSA’s is often used to mean successful WORKING DEFINITION OF treatment, maintaining remission RECOVERY (not using or control of use) and/or systems of support that help maintain sobriety. Recovery-oriented Systems of Care (ROSC) focus on addressing Hope Person- Driven disorders through a chronic care Many management model that includes Respect Pathways longer-term, outpatient care; recovery Strengths / housing; and recovery coaching and Responsibility Holistic management checkups.573 These systems are meant to be “easy to Addresses Peer Trauma Support navigate for people seeking help, Culture Relational transparent in their operations and responsive to the cultural diversity of the communities they serve.” 10 GUIDING PRINCIPLES OF RECOVERY Source: SAMHSA TFAH • WBT • PaininTheNation.org 93 EXAMPLES: MEDICAID EFFORTS TO ADDRESS OPIOID OVERDOSES, MISUSE AND ADDICTION CMS issued a best practice document SAMHSA, CDC and NIDA describing best Examples of some state approaches underscoring that the agency believes practices, state-based initiatives and useful include: a nurse manager model in that “ensuring access to a robust set of resources for the delivery of MAT, and on Massachusetts expanding the number and treatment models is critical to combat- early identification and treatment of teens types of providers who can deliver MAT; ting opioid use disorder and its health- with a substance use disorder. a team of healthcare and social workers care complications.” 574 to obtain access to health insurance, HHS has proposed a number of other primary care providers and referrals to Treating substance use disorders is a pri- rules, such as to offer protections for outpatient providers and social workers ority under the CMS Medicaid Innovation Medicaid beneficiaries under the parity to continue integrated care in Maryland’s Accelerator Program (IAP), which helps pro- laws; to allow states to claim federal funds Buprenorphine Initiative, which reduced vide states and stakeholders with expert for crisis stabilization to improve access opioid treatment waitlists and heroin- resources, coaching services and hands-on to short-term, inpatient behavioral health related deaths; and a “hub and spoke” programs to support policy, program and services; and to allow states, under section model in Vermont with regional coordination payment reforms for substance use disor- 1115 demonstration authority, to support of hubs serving as specialty substance use ders and expand coverage for promising broad and deep substance use disorder disorder coordinating centers to treatment and evidence-based services. CMS has treatment transformation efforts, including and coordinated care for complex patients also issued Informational Bulletins on enabling the ability to provide a full and spokes of teams of providers who Medicaid coverage for behavioral health continuum of care by introducing service, serve less medically complex patients.575 conditions, including a joint publication with payment and delivery service reforms. EXAMPLES: HEALTH PLAN EFFORTS TO ADDRESS THE OPIOID EPIDEMIC Reducing Prescription Drug Abuse substance use disorders; decreasing Health plans across the nation Collaborative was launched in 2013 the number of opioids inappropriately are taking steps to address the by the Association for Community prescribed; limiting permitted dosages of opioid epidemic. Some promising Affiliated Plans (ACAP) with 13 plans prescription opioids to prevent overuse examples include: Harvard Pilgrim participating. To address the high rates or misuse; limiting the ability of multiple Healthcare is encouraging non-opioid of opioid misuse and dependency among providers to write concurrent opioid approaches to managing pain when beneficiaries, participant programs prescriptions; and ensuring access to appropriate. Blue Cross Blue Shield were tailored to their member’s unique naloxone and other drugs that prevent of Massachusetts implemented an characteristics and needs, such as: overdoses. Specific strategies used opioid safety management program Screening, Brief Intervention and by plans include: SBIRT, formulary that requires prior approval to refill Referral to Treatment; outreach to management (after UPMC took Oxycontin short-acting opioid prescriptions and Medicaid healthcare providers and off its formulary, the plan found that for new prescriptions for long acting beneficiaries; specialized support 135 of the members previously using it opioids. This program reduced opioid services for beneficiaries; prescriber and stopped taking it and did not switch to prescriptions by about 21 million pharmacy lock in programs; and quality another prescription opioid); alternative while still providing accessible and improvement for MAT with Suboxone. approaches to pain management; use of appropriate care. Cigna is working Based on the work of this collaborative metrics and algorithms to identify at-risk with the ASAM to verify what works in and subsequent interviews with member members; member engagement; case treating patients with addiction, educate plans, the affiliated plans published best management; MAT; provider education; the medical community of proven practices for plans in 2017, including: value-based payment; and multi- strategies and hasten the adoption of encouraging providers to screen for stakeholder engagement. successful methods. 94 TFAH • WBT • PaininTheNation.org Expand and Improve the Behavioral Health Workforce The gap in the behavioral health workforce is a major impediment to Mental Health Care Health Professional Shortage Areas (HPSAs) meeting the treatment needs in the country. Nationally, there is a reported shortage of 3,400 psychiatrists to meet community needs (not including needs for other mental health professionals), and, as of 2016, every state but one reported having shortages in qualified mental healthcare professionals.576, 577, 578, 579 Fifty-five percent of U.S. counties do not have any practicing behavioral health workers and 77 percent reported unmet behavioral health needs.580 Policies to bolster the workforce moving forward should include: 1) encouraging more Americans to become behavioral health providers Source: Kaiser Family Foundation through financial incentives, including higher compensation, grants, scholarships and loan forgiveness; development initiatives, such as training 2) expanding and developing more for case workers and members of types of behavioral health providers impacted communities to be able to in the workforce (i.e., peer support, serve as community health workers recovery coaches, social workers, and peer counselors, and support for health educators and non-traditional telehealth services. health workers) who can provide A 2013 SAMHSA report to Congress behavioral health treatment; 3) noted that compensation for medical continually updating curriculum and professionals specializing in behavioral training to match the latest evidence- health is significantly below salaries based guidance for best practices; earned in other medical professions and 4) promoting knowledge sharing and in business.582 The mental health around skills, care and management.581 workforce is also aging; the median age Approaches such as learning healthcare for psychologists, psychiatrists, social systems or incentives through advanced workers and counselors is all over 40, payment models could be used to help with 46 percent of psychiatrists over support development and adoption of 65.583 Further, studies show that most these types of advances. training programs for psychiatrists, Efforts to meet the behavioral health social workers and psychologists offer needs in underserved areas should limited or no training on addiction and include behavioral health workforce substance misuse.584 585 TFAH • WBT • PaininTheNation.org 95 Prioritize Behavioral Health Service Availability in Underserved Areas — Including Rural and Low-Income Communities More than 85 million Americans live also added a legal services component enrollment efforts for public and in areas — particularly rural and low- to help with additional issues that private coverage through the Health income urban communities — with an their patients face.590 In addition, a Insurance Marketplaces.593 insufficient number of mental health number of groups are also exploring l E xpanding the workforce and professionals, and more than half increasing the use of telehealth telehealth. Adjust practice of U.S counties (all rural) have no services in rural underserved areas. scope/licensing requirements to practicing psychiatrists, psychologists Some key strategies for increasing and broaden behavioral healthcare or social workers. 586, 587 improving behavioral health services workforce to include more kinds of CMS and some states are actively for underserved areas include: providers and enable non-physician developing innovative models and providers to deliver a wider range of l B olstering federal investment. practices for providing care in service, and to amend telehealth and Increase SAMHSA, HRSA and CMMI underserved areas, including via school regulations to require insurer grants that support behavioral ACOs, frontier community integration reimbursement and reduce barriers healthcare and/or integration initiatives and small hospital to uptake.594 models; particularly increase reimbursement policies.588 One grants that focus on underserved l I ncentivizing students to pursue example is the pilot Pennsylvania areas/populations (low income, behavioral health careers. Grow Rural Health Model, where a global rural, large racial/ethnic, LGBT, student loan repayment and budget — a fixed amount that is set in other minority communities). forgiveness programs and fund advance for inpatient and outpatient additional residency programs hospital-based services — is provided l U sing leverage as public payer. for behavioral health providers in to focus on efficiently and effectively Modify public health insurance underserved areas.595 providing quality care and reducing programs to raise behavioral expenditures while meeting the healthcare and telehealth l F und innovative community needs of the rural patients within reimbursement rates, boosting programs that fill gaps. Many the hospital system.589 The Family financial incentives for individual and successful programs can be Health Centers (FHC) in Kentucky organizations to provide needed care expanded like those providing has added clinical social workers and and services, and expand available behavioral health ser vices in public psychologists to care teams and has providers as much as possible. Also schools and worksites, crisis lines them available to do consultations in create/use funding models for care for those in acute needs, and conjunction with primary care visits as integration that include behavioral training/education programs (e.g., needed, which facilitates connection healthcare (e.g., state Medicaid Mental Health First Aid USA) for to mental health and substance use waivers) and provide technical community members, such as clergy, disorder treatment as needed as well assistance for providers.591, 592 child-care providers and police as to social services. This handoff officers to recognize mental illness l M aximizing health coverage avoids an additional appointment and provide support and other enrollment. Expand Medicaid in (which may not happen) and means action steps.596 all 50 states and support robust patients receive immediate care. FHC 96 TFAH • WBT • PaininTheNation.org BEHAVIORAL HEALTH AND PERSONS WHO ARE INCARCERATED Around 10 percent to 25 percent of that focus on providing more and better mental illness with the aim of preventing individuals who are incarcerated in the available mental health and substance violence, avoiding unnecessary arrests and United States have a serious mental use disorder treatment services in improving mental health services.602 These illness, compared to 5 percent of the communities, improved approaches include local hospitals and community total population.597 Some reviews have where the criminal justice and behavioral centers to adopt no-refusal policies, found that more than half of individuals health services are aligned in response which allow law enforcement officers to who are incarcerated have some form of to people upon incidents or arrests that confidentially transport a person to an mental health problems, and also that focus on addressing health needs and emergency room or other community-based being incarcerated can contribute to providing services, such as diversion services, in lieu of arrest, and the person and/or exacerbate mental illnesses. In to treatment as appropriate, and to will not be turned away from receiving addition, a number of studies have found provide improved services to those who treatment. Two reviews found that in that more than half of individuals who are are incarcerated and ongoing support Birmingham, Alabama and Memphis and incarcerated have a drug and/or alcohol services upon release.598, 599, 600, 601 Knoxville, Tennessee, police were able dependence, compared to around 9 to resolve more than one-third of calls to An example of an approach is more percent of the total population. Of those scenes through this approach — including than 2,600 communities have taken is who are incarcerated who have a serious transporting 46 percent of these calls to develop Crisis Intervention Teams, mental illness, 72 percent also have a to treatment facilities and 13 percent to providing training to police departments co-occurring substance use disorder. mental health specialists. Only between to respond to psychiatric emergencies in 2 percent and 13 percent of mental-health A range of mental health organizations the community, working with mental health related calls results in arrests. and reviews have recommendations providers and families of those affected by TFAH • WBT • PaininTheNation.org 97 Focus on Whole Health, Care Coordination and Management, The siloed nature of health and and Connect Health, Mental Health, Social Services and social service delivery systems Education Services Another major gap in the healthcare can also serve as a platform to administer means that many individuals in system is the lack of regular systems targeted social programs that address need are not identified and do to ensure coordinated care — and healthcare needs, collaborate with partner not receive available support to identify needs and connections organizations and identify ways to generate to services within and beyond the and share in program savings with the healthcare system that support well- healthcare sector. Some of these models being and improved health. offer a pathway to a more integrated system that aligns health and social services Advances in technology and systems — in a manner that lowers costs and improves as well as shifting to a more value-based a person’s well-being. Other models, such healthcare system, which incentivizes as Health Leads, support having physicians outcomes and effective lower-cost models write prescriptions for care beyond — are providing new possibilities for traditional healthcare needs, and Health identifying risks and concerns early, and Lead advocates for voluntary medical ensuring individuals and families receive students to work with patients to identify appropriate services and care to help and connect them with needed services. prevent, mitigate and/or treat issues. There are increasing numbers of There is a particular need to improve models and efforts to better integrate systems that can identify and provide and connect healthcare and social support to at-risk individuals and services, particularly with a growing families. The siloed nature of health understanding for how health status is and social service delivery systems influenced by “social determinants,” such means that many individuals in need as income, education, transportation, are not identified, and do not receive housing and other factors.603, 604, 605, 606 available support and/or the support Systems should reflect an understanding they receive is not coordinated or that individuals and families may enter efficient and not optimally effective. through different service points, such as A stronger focus on coordinated care, through medical care or through various health homes, patient-centered care and social services and should support a “No case worker models and systems help Wrong Door” approach. ensure children and adults receive the In a No Wrong Door entry system, care and services they need, both through multiple agencies retain responsibility the health system and across other social for their respective services while services. For instance, many hospitals and coordinating with each other to integrate health systems are increasing “population access to those services through a single, health” centered approaches, such as standardized entry process administered using case managers, community health and overseen by a coordinating entity.607 workers and/or peer counselors to help A No Wrong Door System can provide patients navigate systems, providing information and assistance to individuals referrals and follow-up to ensure they needing either public or private resources, receive and access care and services (e.g., professionals seeking assistance on behalf stable housing, adequate food and needed of their clients and individuals planning non-emergency medical transportation for their future long-term care needs. services and others). These approaches 98 TFAH • WBT • PaininTheNation.org Successful efforts have included: • stablished under Section 223 of E the Protecting Access to Medicare l “Navigators,” such as the Accountable Act of 2014, the two-year Certified Health Communities (AHC) pilot Community Behavioral Health model launched by CMMI, which Clinic (CCBHC) demonstration focus on bridging the gap between program supports eight states in clinical medical care and community testing certification and payment for services by systematically identifying specialized behavioral health clinics, and addressing beneficiaries’ known as CCBHCs, that are designed health-related social needs and to increase access to quality, evidence- assessing, whether establishing these based behavioral health services in linkages can reduce healthcare communities. Participating states costs and improve quality of care (Minnesota, Missouri, New Jersey, New and outcomes.608, 609 AHCs address York, Nevada, Oklahoma, Oregon housing instability and quality, food and Pennsylvania) are responsible for insecurity, utility needs, interpersonal certifying eligible clinics as CCBHCs violence and transportation needs. per federally-developed criteria and l A ccountable Communities for monitoring clinic compliance. Based Health (ACH) Models have been on similar standards found in state launched in a number of states to Medicaid plans for federally-qualified better integrate health and social health centers and Medicaid Health services — and in some cases are Homes, the CCBHC criteria are also providing follow-up support to organized within six categories: staffing; ensure the services are carried out.610, availability and accessibility of services; 611, 612 Some ACHs across the country care coordination; scope of services; are beginning to tap into healthcare quality and other reporting; and dollars to fund initiatives, including organizational authority, governance Medicaid and innovation funds, such and accreditation.614 States must as State Innovation Models. As ACHs certify that each CCBHC provides a evolve to seek and manage these comprehensive, core set of behavioral funds, they are finding the need to health services either directly or connect to or develop sophisticated through a designated collaborating financial management skills. organization — including crisis interventions, screening, patient- l T he No Wrong Door System, center treatment planning and care including Aging and Disability coordination, among others. CCBHCs Resource Centers (ADRC) is a are compensated through one of two collaborative effort of the U.S. prospective payment systems and may Administration for Community Living claim CCBHC services at the enhanced (ACL), CMS, and Veterans Health Federal Medical Assistance Percentage Administration to support state (FMAP) without seeking Medicaid state efforts to streamline access to long- plan authority.615 The demonstration term services and support options for project runs through 2019. all populations and all payers.613 TFAH • WBT • PaininTheNation.org 99 Four priority areas of focus for whole l risis Services. Crisis services can C health and coordinated care include: help provide essential services within communities to help support l T wo-generation healthcare, mental individuals who are experiencing severe health service and social service difficulties and distress, providing both support, especially for at-risk families. mental health support and connection Improving the health of children to services that can help support includes ensuring their parents and stability, such as financing and housing caregivers are also in good health, assistance or during times of family so they can provide good care and a or interpersonal trauma. Effective supportive, protective environment crises services have been shown to for their children. For instance, help reduce suicides and substance a number of models support an misuse.618 Services commonly include: approach that takes into account the telephone crisis hotlines and “warm” whole health needs of children and lines; peer crisis services; mobile crisis their families beyond basic physical services; crisis stabilization beds; short- care. Zero to Three recommends term residential services; and crisis models that integrate Infant and Early stabilization teams. Crisis services Childhood Mental Health services into have also been shown to reduce all child care and services, including: hospitalizations and emergency room integrating mental health clinicians visits and increase linkages to outpatient into primary pediatric healthcare, services, contributing to significant cost child care and early education savings.619 Delivering an integrated programs; including screening, and comprehensive spectrum of assessment and referral strategies; crisis services often necessitates cross- providing information to parents and sector collaboration and coordination caregivers for how they can support of available local, state and federal social-emotional development; and funding streams. As local capacities offering mental health services that vary, crisis services should be developed address the needs of young children according to the community’s needs exposed to adverse life experiences and delivered as a continuum that and trauma.616 includes strong partnerships, training l P renatal and preconception care and referral systems with mental health and social service support. One service providers, informal support high-impact and essential area for groups and existing community-based quality healthcare is for women of organizations.620 For example, a state childbearing age and all pregnant or locality could coordinate Medicaid women to ensure they have quality, funds for short-term residential services accessible, affordable healthcare, in partnership with the local hospital mental health services and access with housing, community development to social service support as needed. or grant funds from a local community- Evidence suggests that intensive based organization to provide bridge therapies that focus on mothers’ services in times of acute instability mental health and their interactions and distress (i.e., to address displaced with their young children can improve housing, financial crises, or other child outcomes.617 health problems).621, 622 100 TFAH • WBT • PaininTheNation.org l T rauma-Informed Services and Systems. For many children, teens and adults experiencing trauma or prolonged stress without the skill base to navigate systems, accessing health, education and social services can compound stress and/or be too challenging to obtain.623 Federal, state and local government programs, with the support of child care, early childhood education and school systems, are finding ways to take a trauma-informed approach by establishing practices and training that provide respectful, sensitive and culturally-competent care and support that helps identify individuals ameliorate the symptoms of trauma. and families in need of support and And SAMHSA created a Federal connects them to additional services. Partners Committee on Women and For instance, in 2013, HHS, ACF, Trauma to identify federal strategies CMS and SAMHSA jointly issued and services to support women who a letter to state agency directors to have experienced trauma through encourage trauma-informed and domestic and community violence or social-emotionally sensitive services for those serving in the armed forces within the child welfare system, or are military veterans.627 including the possibilities for using Medicaid to support services to meet • he Trauma-Informed Care for T children’s trauma-related behavioral Children and Families Act of 2017 was health needs (cognitive behavioral introduced in March 2017.628 The bill therapy, crisis management services, would establish: 1) an Interagency Task Alternative Benefit Plans, Home and Force on Trauma-Informed Care; 2) a Community-Based Services, Health National Law Enforcement Child and Homes, Managed Care, Integrated Youth Trauma Coordinating Center; 3) Care Models and research and a Native American Technical Assistance demonstration projects).624, 625 There Resource Center to provide trauma- are multiple ways that Medicaid can informed technical assistance; and support trauma-informed care. This 4) Medicaid demonstration projects joint guidance encourages the use of to test innovative, trauma-informed trauma-focused screenings, assessments approaches for delivering EPSDT and care to address complex services to eligible children. CDC interpersonal trauma.626 The guidance must encourage states to collect and identifies the impact that symptoms of report data on ACEs. The Department trauma may have on a child’s social- of Education may award grants for emotional well-being and identifies the improvement of trauma support appropriate assessment and treatment services and mental health care for methods to identify, mitigate and children in educational settings. TFAH • WBT • PaininTheNation.org 101 EXAMPLES: COORDINATING AND/OR INTEGRATING SERVICES AND SUPPORTS The Mental Health Virginia’s Children’s A case manager helps the youth navigate Center of Denver’s Dahlia Services Act (CSA) is and receive available services — ranging Campus for Health and a case management from education, healthcare, housing, Well-Being, opened January of 2016, model that blends at least seven funding transportation and food assistance. was built to support all aspects of streams across four state agencies Through improved coordination of services well-being. The Mental Health Center (social services, juvenile justice, education and funding streams, case managers of Denver engaged in a three-year and behavioral health), realigns their have the flexibility to focus on tailoring community engagement process, rules and structures in the service of a services to the youth’s needs and avoiding meeting with community members common goal and allocates these funds unnecessary bureaucracy.629 and other stakeholders to understand to localities to support the needs of at-risk The Southwest Advocacy their needs. As opposed to a stand- youth and families. Although the state Group (SWAG) is a alone mental health center, top agencies whose funds had been pooled grassroots, community- priorities in the community included no longer had exclusive control over those based organization working fresh and healthy food, preschool, dollars, the agencies participated in the to connect residents in a cluster of children’s dental care and a place new infrastructure created by the CSA neighborhoods in southwest Gainesville, for social and educational activities to allocate the pooled funds. Heads of Florida with needed resources and services focused on well-being. In response to state agencies still serve alongside other using a trauma-informed community these community needs, the Mental stakeholders on the State Executive response.630 Using GIS mapping, the group Health Center of Denver sought out Council for Children’s Services, which was able to overlap data on premature partnerships with various commercial oversees the fiscal and programmatic births, child abuse and neglect and and nonprofit service providers to policies of the CSA system. The state domestic violence to identify neighborhood create the four-acre Dahlia Campus, budget allocates CSA funds to localities “hotspots” for targeted intervention. SWAG which includes a preschool, gym, urban based on a funding formula. The local implemented several targeted interventions farm, school, greenhouse, dental clinic, funds are received and managed by the in these hotspot neighborhoods, including community kitchen, mental health local Community Policy and Management free weekly mobile clinics to provide services and education classes. By Team, which is appointed by the local primary care with a trauma responsive capitalizing on the community’s grit, governing body. The Community Policy focus; a SWAG Family Resource center to determination, perseverance, and Management Teams authorize the funds supply concrete family supports such as foresight, the treatment center was to pay for the services recommended food, clothing, and shelter; and changes able to go beyond the traditional by the local Family Assessment and to local law enforcement response to mental health clinic model and Planning teams. Localities also contribute domestic violence victims, including provide comprehensive services to matching funds to the CSA state pool and screening for lethality risk and immediate the communities that need it most. report to the state on pool expenditures connection by the sheriff deputy’s phone Dahlia Campus offers an infant mental as a whole; they do not report on with the domestic violence network of health program, deaf and hard of expenditures by stream. At-risk youth are services.631 Within four years, SWAG saw hearing services, horticultural therapy referred through a range of individuals or a reduction in premature births and a 45 in therapeutic gardens, learning organizations or schools — and assigned percent reduction in cases of child abuse landscapes, playgrounds, parenting to a Family Assessment and Planning and neglect.632 classes, yoga for all ages and more. Team who develop an individualized plan. 102 TFAH • WBT • PaininTheNation.org Reduce Stigma A NASEM report, Ending Discrimination l A dvocacy and engagement campaigns Against People with Mental and Substance (efforts focused on federal, state Use Disorders: The Evidence for Stigma and local public policy, professional Change, pointed to persistent stigma as and community leadership/thought- a major barrier to the success of mental leadership, social media, community- health reform. The report found that and school-based programs, etc.); several features of the nation’s healthcare l C ontact-based education programs system also contribute to the problem, to facilitate social contact between including: fragmented bureaucracy people, with and without, behavioral for accessing behavioral healthcare; disorders; and overuse of coercive approaches to care; rejection of facilities by communities; l eer programs in which people who P and lower funding for research in areas have disclosed their condition offer of behavioral treatment and services than support through personal experience for neuroscience and physical health. and expertise (informal peer-led efforts and specialized services). Changing perceptions and normalizing the issue, must mean addressing stigma The report recommends that creating across multiple levels of society, including sustainable systemic changes, and the structural level of institutional normalizing mental health and addiction practices, laws and regulations, as issues at scale, also requires policy well as among the general public and changes at the federal level, including: groups such as healthcare providers, l N on-discriminatory evaluation employers and others able to reach those procedures. An HHS-led collaborative in communities struggling with mental among federal partners and other health and addiction challenges. stakeholders would ensure the design, Effectively addressing stigma must also implementation and evaluation of mean focusing on the individual. Self- policies and programs — including stigma, which reflects internalized negative within the criminal justice system and stereotypes, significantly contributes to federal and state agencies — do not the masking of problems and avoidance directly or indirectly discriminate in seeking support — and continues to be against people with disorders. among the most pressing challenges to the l S tigma-reduction messaging and nation’s well-being. Key community-based communications programs. SAMHSA strategies to reduce stigma include: should design, evaluate and implement l P ublic awareness and education, evidence-based programming that with content designed to increase promote affirming and inclusive understanding of, and normalize, attitudes and behavior, and that provide mental and substance use disorders support during recovery and encourage (traditional and social media, participation in treatment. It is community and parent/family direct important that this be well-researched education programs, etc.); and demonstrated effectiveness. TFAH • WBT • PaininTheNation.org 103 Early Identification of Issues and Connections to Services and Care The healthcare and mental health can be averted by early detection and systems should increase their emphasis counseling about lifestyle changes. For on and incentivize early identification most adults covered by employer-based of concerns — and facilitate connecting healthcare, Medicaid in expansion states those in need to care and services. and Medicare, preventive screening for alcohol misuse and depression are Early intervention can help prevent covered as routine preventive services and mitigate problems — and there and depression screening is covered are a range of policies and practices to for teens ages 12 to 18, with both support regular screenings by someone recommended by the U.S. Preventive trained to spot risk factors, counsel on Services Task Force.634, 635, 636, 637 In protective factors, and recognize early addition, AAP recommends substance warning signs of substance misuse or misuse screening for adolescents.638 mental illness and connect individuals And SAMHSA notes the importance of to professional care to prevent misuse, ensuring that processes include referrals build resiliency and save lives. to appropriate care that is culturally These begin with early childhood and sensitive. The agency has found that family screening programs and should “the absence of a proper treatment be a continued practice for teen and referral will prevent the patient from adult care. It helps identify individuals accessing appropriate and timely care at risk for behavioral health concerns, that can impact other psychosocial and including identifying circumstances medical issues.”639, 640, 641 like financial or relationship stress Some key strategies for early or isolation and individuals who may identification of issues and connections already be struggling with mental to services and care, include: illness, such as depression and who may be misusing drugs or alcohol. l arly Childhood Screenings. Even E though most public and private This includes better integration of insurers cover regular screenings physical and developmental health for children, many do not receive screenings so they include identifying them. Screenings are essential tools mental health and social service needs. for identifying physical, mental and These types of screenings should be behavioral health development and integrated with primary care and milestones. Early identification and regular healthcare services — and intervention can help prevent, delay made routine and guaranteed as part or mitigate different conditions and of annual physicals and well care provide an important opportunity to visits. In addition, professionals and identify adverse experiences and other “gatekeepers” in other high-impact roles risks that children and their families (such as in schools, community-based may be facing. Recommended and faith groups, human resources roles, screenings include: those required for etc.) should be trained to identify risk children enrolled in Medicaid under and provide support when needed.633 EPSDT; and AAP’s Bright Futures, Early identification of substance use Guidelines for Adolescent Preventive disorders is an important area of priority. Services or similar screening tools for They can emerge slowly over time and children enrolled in the Children’s 104 TFAH • WBT • PaininTheNation.org Health Insurance Program (CHIP) and private insurance.642 As of 2015, more than 42 million individuals from birth to age 21 were eligible for EPSDT, but participation in the program for was just 58 percent.643 • art C of the Individuals with P Disabilities Education Act (IDEA) helps provide screening services for children from birth to age 2 for disabilities and helps connect families with early intervention services.644 The goals of IDEA Part C are to enhance the development of infants and toddlers with disabilities, reduce educational costs by minimizing the need for special education through early intervention, minimize the likelihood of institutionalization and maximize independent living and enhance the capacity of families to meet their child’s needs. Twenty- helps identify parents who need help health officials advise that screening eight states, Washington, D.C. and or treatment for substance misuse should be used as a tool to identify Puerto Rico meet the requirements and to connect with ongoing support the need to provide services and for IDEA Part C as of 2017.645 services for the family. Fetal Alcohol treatment to mothers and children; • arly Head Start requires that E Spectrum Disorder is a leading • wenty-three states and Washington, T children be screened in the areas cause of mental retardation and a D.C. require healthcare professionals of development, behavior, motor, preventable cause of birth defects to report suspected prenatal drug language, social and emotional and (an estimated 400,000 babies are use, and seven states require them cognitive status soon after enrollment, diagnosed annually, costing to test for prenatal drug exposure if and that they be assessed regularly.646 $5.4 billion to the economy as of they suspect drug use; 2004).647, 648 Prenatal drug exposure • creening Infants for Substance S increases risk for prematurity, • ineteen states have either N Misuse Exposure. Twenty-one states low birthweight and other health created or funded drug treatment and Washington, D.C. have specific concerns. In 2012, an estimated programs specifically targeted to reporting procedures for infants who 21,000 babies were born with opioid pregnant women, and 17 states show evidence at birth of having been withdrawal symptoms.649, 650 and Washington, D.C. provide exposed to drugs, alcohol or other According to a September 2017 pregnant women with priority controlled substances, which can help review by the Guttmacher Institute:651 access to state-funded drug identify parents who need treatment treatment programs; and and connect families and children • wenty-four states and Washington, T with support services. This can help D.C. consider substance misuse • en states prohibit publicly T ensure infants get treatment as early during pregnancy to be child funded drug treatment programs as possible to help with withdrawal or endangerment under civil child- from discriminating against early intervention for other medial welfare statutes and three consider it pregnant women. and developmental problems. It also grounds for civil commitment. Public TFAH • WBT • PaininTheNation.org 105 STATE POLICIES ON SUBSTANCE USE DURING PREGNANCY Substance use during When drug use suspected, Drug treatment for pregnant women pregnancy considered: state requires: Pregnant Women Given Pregnant Women Protected Grounds for Civil Child Abuse Reporting Testing Targeted Program Created Priority Access in General from Discrimination in Commitment Programs Publicly Funded Programs Alabama X* X X Alaska X Arizona X X X Arkansas X X X X California X X Colorado X X§ Connecticut X Delaware X D.C. X X X Florida X X X Georgia X Illinois X X X§ X X Indiana X†​ X X Iowa X X X X X Kansas X X Kentucky X X X X X Louisiana X X X Maine X X Maryland X X X Massachusetts X Michigan X Minnesota X X X X X Missouri XΩ​ § X‡​ X Montana X Nebraska Nevada X X New York X North Carolina X North Dakota X X X Ohio X X X§ X X Oklahoma X X X X Oregon § Pennsylvania X X Rhode Island X X X South Carolina X* X South Dakota X X Tennessee X§ X X Texas X Utah X X X Virginia X X X§ Washington X X§ West Virginia Xµ Wisconsin X X X X Xß TOTAL 24+D.C. 3 23+D.C. 7 19 17+D.C. 10 Source: Guttmacher Institute * The Alabama Supreme Court held that drug use while pregnant is considered chemical endangerment of a child. The South Carolina Supreme Court held that a viable fetus is a “person” under the state’s criminal child-endangerment statute and that “maternal acts endangering or likely to endanger the life, comfort, or health of a viable fetus” constitute criminal child abuse. † Indiana law prohibits a medical provider from releasing information about a pregnant woman’s drug or alcohol test without her consent. ‡ Priority applies to pregnant women referred for treatment. § Establishes requirements for healthcare providers to encourage and facilitate drug counseling. Ω Missouri child abuse law considers a parent to be unfit if the woman tests positive for substances within 8 hours after delivery and she has previously been convicted of child abuse or neglect or if she failed to complete a drug treatment program recommended by Child Protective Services. µ West Virginia substance use providers that accept Medicaid must give pregnant women priority in accessing services. ß Wisconsin provides priority access to pregnant women in both general and private programs. 106 TFAH • WBT • PaininTheNation.org l amily Risk Factor Screening. AAP F and others have also adopted the use of additional tools, such as the Safe Environment for Every Kid (SEEK) program, which helps screen children and their caregivers for ACEs and other risk factors beyond traditional health concerns. These types of screenings provide opportunities to identify family needs and connect them with physical and mental health and substance misuse treatment services as well as social services, family home visiting programs, child care, education, financial, housing and nutrition assistance programs and other resources. A number of new screening tools are being developed l S chool-based and Tween/Teen as CRAFFT, a short behavioral health and used such as the National Screenings and Identification of Risks. screening tool for youth under the Association of Community Health A growing number of school systems age of 21 recommended by AAP used Center’s Protocol for Responding are supporting screenings for risks to assess when a longer conversation to and Assessing Patients’ Assets, — either within the school system by and intervention may be needed, Risks, and Experiences (PRAPARE), trained professionals or in partnership SBIRT and other tools that screen a national effort to help health with healthcare providers — to help for the impact of prolonged trauma centers and other providers collect with identifications of concerns and and ACEs to help identify students the data needed to better understand connections to services and care. There at risk and connect them with and act on their patients’ social a number of evidence-based approaches appropriate services. Making these determinants of health. As providers for identifying students at risk for types of screenings routine through are increasingly held accountable mental health concerns, substance brief questionnaires and counseling for reaching population health goals misuse and suicide. School systems can with teens and youth helps reduce while reducing costs, it is important help ensure at-risk students are screened the stigma associated with mental that they have tools and strategies to for physical, behavioral and mental and behavioral health concerns, identify the upstream socioeconomic health concerns and special education emphasizes a cultural value of care drivers of poor outcomes and higher needs via tools from the AAP and special and support and normalizes the use costs. With data on the social education programs. Examples of of systems for providing help and determinants of health, health centers two teen-focused early identification resources. CMS allows state Medicaid and other providers can define and screening initiatives and tools include plans to cover SBIRT services for document the increased complexity the AMA Guidelines for Adolescent adults. Without programs like of their patients, transform care with Preventive Services (GAPS) and the CRAFFT and SBIRT, many teens and integrated services and community Rapid Assessment for Adolescent adults are never directly asked about partnerships to meet the needs of Preventive Services© (RAAPS). aspects of their behavioral or mental their patients, advocate for change in health, and given the opportunity their communities, and demonstrate • any school systems are using M to connect with help or support in a the value they bring to patients, evidence-based mental and substance safe environment and by a trained, communities and payers. misuse risk screening practices, such TFAH • WBT • PaininTheNation.org 107 caring provider. Efforts like these available for students/peers, peer The Garrett Lee Smith grant provide reassurance and encourage leaders and parents. Communities gatekeeper training program teens to be open about their needs. that implemented SAMHSA-supported It is a quick, low-cost way to reach Garrett Lee Smith grant gatekeeper helped prevent more than teens and adults on a broad scale training programs had significantly 79,000 suicide attempts from to deter risky behavior, and can fewer suicides (1.3 per 100,000 fewer be delivered effectively via trained deaths) among 10- to 24-year olds, and 2007 to 2010. professionals in school, healthcare a review found the program helped (primary and emergency care) and prevent more than 79,000 suicide community program settings. attempts from 2007 to 2010.664 • n 2016, Massachusetts passed a law I • he Community Preventive Services T requiring public schools to verbally Task Force reviewed 31 studies screen middle and high school of electronic screening and brief students for substance use disorders intervention efforts and found that using a validated screening tool, they supported the continued use of such as the SBIRT questionnaire.652 technology to reach people at risk of excessive alcohol use, or who may • tudies show that even a single S develop an alcohol use disorder, and instance of SBIRT or a brief the Surgeon General noted that web- discussion about a patient’s based approaches can be effective for behavioral health can help lower connecting with youth, individuals in healthcare costs, lessen rates of harder to reach areas and/or those drug and alcohol misuse and who may avoid face-to-face treatment.665 reduce the risk of traumatic events having long-term negative • Another school-based practice is to impacts.653, 654, 655 656,657, 658, 659, 660, 661 track chronic absenteeism. A high Investing in SBIRT has been number of missed school days can found to result in savings be a warning sign for health, mental between $3.81 and $5.60 for every health and family concerns. dollar spent.662, 663 • chool systems must offer S • here are an increasing number of T screenings aimed at early Investing in SBIRT has been approaches for training educators identification of concerns and and other school professionals as well special education and services found to result in savings as “gatekeeper” adults who tweens for preschool and school-aged between $3.81 and $5.60 for and teens interact with, such as children (ages 3 to 21) with every dollar spent. community-group leaders, coaches disabilities, including behavioral and faith leaders to help identify health disorders and learning concerns (including risks and signs disabilities under IDEA Part B. of mental illness, substance misuse Twenty-two states, Micronesia, the or suicidal thoughts) and connect Marshall Islands and Palau meet individuals to appropriate supports. the requirements of IDEA Part B Evidence-based training is also as of 2017.666 108 TFAH • WBT • PaininTheNation.org EXAMPLES: EARLY IDENTIFICATION AND CONNECTION TO SERVICES AND SUPPORTS EFFORTS Screening for Mental Health (SMH) 1. STS therapist training for all of the H young adults. By educating and helping provides online and in-person screenings people (caregivers, Head Start staff, day- those closest to at-risk individuals, EDIPP and risk assessments to identify and care providers, neighbors, grandparents, is then able to engage and treat these treat mental health problems early, etc.) who are part of a child’s life to help young people earlier. A recent study before they turn into a crisis, similar to the child identify and share feelings. of EDIPP found that the initiative helps screenings for physical illnesses such This includes props or games to help families better support someone with as cancer and diabetes. SMH online children develop self-regulation and mental illness and that patients succeed screenings give individuals a safe and appropriate competencies. better in school and work. According anonymous way to assess their mental 2. ntensive Individual Trauma-Focused I to the study, the early intervention health to see if their signs and symptoms Intervention, which includes short helped at-risk individuals stay in school, are consistent with a mood and anxiety therapy sessions for children and remain employed and maintain personal disorder, eating disorder or alcohol use their families. Because it is difficult connections. disorder, and access information about for an entire family to take part, Lily’s Place, in Huntington, West local, high-quality treatment options.667 therapists make weekly phone Virginia, is a model clinic focusing on SMH offerings are used by colleges and calls, send notes to parents and, providing comprehensive medical care universities, workplaces, the military and sometimes, make home visits. to infants with Neonatal Abstinence community organizations to educate, 3. STS therapists provide classroom H Syndrome and “offer non-judgmental screen and connect users with resources consultation to all teachers and support, education and counseling and treatment options specific to their children, during which the therapist is services to families and caregivers” to campus, organization or neighborhood.668 able to bring the skill-based training into help create healthier families.673 The online platform is also available in the classroom and support the teacher. the form of a MindKare Kiosk for public SafeStart, in Allentown, Pennsylvania, is spaces, designed to make checking in on 4. eer-based mentoring for teachers P a special Early Head Start program that mental health as easy and commonplace and others to help sustain progress. provides day care for dozens of infants as checking blood pressure. Other SMH An article in the Journal of Child and and toddlers under the age 3 from families programs include public awareness Family Studies found that HSTS resulted with low incomes and parents with drug campaigns and the SOS Signs of Suicide in significant benefits for children by or alcohol addiction.674 Many of the Prevention Program, a two-part middle reducing attention deficit, defiant and kids have health problems, emotional and high school-based suicide prevention externalizing issues and hyperactivity, trauma and developmental delays that program, which includes an educational all of which also support improved required extra attention, and the program curriculum about suicide and depression academic performance. has low child-teacher ratios and extra and a brief depression screening. The SOS specialized therapy to meet these needs. Program has reduced self-reported suicide Early Detection, Intervention and The program has seen success with its attempts by 40 percent to 64 percent in Prevention of Psychosis in Adolescents methods: in 2016, all of the children randomized control studies.669, 670 and Young Adults (EDIPP)672 is a who aged out of SafeStart had marked project funded by Robert Wood Johnson improvement in their symptoms and 84 Crittenton Children’s Center at Saint Foundation (RWJF) that focuses on the percent had them resolved. The program Luke’s Health System671 in Kansas City, mental health needs of adolescents and has been run since 2003 by the nonprofit Missouri developed Head Start-Trauma young adults. The initiative connects organization Community Services for Smart (HSTS) to help children, ages 3 with those who interact directly with youth Children in partnership with the Children to 5, handle complex trauma (violence, (family, teachers, social workers, doctors and Youth Services in Lehigh and arrest/incarceration, substance misuse, and nurses) and works to educate them Northampton counties; it is funded partially homelessness, death and others). on the early signs of severe mental by both federal grant and county funds. Elements of HSTS include: illness to help identify at-risk teens and TFAH • WBT • PaininTheNation.org 109 Active Federal Grant Awards to States: Funding to Help Address Prescription Drug, Opioid and Heroin Problems (in Millions)* NH WA 13.4 60.1 ME MT VT ND 15.2 12.4 14.8 8.6 OR MN 34.8 ID 31.5 MA 59.6 SD WI NY 11.1 11.1 156.4 WY 42.6 MI RI 20.2 7.8 67.7 IA PA CT 34.3 NV NE 20.0 OH 72.6 IN NJ 58.2 25.5 11.3 CA UT IL 39.2 86.8 WV DE10.9 21.7 CO 85.6 285.5 36.0 KS MO 15.0 VA MD 48.9 KY 55.9 15.6 45.4 34.4 DC 17.9 NC OK TN 41.4 53.5 AZ 51.6 NM 30.4 AR SC 18.4 17.2 31.6 GA MS AL 69.3 TX 18.7 33.3 161.5 LA US ~2.3 Billion AK 34.2 10.4 Median 33.3 FL 137.6 HI 14.0 Source: National Alliance for Model State Drug Laws SELECT FEDERAL SUBSTANCE MISUSE AND BEHAVIORAL HEALTH GRANTS Substance Abuse and Mental Health Services Administration The Opioid STR is a two-year grant program to increase opioid use disorder prevention, treatment, State Targeted Response to the Opioid Crisis and recovery services. Authorized in December 2016 in the 21st Century Cures Act; $500 million Grant (Opioid STR) was appropriated in FY 2017. In April 2017, grants were awarded to states and territories via a formula that is based on unmet need for opioid use disorder treatment and drug overdose deaths.675 MAT-PDOA grants to expand/enhance access to medication-assisted treatment (MAT) services for Targeted Capacity Expansion: Medication persons with an opioid use disorder. The funding is restricted to states with the highest admissions Assisted Treatment — Prescription Drug and rates for heroin and opioids and/or those with the biggest increases. Grant applications were due in Opioid Addiction (MAT-PDOA) Grants July 2017. There is $28 million in grants available for up to five states for up to three years.676 The SAPT program funds all 50 states, Washington, D.C., Puerto Rico, the U.S. Virgin Islands, six Pacific jurisdictions, and one tribal entity to help plan, implement and evaluate activities that prevent Substance Abuse Prevention and Treatment and treat substance use disorders, with at least 20 percent of funds going to substance misuse Block Grant (SAPT/SABG) primary prevention strategies. The grant amounts are determined by the size of the at-risk population, service costs, and certain other factors. SABG is authorized by the Public Health Service (PHS) Act.677 The MHBG program funds all 50 states, Washington, D.C., Puerto Rico, the U.S. Virgin Islands, and six Pacific jurisdictions to provide comprehensive community mental health services and Community Mental Health Services Block Grant monitor progress in implementing a community-based mental health system. The grant amounts (MHBG) are determined by the weighted at-risk population, service costs, and certain other factors. MHBG is authorized by the PHS Act.678 Health Resources and Services Administration AIMS is a new FY 2017 funding opportunity for $195 million for community health centers to expand Access Increases in Mental Health and access to mental health and substance use disorder services focusing on the treatment, prevention Substance Abuse Services (AIMS) Funding and awareness of opioid misuse. Applications were due in July 2017 and are expected to be Opportunity awarded in September 2017.679 680 Three-year funding of programs aimed at expanding the delivery of opioid related healthcare services to rural communities and developing broad community consortiums to respond multifaceted to the Rural Health Opioid Program (RHOP) opioid epidemic in a rural community. RHOP is authorized under the PHS Act. Applications were due July 2017 and awards are expected in September 2017.681 SAT-TNGP funding supports telehealth treatment for substance use disorders and chronic conditions, Substance Abuse Treatment Telehealth Network and will demonstrate how telehealth programs can improve access to healthcare services, particularly Grant Program (SAT-TNGP) substance use disorder treatment services, in rural, frontier, and underserved communities. Grant applications were due in August 2017 and are expected to be awarded in September 2017.682 110 TFAH • WBT • PaininTheNation.org SUBSTANCE ABUSE PREVENTION AND TREATMENT BLOCK GRANT SAMHSA’s Center for Substance Use agency collaboration; and promoting Treatment administers the Substance effective planning, monitoring and Abuse Prevention and Treatment Block oversight. Funding for the grant program Grant, which is distributed by formula has decreased by 29 percent in the past to all states and Territories and is decade, adjusting for inflation. managed by the State Alcohol and Drug State Alcohol and Drug Authority Authority Directors. Directors design, manage and evaluate The SAPT Block Grant provides the publicly funded substance misuse treatment services for 1.5 million prevention, treatment and recovery Americans. It has shown results in system in each state. State Directors 70 percent of clients demonstrating provide leadership by promoting abstinence from illegal drug use, 83 standards of care, evidence-based percent abstinence from alcohol use services and continuous quality and 89 percent having stable housing improvement innovations. State and 93 percent having no arrests Directors also ensure that public dollars upon discharge from treatment. 683 are dedicated to programs that work Evaluations have found the grant through the use of performance data program is effective in: increasing management and reporting, contract employment; improving states’ monitoring, corrective action planning, on infrastructure and capacity; fostering site-reviews and technical assistance. development and maintenance of state State Mental Health Funding State mental health budgets experienced significant cuts during the recession — decreasing by $4.35 billion from FY 2009 to FY 2012. In FY 2015, only 24 states increased mental health funding, while 13 RI states had level funding and 11 states and Washington, D.C. decreased funding.684 DC Increased Decreased Maintained Pending Source: National Alliance on Mental Illness TFAH • WBT • PaininTheNation.org 111 C. PRIORITIZING PREVENTION — SUPPORTING STRONGER, HEALTHIER COMMUNITIES AND RAISING A (MENTALLY AND PHYSICALLY) HEALTHIER GENERATION OF KIDS The opioid, alcohol and suicide epidemics have serious consequence for Social Determinants of Health individuals, families and communities. There is an urgent need to take increased action to prevent issues in the first place — and focus on the root causes that can increase risk for substance misuse, mental health issues and/or suicide. These approaches have a broader effect and can also support positive outcomes for a range of other related issues like poor academic and career attainment, bullying, depression, violence, unsafe sexual practices and job and economic attainment. More than four decades of research Source: Kaiser Family Foundation have identified effective, evidence-based strategies to reduce these risk factors and all members of a community, and that l S upporting Multi-Sector, Place-Based that can promote positive “protective” are particularly impactful for those at Partnerships for Community-Wide factors. These can help build resiliency higher risk for concerns. Efforts and the ability for people to cope with For instance, financial stress and housing l T he Impact of the Opioid Crisis on and adapt to challenges and adversity. stability are identified as two of the most Child Welfare — and the Need for Well-being is also impacted by significant factors that can increase Multi-Generational Care circumstances — including the ability risk for mental health issues, substance l E ffective Early Childhood Well-being for families to take care of basic needs; misuse and suicide — in addition to Policies social relationships and community domestic violence and child abuse.687, 688 connectedness; community support and l E ffective School-aged Children, This section examines a range of amenities; and the opportunities that Tweens and Teens Well-being Policies policies and programs that promote are available in the communities where resilient children, families and l O pportunities for Families by Addressing people live.685, 686 There are a range of communities, including: Core Needs and Promoting Stability policies and programs that can benefit 112 TFAH • WBT • PaininTheNation.org STRENGTHENING FAMILIES: PROTECTIVE FACTORS FRAMEWORK The Center for the Study of Social Policy and developmental expectations, being developed a framework summary of attuned and emotionally available, protective factors, which includes:689 nurturing, responsive, predictable, interactive, and having a safe and l P arental Resilience. Managing stress educationally stimulating environment). and functioning well when faced with challenges, adversity and trauma l C oncrete Support in Times of Need. (including general life stressors and Access to concrete support and parenting stressors). services that address a family’s needs and help minimize stress caused l S ocial Connections. Positive by challenges (including navigating relationships that provide emotional, and accessing service systems and informational, instrumental and building financial security). spiritual support. l S ocial and Emotional Competence of l K nowledge of Parenting and Child Children. Family and child interactions Development. Understanding that help children develop the ability child development and parenting to communicate clearly, recognize and strategies that support physical, regulate their emotions and establish cognitive, language, social-emotional and maintain relationships. development (including age-appropriate Supporting Local Multi-Sector, Place-Based Partnerships for Community-Wide Efforts One of the biggest challenges connections or infrastructure needed their response while at the same time communities face in countering the to support multi-sector problems. For meeting more immediate needs and opioid crisis is the lack of a standing instance, many state and local areas emergencies. The lack of ability to mechanism that bring all of the needed create child well-being coalitions that tap into and leverage an existing partners and resources together to address are either short in duration or do not infrastructure or collective partnership major epidemics within a community. have sufficient resources or the ability across sectors has put most areas behind to support systemic change to be able the curve in their response, or to even The problem is bigger and more to fully carry out their goals. Many consider a long-term well-being strategy. challenging than any one institution can communities also create task forces or address (i.e., the health system or public Experts have identified the most effective coalitions to respond to public health health departments) — and it impacts way to tackle major health and well-being crises after they have emerged and they stakeholders across every sector and issues is to develop local partnerships are disbanded after the emergency corner of a community. — that bring together the different subsides or due the perception of lack of expertise, capabilities and resources There is a pattern of communities progress, when the issue is often about across an entire community. Local developing task forces or committees to not having sufficient resources or systems leaders, institutions and citizens have address the latest crisis — or cross-cutting to tackle the problem. both a greater understanding of their priority problems or concerns. They are Regarding the opioid epidemic, states community’s most pressing challenges often, however, not sufficiently funded and local communities are growing and shared interest in addressing them. or do not address the underlying lack of TFAH • WBT • PaininTheNation.org 113 For most communities, there is not a standing mechanism to support Local Health Trust: Braiding Traditional and Non-Traditional Funding Streams and coordinate efforts, services and programs to improve health and well- Level 1: Traditional Grants being. Many current health priorities Increasing Flexibility and Scalability Increasing Need for Coordination • Government Dedicated Revenue Streams require cross-cutting responses, which • Philanthropic require strong management and coordination. Without a focused, sustained infrastructure to support Level 2: Non-Traditional Funding • Community Hospital Benefits these types of partnerships, many of the • Medicaid and Commericial Health Insurance programs are short-lived or fall short. Reimbursement The opioid epidemic, as well as the suicide and alcohol crises, provide Level 3: Innovative Financing Mechanisms poignant examples of the problem • CDFI Community Development created by this void. When new crises • Pay for Success arise, there is a cycle of creating or Source: TFAH bolstering community- and sector- connecting mechanisms to quickly respond to the urgent aspects of emergencies. Too often, they are insufficient to address the full-scale impact and/or unable to secure a long-term solution. Local health and well-being improvement partnerships provide a mechanism to support and implement evidence-based policies and programs within a community, while at the same time raising critical resources and coordinating efforts from a range of stakeholders. Key partners may include: public health, substance misuse response agencies and treatment providers; mental healthcare providers; hospitals; area businesses; school districts and Source: TFAH universities; community and faith groups; local government and law enforcement; Important elements of a collective a Healthy Communities Funding Hub nonprofits and social service agencies; approach include: model — to provide fiduciary oversight and citizens or other local stakeholders. and effective use of funds);690 l ead partners that are responsible for L Best practices for successful public the ongoing management of the efforts, l E xpert guidance and technical health initiatives have emerged from which can often be an already established assistance to ensure policies and communities that have built and organization in the community; programs being supported are high- sustained multi-sector partnerships, and quality, evidence-based and effective, addressed the underlying contributing l trong financial management that S and to help with technical assistance for factors in a community rather than just focuses on making sustained, sufficient implementation and evaluation; and responding to immediate concerns. funding a top priority (such as through 114 TFAH • WBT • PaininTheNation.org l hief Health Strategists where public C health departments serve in the role of Building Community Resilience: Process of Assessment, Readiness, supporting greater understanding of Implementation and Sustainability community health problems or those facing certain segments, as well as best • ACEs • Provider Capacity/Capability practice strategies for addressing them. • Resilience • System • Narratives of the Successful community health initiatives Capacity/Capability Community Shared State of also support community agency — or Undertaking Readiness • Policy Supports the community’s ability to collectively make purposeful decisions and influence the conditions around them through shared leadership from within the local • Organizational • How to Connect Linkages Community Cross-Sector area.691 At an individual level, community Partners • Resource Distribution • Citizen Leadership engagement, agency, control and strong, • Community & supportive social networks can serve as a • Social Supports Political Partnerships buffer against stressors that can negatively • Attachment to Place • Collabotation impact both physical and mental health.692 Supportive, positive relationships can help Ellis, W., Dietz, W. (2017) A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience (BCR) Model. Academic Pediatrics. 17 (2017) pp. S86- prevent depression and reduce risk for S93. DOI information: 10.1016/jacap.2016.12.011 suicide and substance misuse. DISCRIMINATION AND HEALTH Discrimination, like other traumatic Ferguson, Missouri after the 2014 death interactions, causes psychological stress of Michael Brown found that 43 percent in those targeted and can lead to a variety of the majority Black community met the of negative mental and physical health criteria for depression and 34 percent for effects with continual exposure. This PTSD, many times the national prevalence toxic environment hurts racial and ethnic of 6.7 and 7.8 percent respectively. 694 minorities, LGBTQ individuals, and women Other racial and ethnic minorities are also in the United States, and can take many harmed by discrimination and harmful forms, from blatant acts of individual-level individual-level interactions are sufficiently discrimination or less overt, but continual pervasive that stress responses can occur microaggressions, to societal-level biased in anticipation of discrimination. As one treatment that systematically constrains example, a study of Latina students showed certain groups from opportunities and that they had higher blood pressure and resources. 693 heart rates when interacting with someone Among Blacks in the United States, the they perceived to hold racist ideas. 695 adverse impact of discrimination on Discrimination, along with related mental and physical health has been well stress and mental health issues, forces documented. For instance, one recent individuals to find coping mechanisms, study found Black participants had five many of which are unhealthy, like times the emotional stress (18.2 percent increased substance misuse. One study versus 3.5 percent) and six times (9.8 found that young women who experienced percent versus 1.6 percent) the physical higher levels of discrimination had had stress as their White counterparts. levels of stress and prior drug misuse.696 Another study on emotional stress in TFAH • WBT • PaininTheNation.org 115 In addition to the daily harmful these health measures.697 Another study interactions, there are many societal-level found that states that enacted same-sex biases. For example several studies marriage rights between 1999 and 2015 looked at changes in the health of LGBTQ were associated with a reduction in the individuals around same-sex marriage percent of high school students reporting laws, and found dramatic changes. suicide attempts.698 One study found that lesbian, gay and A range of mental and behavioral health bisexual adults who lived in states that expert organizations have identified the passed same-sex marriage bans between importance of governmental policies, 2001 and 2005 had increases in mood programs, and officials to not perpetuate disorders (37 percent increase), alcohol discrimination either overtly or covertly— use disorders (42 percent increase) and and where ever possible, should actively anxiety disorders (248 percent increase) counteract the negative health effects of over those four years. LGB adults in states discrimination and lift up affected groups that did not pass same-sex marriage and communities. bans had no significant changes in any of 116 TFAH • WBT • PaininTheNation.org EXAMPLES: MULTI-SECTOR COMMUNITY PARTNERSHIPS Massachusetts General economic security in the Northeast Making Connections for Mental Health Hospital Center for Hartford community. 699 NHP serves and Well-being Among Men and Boys Community Health as the backbone organization and was launched by The Prevention Institute Improvement (2015 Foster McGaw convenes community leaders to in 2014 with support from the Movember Prize Winner) launched four multi- develop innovative ways to coordinate, foundation to help transform community sector coalitions all working together integrate and align healthcare and conditions that influence mental well- on the prevention of substance use social services. Key partnerships with being, especially for men and boys of disorder — along with the promotion local and state government, hospitals, color, veterans and their families. The of healthy eating and active living. The universities and community nonprofits goal of Making Connections is to change hospital worked with stakeholders at the are essential to NHP’s success. NHP the narrative around mental health to grassroots level to gain community buy-in is transforming the once abandoned one focused on wellness and prevention. and engagement. Prevention initiatives gold-leafing factory into a community A national assessment of mental included prescription Take Back programs, hub that can centrally house cross- health and well-being was conducted naloxone distribution throughout the sector partners and facilitate to determine common themes, which community and recovery coaches that innovative collaborations. Initial would later shape the overall goals of ensure access to treatment. Contributing results are promising. In a pilot the initiative. Sixteen communities their own expertise, the hospital screens intervention, Community Solutions across the United States are developing all patients for substance misuse as observed a 57 percent drop in the and implementing strategies to enhance part of their plan to strengthen addiction emergency room use among the high their sociocultural, physical/built, and treatment and early intervention. Through utilizers. Moving forward, the Cigna economic and educational environments engaged community partners and Foundation plans to use its experience to impact their mental health and dedicated staff, the hospital has been in tool development to co-create a well-being. By focusing on broader able to decrease emergency department neighborhood health risk assessment community conditions related to men visits and inpatient admissions related with Community Solutions to analyze and boys, the effort served as a critical to substance misuse in the first three the underlying social, economic mechanism to address and reduce months of the initiative by 57 percent and and environmental determinants stigma around mental illness, and was 62 percent, respectively. of health in Northeast Hartford. In successful in beginning to shift mental 2015, NHP received a $125,000 health perceptions, from “what is wrong The North Hartford World of Difference grant from the with you?” to “what happened to you?” Partnership (NHP) was Cigna Foundation to continue their and ultimately to “what can we change launched by the Cigna Foundation work. NHP also receives funding from in our community to better support and nonprofit Community Solutions Fidelity Charitable, Rx Foundation, The mental well-being for you and others?” to address the increasing rates Kresge Foundation, Newman’s Own The grant includes a 12- to 18-month of mental illness, substance use Foundation, Boehringer Ingelheim and planning period during which the 16 disorders and poor chronic care the John H & Ethel G Noble Charitable identified communities established local management in the Northeast Hartford Trust to support the initiative, which coalitions to inform and guide the work community. It focused on the social had a budget of $760,000 in 2015. for the rest of the initiative. determinants of health and boosting TFAH • WBT • PaininTheNation.org 117 EXPERT GUIDANCE AND TECHNICAL ASSISTANCE FOR COMMUNITIES The ability to access expert guidance of experts, access to research and best accountability; 5) identify and implement and support is critical to this collective practices and multi-sector collaboration. plans for sustainability and 6) perform approach. Experts help identify the most continuous quality improvement and One model is to have a state-level public- effective evidence-based approaches updates to improve programs. Technical private partnership expert organization that fit their local needs, and have the support and ongoing data collection and in a state that can: 1) help conduct data and tracking information available to analysis at a community level can help needs assessments to match the best accurately assess their community. They identify patterns of concerns, including risks policy and program choices to specific also provide the technical assistance to and protective factors, and help understand community’s needs; 2) help develop implement policies and programs, and are where and how to direct programs and coalitions and ensure programs are able to conduct evaluations to measure efforts. An expert organization, housed implemented successfully by providing effectiveness and ensure accountability at an academic center or a nonprofit technical assistance and access to learning for efforts. organization, can provide assistance to networks; 3) train and support a range of support community-based multi-sector To be successful and sustained over time, professionals from different backgrounds collaborations and coalitions and help strategies, programs and services need end- and sectors; 4) conduct regular evaluation, identify and braid different funding streams. to-end support including through networks measuring results and ensuring EXAMPLE: EXPERT NETWORK SUPPORTING EVIDENCE-BASED APPROACHES AND TECHNICAL ASSISTANCE Evidence-based Prevention and Intervention Support Translating Science to Practice Assess Center (EPISCenter) 700 is a state- Public Monitor level expert organization that supports Quality of Health Set & Program Impact community-level infrastructure for Collect Provide Implemen- prevention planning; evidence-based Technical Performance tation Implement programs and practices; and continuous Assistance Measures & Evaluate improvement of locally-developed Develop & Programs Identify Test juvenile justice and substance misuse Risk and Interventions Define the programs, which also provide much Protective Problem broader support for positive childhood Factors and youth development. EPISCenter helps communities identify and prioritize Problem Response risk and protective factors and determine Source: EPISCenter which interventions can best address the identified needs (many of which start in early childhood), as well as provides on Crime and Delinquency (PCCD), the State University. The annual estimated technical assistance and support for Pennsylvania Department of Human cost for an EPISCenter initiative is quality implementation of the programs. Services (DHS) and the Bennett Pierce around $1 million per year per state, EPISCenter is a collaborative partnership Prevention Research Center, College of depending on the structure and scope of between the Pennsylvania Commission Health and Human Development at Penn the programs. 118 TFAH • WBT • PaininTheNation.org The Impact of the Opioid Epidemic on Child Welfare — and the Need for Multi-Generational Care The opioid epidemic has placed a significant new strain on the child welfare and foster system. States are grappling with how to adapt infants and 40 percent of older children child welfare laws and policies — including are from families with active alcohol or Percent of infants in foster care that are from families with active alcohol the need to increase budgets for additional drug misuse.713 or drug misuse social workers, higher stipends for foster Child abuse and neglect occur at every parents and child welfare services.701, 702 socioeconomic level, across ethnic and Some states, including Alaska, Kansas and Ohio have issued emergency pleas for additional foster parents. cultural lines, within all religions and at all levels of education.714 Children 60% are at increased risk for experiencing The number of children entering the severe maltreatment if their families Percent of older children in foster child welfare and foster system increased experience multiple problems, such care that are from families with by 8 percent from 2012 to 2015 — and as financial distress, lack of a job, active alcohol or drug misuse state reports suggest that increase will inadequate housing, emotional stress, be significantly higher for 2016 and drug or alcohol misuse mental illness 2017.703, 704 Some states with particularly and/or domestic abuse.715 Lifetime high increases around this timeframe costs of just one year of confirmed child include Florida (24 percent increase), maltreatment cases is estimated to be 40% Georgia (74.5 percent increase), $124 billion nationally (as of 2008).716 Indiana (37 percent increase), Kentucky Each state maintains a system of public (33 percent increase) and Minnesota and private child and family services, (33 percent increase).705, 706 and specific systems vary by state. The The epidemic is also resulting in a Children’s Bureau with ACF provides growing number of grandparents and federal level support through research, other relatives caring for children, which evaluation, technical assistance, raises different policy and practical needs. data collection and setting national standards — and providing grants to Around 2.5 million children are being states. A number of states have moved raised in “grandfamilies” or “kinship” toward more research-based and (other relatives) care.707 Roughly 29 trauma-informed approaches, such as percent of children in foster care are implementing a differential response placed with relatives — and for every within the child welfare system that allows child in foster care with relatives, there child protective services to respond in are 20 being raised by grandparents or multiple ways to different situations and other relatives outside the system.708, 709, 710 levels of risk.717 In cases where a child is Overall, more than 680,000 children removed from a parent due to substance experience severe forms of maltreatment use disorders or other factors, it is — neglect (79 percent) or physical abuse important to recognize that the removal (18 percent) — each year. Moreover, is another traumatic experience — and 400,000 children are in out-of-home it is essential to build a strong system of foster care at any time.711, 712 And, of support for these children. these children, more than 60 percent of TFAH • WBT • PaininTheNation.org 119 Key Policies l S upport for “grandfamilies” and other • Ensure states are fully using relatives. Generations United has available National Family Caregiver several recommendations for solutions Support Program funds for and support for grandparents and caregivers age 55 or older; other relatives who are “raising the • implify application requirements S children of the opioid epidemic.”718 and broaden eligibility for the These include: Temporary Assistance for Needy • rioritize relative placement and P Families (TANF) for these family-like settings for children in families; and foster care, and adopt the Model • Improve availability of legal Family Foster Home Licensing aid and resources for extended Standards to eliminate unnecessary family caregivers to ensure they barriers that prevent suitable understand the continuum of legal relatives and nonrelatives from relationship options. becoming licensed foster parents. l M odernize the child welfare system. • nsure financial, legal and E A number of groups, including programmatic support is available, AAP, have recommended the need including specifically: to continue to improve the child • nstitute broader eligibility for I welfare system to prevent child abuse children and relative caregivers and neglect, better serve vulnerable under federal child welfare funds children and their families, and for trauma services; ensure that children and caregivers • eauthorize and bolster federal R have access to coordinated, high- funding for Kindship Navigator quality, trauma-informed health and Programs that help connect social services.719 caregivers to services and supports; 120 TFAH • WBT • PaininTheNation.org FAMILY FIRST PREVENTION SERVICES ACT OF 2017 The Family First Prevention Services Act and determine the non-family setting l I mprove support for the transition to was introduced in 2016 and was amended was the most appropriate, subject to adulthood by updating the John H. and re-introduced in January 2017. The ongoing judicial approval; and non-family Chafee Foster Care Independence bill includes measures to: 720, 721 settings would be subject to licensing Program to allow states the option of and accreditation standards to ensure continuing to assist older former foster l S trengthen families and reduce they provide appropriate supervision youth up to age 23, including providing unnecessary foster care placements and have the necessary clinical staff to education and training vouchers. by allowing states to use federal foster address their needs. care dollars to pay for up to 12 months l R educe the amount of time foster of family services to prevent children l S upport family relationships by allowing children wait to be adopted, placed with from needing to enter foster care. states to receive a partial match for relatives or placed with foster parents, Biological families, adoptive families evidence-based Kinship Navigator encouraging states to use electronic and families in which a relative is programs to help children remain with systems when placing children across caring for the child would all be eligible family members whenever possible. state lines. for services, if needed to keep the Kinship Navigator programs provide l H elp relative caregivers avoid child safely at home. Only prevention information, referral and follow-up bureaucracy by promoting best practices services classified as “promising,” services to grandparents and other for states by providing model foster “supported,” or “well-supported,” relatives who unexpectedly assume care licensing standards with a focus based on an evidence structure caregiver responsibility for children who on ensuring states promote placements developed by the California Evidence- cannot remain safely with their parents. with family members for children in care. Based Clearinghouse, would be eligible l H elp families stay together by Keeping children with family members, for reimbursement. These services reauthorizing the Regional Partnership when possible, improves outcomes for would include: mental health services; Grant program, which provides funding children and families. substance use disorder services; and to state and regional grantees seeking in-home parent “skill-based” programs l S upport existing child welfare services to provide evidence-based services (parent training, home visiting, individual by extending for five years the Promoting to prevent child abuse and neglect and family therapy). Safe and Stable Families and Child related to substance misuse. Grant Welfare Services programs (each in l E nsure more foster children are requirements would be updated based on Title IV-B of the Social Security Act) placed with families by ending lessons learned from the most effective as well as the Adoption and Legal federal reimbursement when states past grants. In addition, the bill updates Guardianship Incentive Payments, whose inappropriately place children in non- the program to specifically address the authorizations are set to expire at the family settings, such as group homes opioid and heroin epidemic and leverage end of the fiscal year. or congregate care facilities. To be what’s been learned to ensure that new eligible for federal payment: the state foster care prevention funding provided would have to assess the child’s needs under the bill is used effectively. TFAH • WBT • PaininTheNation.org 121 EXAMPLES: CHILD WELFARE APPROACHES Sobriety Treatment and Connecticut Family Recovery Teams (START) Stability Pay for Success was developed in Kentucky in 2007 as Project was launched in September a Child Protective Services program for 2016 by the Connecticut Department families with parental substance use of Children and Families (DCF) to disorders and issues of child abuse promote family stability and reduce and/or neglect to help parents achieve parental addiction and substance sobriety and keep children with parents misuse among DCF-involved families.724 when it is possible and safe.722, 723 The The program is supported by $11.2 program model uses case manager million in investments — and expands and family mentor teams to support a Family-Based Recovery programs and small number of families and includes services to 500 additional families home visits, mentorships, peer support, within the state. Positive outcomes, intensive treatment, child welfare such as reductions of re-referrals and services and subsidies for child care out-of-home placements, will result and transportation, and have resulted in repayment to the investors. The in a number of notable outcomes. program focuses on: Mothers who participated in START l C reating long-term and lasting results achieved sobriety at nearly twice the rate for families statewide, by supporting of mothers treated without START (66 parents in substance misuse recovery percent and 37 percent, respectively). and improving parent-child interactions; Children in families served by START were half as likely to be placed in state l P reventing out-of-home placements custody as compared with children in and re-referrals to DCF and reducing a matched control group (21 percent substance misuse by parents and and 42 percent, respectively). This caregivers; and outcome also resulted in greater cost- l U sing an independent evaluation to effectiveness; for every dollar spent on understand the efficacy of the Family- START, Kentucky avoided spending $2.22 Based Recovery model, providing on foster care. In Kentucky, areas have important insight on how to best scale reported that demand for the program is this program. higher than the available services. 122 TFAH • WBT • PaininTheNation.org Early Childhood Resilience Policies Investing in well-being for young children to forestall what one study recently called a is one of the most effective strategies “cascade of risk,” or the multi-generational for prevention — it can yield lifelong impact of adverse experiences.725 benefits, including reducing the risk for Early childhood programs have been future substance misuse and suicide — shown to have a positive effect on all and improving overall well-being. children — but have the biggest impact A healthy start can put children on a on children with risk factors. path toward achievement in school, Effective early childhood policies, career, community, family and life. programs and practices focus on When children are young, their bodies supporting positive protective factors and brains develop rapidly. During and efforts that reduce risks, helping this period, it is important to focus on to prevent and mitigate the effects of those areas critical to their long-term prolonged stress and ACEs. CDC, NIH, success and development: high-quality ACF, SAMHSA and other experts have preventive healthcare, nurturing, stable developed and identified research to caretakers and relationships; good support key strategies and programs giving nutrition and physical activity; positive greater lift to positive early childhood learning experiences; and a safe home, development.726, 727 And a number of neighborhood and environment. organizations — such as AAP, Zero to Conversely, unhealthy conditions and Three, the Alliance for Early Success and prolonged or repeated periods of stress, the Urban Institute — have outlined disruption and trauma can harm and alter shared policy agendas for supporting early their development, impacting them for childhood efforts.728, 729, 730, 731 life. Early intervention is also the best way TFAH • WBT • PaininTheNation.org 123 CHILDHOOD RISKS l A dverse Childhood Experiences. Two- thirds of Americans report having experienced an ACE while growing up — across all socio-economic levels. Examples of ACEs include substance misuse or mental illness in the household or physical or sexual abuse.732, 733, 734, 735, 736 Thirty-eight percent of children experience two or more ACEs, and 22 percent experience three or more ACEs. • Children who grow up in an environment where a member of the family has a mental illness or alcohol or drug use disorder can have lifelong health consequences — with the impact being strongest for infants and toddlers.737 • hildren whose parents misuse alcohol C and other drugs are three times more likely to be abused and more than four times more likely to be neglected than from non-abusing families.738 This in turn makes it more likely that they will develop anxiety disorders, several personality disorders, and misuse alcohol and drugs themselves.739, 740 • arents who misuse alcohol or P other drugs are more likely to be experiencing multiple sources of Source: CDC stress themselves, including low socio- economic status, single parenthood, lack of social support and resources depressive symptoms.743 Children l P rolonged Stress and Poverty. In and mental health problems such as with mothers with depression are at addition, one in five babies and toddlers depression, or have experienced abuse higher risk for cognitive developmental (around 23 percent) live below the when they were growing up.741 delays, behavior issues and lower poverty line, and 45 percent are in low- • ne in 11 infants are impacted by O school performance and attainment. 744 income families.746 Children who grow their mothers’ major depression in In addition, children of mothers who up in persistent poverty or low-income their first year of life.742 In households were depressed during pregnancy families are more likely to remain poor below the poverty threshold, one in were 1.28 times more likely to have as adults, and have lower educational, four mothers of infants experience depression by age 18. 745 employment and health outcomes.747 moderate-to-severe levels of 124 TFAH • WBT • PaininTheNation.org ACEs, trauma and prolonged stress mitigated or reduced by the introduction increase the likelihood that a child will of protective factors, such as stable experience cognitive and developmental nurturing relationships, positive academic delays, depression, anxiety, aggression experiences, safe environments and and other mental, behavioral and community engagement.750 For instance, physical health problems. Traumatized developing secure attachment to at least children often have parents who one caregiver is one of the strongest experienced some form of trauma, and protective factors for young children. many mothers who experienced complex Others include having care that is warm, trauma may repeat these patterns of responsive, consistent and provides rejection and maltreatment with their positive cognitive stimulation (reading, own infants.748 Adults who experience talking, singing, etc.). Caregivers should trauma in childhood have higher risks have age-appropriate expectations for difficulty in maintaining fulfilling for children and foster positive social relationships and employment. 749 interactions, which is critical in helping children develop self-reliance, self- l uilding Protective Factors and Reducing B regulation and adaptive coping skills to Risks. Research has also shown that manage stress and adversity.751 negative experiences in childhood can be Ellis, W., Dietz, W. (2017) A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience (BCR) Model. Academic Pediatrics. 17 (2017) pp. S86-S93. DOI information: 10.1016/jacap.2016.12.011 TFAH • WBT • PaininTheNation.org 125 Key policies l H igh-quality home visiting programs. skills and abilities. Targeted programs Quality Rating and Information Systems. Home visiting programs have been shown for at-risk families, when provided in Child care can vary dramatically in terms to have one of the strongest evidence conjunction with other services and of quality. Effective programs provide bases for results in improving health support, can help foster a nurturing nutritious meals, the opportunity for and broader support for low-income home environment, manage parents’ physical activity, and age-appropriate, families with young children. They expectations for age-appropriate evidence-based experiences to support help to ensure needs are identified and behaviors and reduce the risk of positive cognitive and behavioral individuals and families are connected disruptive behaviors in children.754, 755 development.759 Long-term studies have with critical healthcare, mental health Zero to Three has recommended the shown that participants in programs and social services, including financial, creation of a Parenting Edge Initiative such as Early Head Start and Child employment and food assistance services. to provide more support to parents Parent Centers have better cognitive and They can also help reduce family stress through a comprehensive array of public- language development, higher rates of and repeat teen births and child abuse, private approaches, including: placing education and employment attainment as well as improve parenting practices, child development specialists in pediatric and lower rates of violent behavior and maternal health child development practices; providing parents with quality arrests.760 Key focus areas must include: and school readiness.752, 753 To be information and support to nurture their ensuring access to high-quality child effective, home visiting programs must child’s development; seeding community care and early education for all families; be based on high-quality models and partnerships to promote support for increasing the number of children in implemented well. It is critical that they parents including approaches such as pre-kindergarten; and improving access also be integrated with other programs parent peer groups to help parents to proven, high-quality early learning and supports, and connected to systems connect with and support each other, or programs. At the federal level, this that ensure ongoing service delivery community-wide efforts to highlight ways includes supporting ACF programs, the as children and families age-out of the parents can support early development; Office Child Care and the Child Care programs. The Maternal, Infant, and expanding and continuing to innovate Development Block Grant (CCDBG), Early Childhood Home Visiting Program home visiting programs that put families and Head Start and Early Head Start.761 (MIECHV) was created by the Affordable at the center of services; and ensuring • ore than 1.1 million children ages M Care Act (P.L. 111–148), and receives child welfare programs provide research- zero to 5 are enrolled in Head Start its funding via HRSA. HRSA and ACF and trauma-informed services developed programs around the country, which partnered to implement the program, for parents’ specific needs in nurturing provide comprehensive educational, with the purpose of responding to the their babies’ development.756 nutritional, health, social and other diverse needs of children and families services to low-income children — and l I nvest in quality child care and early in at-risk communities and to provide often delivered by public and private childhood education. Quality early an opportunity for collaboration and nonprofit and for-profit agencies.762 education programs have been shown partnership at the federal, state and Roughly 75 percent of Head Start to produce returns on investment of 7 community levels to improve health enrollees are 3- to 4-year olds, and 20 to 10 percent.757 Early education can and development outcomes for at-risk percent are zero to 2-year olds. help children learn how to interact with children through evidence-based home their peers and relate to others, regulate l S upport social-emotional learning in visiting programs. their emotions, adapt to change and child care and early education programs. l E vidence-based parent education and build resilience.758 Federal, state and Social-emotional learning programs — support initiatives. Parenting skill and local policies should focus on promoting in child care, early education and K-12 — family relationship programs provide high-quality initiatives, with the goal of focus on developing and strengthening caregivers with support and are designed safe, healthy environments in all child communication and problem-solving to give parents the tools they need to care, day care and early childhood skills, emotional regulation, conflict succeed, as well as enhance positive education programs. States can resolution and coping skills. They parent-child interactions and improve strengthen licensing requirements for provide children and youth with skills to children’s behavioral and emotional child-care settings and implement strong resolve problems in relationships, school 126 TFAH • WBT • PaininTheNation.org Social, Emotional, and Social, Emotional, and FA ST FAAT S FC ST Academic Development Academic Development FAC T S and with peers, and reduce risks for mental health issues, substance misuse Social, Emotional, and Academic Development Fast Facts and suicide. Some of the key capabilities What we know about social, emotional, and academic development. 90+10+T 80+20+T What we know about social, emotional, and academic development. include: coping and problem solving, emotional regulation, conflict resolution Nine out of ten Nine out of and Four in five and critical thinking, including avoiding teachers believe social ten Four in five teachers want more support teachers believe social taught emotional skills can be and teachers want more social to address students’ support and overcoming hopelessness. States emotional benefits students.1 and that it skills can be taught to address students’ social 1 and emotional development. and that it benefits students.1 and emotional development.1 can use new opportunities available through the Every Student Succeeds Act (ESSA) of 2015 to use a portion of Title 75% of the words 75% of the describe how stressed happy Integrating social and students use to words I funds for early childhood education stressed happy bored Integrating social and tired emotional development and the transition from pre-kindergarten they feel at use to describe how students school are negative. tired bored emotional development they feel at school are negative. Students most commonly report improves students’ to elementary school. In 2016, the Students most commonly report they are tired, stressed, and bored.2 improves students’ attitudes and engagement.3 Aspen Institute launched the National they are tired, stressed, and bored.2 attitudes and engagement.3 Commission on Social, Emotional and Academic Development with support 80+20+T from RWJF to outline and widely Growth in Growth in that Eight in ten employers say social Eight in ten employers say social and emotional skills are the promote an evidenced-based action occupations that occupations and most important and emotional skills are the plan to accelerate efforts to integrate require the mastery of social require theskills has outpaced most important to success emotional mastery of social and the social-emotional development of emotional skills has outpaced growth of all other occupations.4 toyet are also the hardest skills and success and yet to find.5 are also the hardest skills children in educational settings, and growth of all other occupations.4 to find.5 facilitate alignment and coordination of education stakeholders toward a shared vision of change in policy and practice. Social and emotional competency is at least as predictive Socialof academic and career achievement as is IQ.6 and emotional competency is at least as predictive l upport a continuum of services between S of academic and career achievement as is IQ.6 early care and education to elementary school. A smooth transition of services, Supporting students’ social and Social and emotional skills help 87% Supporting students’ social and an emotional development produces Social and emotional skills help to build cognitive skills. They programs and supports is critical to 87% building upon and strengthening the 76% 76% 11-percentage- emotional development produces an 11-percentage- help students to build cognitive skills. They help students social-emotional skills developed in early point gain point gain learn academic learn academic childhood settings. Schools and early in grades and test scores. in grades and test scores.3 3 content content and apply their knowledge. 7 care settings can help support social- and apply their knowledge.7 emotional learning — and other supports www.AspenSEAD.org @AspenSEAD After paying for college, the next After paying for college, the next www.AspenSEAD.org @AspenSEAD across settings, including: recommending biggestconcern among parents biggest concern among parents state ESSA plans include language that is their children’s social and emotional well-being.8 8 is children’s social and emotional well-being. promotes coordination of services and plans between early child care and Attention to social and emotional development $11 schools; coordinating age-appropriate Attention to social and emotional development $11 Integrating social and emotional is not only valuable in early childhood. Integrating social and emotional is not only valuable in early childhood. development with academic comprehensive early developmental Sustaining aa focuson social Sustaining focus on social development with academic learning returns learning returns and behavioral screening tools and and emotional growth through $1 $11 for every protocols for action; establishing data and emotional growthfor improving adolescence is crucial through $1 $11 for every $1 invested. 10 10 adolescence isoutcomes beyond school. crucial for improving sharing agreements between schools achievement and achievement and outcomes beyond school.9 9 $ $ $1 invested. and early care settings; and delivering the same services in elementary schools High social and emotional competency... High social and emotional competency... that are available in early childhood programs under Title I funds, such as Increases high school Decreases dropout rates, Increases high school graduation rates, postsecondary enrollment, postsecondary completion, Decreases school and classroom behavior issues, dropout rates, drug use, teen pregnancy, mental health behavioral health supports and referrals graduation rates, postsecondary employment rates, and average wages.11 school and classroom behavior issues, problems, and criminal behavior.11 enrollment, postsecondary completion, drug use, teen pregnancy, mental health to community-based organizations.763 employment rates, and average wages.11 problems, and criminal behavior.11 Source: Aspen Institute CI TAT I O N S TFAH • WBT • PaininTheNation.org 127 1 C I TATI O N S Bridgeland, J., Bruce, M., & Hariharan, A. (2013). The missing piece: A national teacher survey on how social and emotional learning can empower children and transform schools. A report for CASEL. Washington, DC: Civic Enterprises. EXAMPLES: EARLY CHILDHOOD INITIATIVES, HOME VISITING AND PARENT EDUCATION Project LAUNCH is a SAMHSA prevention Monetary Benefits to Society initiative in partnership with other agencies to improve the well-being of Lower-risk $7,271 children ages birth to 8 by addressing families $9,151 various developmental components (physical, social, emotional, cognitive Higher-risk $7,271 and behavioral).764 It involves five core families $41,419 prevention and promotion strategies, including: child screenings and $0 10,000 20,000 30,000 40,000 50,000 assessments; home visits; mental health Net present value dollars per child 2003 consultations; family and parenting skills training; and integrating behavioral health Increased participant income (net of welfare loss) Savings to government Reduction in tangible crime losses Cost into primary care settings. The effort Source: 2005 RAND Corporation Study works to improve coordination across child-serving systems, build infrastructures and increase high-quality prevention and $34,148 (in 2003 dollars) per higher-risk to be associated with reductions in poor wellness promotion services. family served, totaling a return of $5.70 behavior and maternal depression and for every dollar invested. Another study, in improved language development and Nurse-Family Partnership (NFP) works 2012, found long-term benefits of almost inhibitory control. with young, low-income, first-time $23,000 per participant. Moreover, the pregnant women who are not ready to Abriendo Puertas (Opening Doors) is an program has demonstrated the ability to take care of a child by, first, establishing evidence-based training program that was reduce child abuse and neglect, arrests a trusted relationship with a public health developed by Latino parents for Latino among children, emergency room visits nurse who meets with the mother from parents with children ages zero to 5-years- for accidents and poisonings and behavior pregnancy until the baby turns two years old.767 The curriculum uses the “popular and intellectual problems among children. old.765 For more than 35 years, NFP, education” approach — which focuses on which is supported by RWJF, has enrolled Family Check-Up (FCU) models are empowering individuals who often feel mar- mothers early in their pregnancies and designed for children ages 2- to 17- ginalized in society — and provides lessons helped public health nurses continuously years old, who are typically from high- that reflect Latino culture. Abriendo Puertas conduct home visits over a two-and-a-half risk families, to address behavioral features 10 interactive sessions, each of year period. Home visits are important challenges before they can become which promotes school readiness and fam- because they connect first-time mothers more problematic.766 FCUs are typically ily well-being by focusing on early childhood with the care and support they need to preventive, assessment-driven health development, health, attendance and bilin- ensure a healthy pregnancy and birth, and maintenance models that emphasize gualism, among others. Since it began in to be the best parent they can. The model motivation for change. Typically, the FCU 2007, the program has served over 55,000 has been shown to have dramatic benefits begins with three home visits with a trained families in 256 cities. In June 2014, Child to society. For instance, when Medicaid consultant, who then makes family-specific Trends completed an evaluation of Abriendo pays for NFP services, the federal intervention recommendations that might Puertas, finding that the program strength- government gets a 54 percent return on include parent management training, ened development of parenting practices its investment. Additionally, NFP services preschool consultation and/or and improved children’s learning and prepa- have resulted in lower enrollment in community referrals. The Early Steps ration for school. In addition, the study Medicaid and the Supplemental Nutrition Project, a University of Oregon study of found that Abriendo Puertas successfully Assistance Program (SNAP), a 9 percent an FCU that included 731 families with increased parent engagement and parent reduction in Medicaid costs and an 11 children who were 2-years-old recruited at education activities: reading and reviewing percent reduction in SNAP costs in the 10 Special Supplemental Nutrition Program the letters of the alphabet in the home; li- years following birth. Also, a 2005 RAND for Women, Infants, and Children (WIC) brary use; knowledge about the importance analysis found a net benefit to society of program offices, found the intervention of high-quality child care; and others. 128 TFAH • WBT • PaininTheNation.org Effective School-Aged Children, Tweens and Teens Well-being Policies Parents and educators know that separation/divorce. Other heightened many current health and education children who are healthier are better risks include being withdrawn, policies do not reflect the most prepared to learn, succeed in school and having behavior or aggression issues, effective evidence-based approaches for thrive out-of-school. Good nutrition, negative academic performance and improving well-being and achievement. physical activity, basic safety, clean air and experiencing peer rejection. Parents Many school systems have few to no water, education about making healthy and/or friends who misuse substances, mental health services. And, many choices, a supportive school environment as well as the availability of drugs widely-used substance misuse prevention and access to physical, behavioral and and alcohol in a community, are also strategies are particularly out of date — mental health services allow children increased risk factors. In addition, where many schools have no programs to flourish. The long-term success of during these years, the prefrontal cortex at all, or use “pep rally” approaches or children requires that they are healthy, of the brain is still forming, which is “information about the harms of drugs” safe, engaged, supported and challenged. related to rational decision-making and in isolation, which have been shown to risk-taking. There is a significant body of research — be ineffective and reinforce stigmas. including multi-decade studies by According to NIDA, while the initial A number of leading experts have NIH/NIDA — that shows the value decision to take drugs is mostly called for a reboot of mental health of focusing on social-emotional voluntary — once drug addiction takes and substance misuse prevention in development, coping and life skills over, a person’s ability to exert self- schools. This includes focusing on to perform better in school, reduce control can become seriously impaired. promoting supportive environments negative and risky behavior and form Brain imaging shows that substance and social-emotional learning, providing better relationships and ties with the misuse can physically alter the brain — behavioral health services, connecting community.768 including impacting judgment, decision- school efforts with broader community making, learning, memory and behavior Children experience a range of changes programs and systems to identify control. It can increase compulsive and that can serve as triggers for increasing issues early and connect children with destructive behaviors. Tobacco use is risk for negative well-being, substance appropriate services and supports. A often the first substance that tweens or misuse and depression or suicidal successful school approach must also teens misuse and can begin altering thoughts. The tween, teen and young require providing training and education brain structure to be more likely to adult years are the biggest “hot spot” for educators and parents about what develop an addiction and impact for the emergence of drug and alcohol works best, as well as sufficient funding decision-making abilities.769, 770 misuse, depression, suicidal ideation to implement and scale evidence-based and other mental health concerns. Building protective factors, positive programs over the long-term. environments and coping skills can Transition times, like starting middle The President’s Commission on mitigate against the risk. Policies and school, high school, college, leaving Combating Drug Addiction and Opioid programs that support better well-being home for the first time and/or starting Crisis interim report reaffirmed this show benefits for all school-aged children a job, can be trigger points. Tweens and approach. The report identified the — including reducing risk for substance teens experience less adult supervision, importance of using “evidence-based misuse and suicide — but benefit those have interaction with wider groups prevention programs for schools, at risk the most significantly. of peers, begin developing romantic tools for teachers and parents to interests and relationships, have One major challenge is that traditional enhance youth knowledge of the exposure to peers who may be misusing school systems are not designed to dangers of drug use, as well as early substances, experience increased address these concerns. There are intervention strategies for children academic pressure and face higher currently 55 million school-aged with environmental and individual expectations for individual responsibility. children — which can make school- risk factors (trauma, foster care, Some children experience additional based strategies an effective way to reach adverse childhood experiences and disruptions, like moving or parental children, teens and tweens. However, developmental disorders).”771 TFAH • WBT • PaininTheNation.org 129 SCHOOL-AGED TRENDS (AROUND 55 MILLION CHILDREN AND YOUTH ARE CURRENTLY SCHOOL-AGED) l S uicide Risk. More than one out of More than 90 percent of adults who every 12 high school students attempted develop a substance use disorder began suicide in 2015, and nearly 15 percent using before they were 18 years old.783 had made a “suicide plan.”772 l T reatment for Mental Health Issues and l P overty, Toxic Stress and Food Substance Use Disorders. Only one in It could be someone you Insecurity. More than half of U.S. public 12 teens who needed substance misuse KNOW. TEACH . LOVE. school students live in poverty and are treatment received treatment in 2016; at increased risk for the negative impact and four in 10 with a major depressive Students reported they... of prolonged stress. 773 Three out of episode received treatment.784 four public school students regularly Seriously Considered l B ullying. Around 20 percent of high Attempting made a come to school hungry.774 Suicide * Suicide Plan * school students report being bullied l A dverse Childhood Experiences. More on school property and 15.5 percent than half of children — across socio- report being bullied through electronic economic levels — experience an ACE, or social media.785 such as physical abuse (28.3 percent), 15% 12% of Heterosexual 43% ofLGB students of Heterosexual 38% ofLGB students substance misuse in the household l E xpulsions/Suspensions. More than students students 3.3 million students are suspended (26.9 percent), sexual abuse (24.7 or expelled from U.S. public schools attempted Suicide percent for girls and 16 percent for attempted annually, even though these practices are * Received and boys) and parent divorce or separation suicide at least once Treatment tied to lower school achievement, higher by a Doctor or Nurse* (23.3 percent).775, 776, 777 The more ACEs truancy and dropout rates, behavior experienced, the higher likelihood for a problems and more negative school range of health and behavioral risks and 6% 2% climate.786 Black students (kindergarten of Heterosexual 29% of Heterosexual 9% negative consequences. students ofLGB students students ofLGB students to high school) are almost four times as * During the 12 months before the survey l L GB Youth. More than 40 percent of likely to receive one or more out-of-school lesbian, gay and bisexual youth consider suspensions as White students.787 Prevention is poSsible! suicide, 34 percent experience bullying l C hronic Absenteeism. Chronic Be the change in your community. and 18 percent experience physical absenteeism rates, where students dating violence.778 missed more than 10 percent of the l M ental Health Disorders. As many as school year, are often a warning sign of one in five children and teens, either health, family, financial or other concerns. currently or at some point in the past, Thirteen percent of U.S. public school have had a serious debilitating mental students (6.5 million) missed 15 or disorder. 779 More than 25 percent of more school days in the 2013-2014 teens are impacted by at least mild school year. Eighteen percent of high symptoms of depression. school students (3 million); and 11 percent of elementary students (3.5 l S ubstance Misuse. 7.4 percent of million) are chronically absent.788 Rates teens report regular marijuana use, vary significantly across communities, 4.7 percent misuse prescription drugs, ranging from 6 percent to 23 percent in 10.8 percent smoked cigarettes, 16.0 six states, and with high poverty urban percent used e-cigarettes, 32.8 percent schools reporting up to one-third of of high schoolers drink alcohol and 17.7 students as chronically absent.789 percent report binge drinking.780, 781, 782 130 TFAH • WBT • PaininTheNation.org ROI FOR EFFECTIVE SCHOOL-BASED SUBSTANCE MISUSE, VIOLENCE AND SUICIDE PREVENTION PROGRAMS l F ive of the strongest school-based reduced violence rates (including substance misuse prevention strategies suicides) of 29.2 percent among high have returns on investment (ROI) school students, 7.3 percent among ranging from $3.80:1 to $34:1 — and middle school students, 18 percent have demonstrated results in reducing among elementary school students and misuse of a range of drugs, alcohol and 32.4 percent among pre-kindergarten tobacco along with other risky behaviors, and kindergarten students — all of while improving school achievement and which led to decreased substance future career attainment.790, 791, 792, 793 misuse and increased academic performance.794, 795 ROIs ranged from l review of 53 school-based violence A $15 to $81 for every $1 spent.796, 797, 798 prevention program studies found Reducing Risks and Increasing Protective Factors for Whether Teens Initiate, Regularly Use or Become Dependent on Alcohol and/or Drugs799 Some Key Risk Factors Some Key Protective Factors Family • Lack of mutual attachment and • strong bond between children A nurturing by parents or caregivers and their families • Ineffective parenting • arental involvement in a child’s life P • A chaotic home environment • upportive parenting that meets S • Lack of a significant relationship financial, emotional, cognitive and with a caring adult social needs • caregiver who misuses A • etting clear limits and expecta- S substances, suffers from tions for behavior mental illness or engages in criminal behavior Outside the family • lassroom behavior concerns, C • ge-appropriate monitoring of A such as aggression and impulsivity social behavior, such as curfews, • Academic failure adult supervision, knowing a child’s friends, enforcing house- • Poor social coping skills hold rules • ssociation with peers with problem A • uccess in academics and S behaviors, including drug misuse involvement in extracurricular • Misperceptions of the extent activities and acceptability of drug-abusing • trong bonds with pro-social insti- S behaviors in school, peers and tutions, such as schools the community • cceptance of norms against A drug misuse TFAH • WBT • PaininTheNation.org 131 Key Policies Some key policy priorities and programs Many schools are also adopting • raining school personnel to T to promote well-being among school- Positive Behavior Interventions and address school climate issues, such aged children, tweens and teens include: Supports (PBIS) models that as SEL programming or screening emphasize strategies to support social tools, using ESSA professional l P rioritizing a healthy, positive school and behavioral improvement, such as development funds; climate for all individuals in the school. character education, social skill • eveloping academic standards and D State and local school districts and instruction, bullying prevention, assessments for social-emotional schools can conduct needs assessments behavior support and building learning; and and adopt wellness plans to identify consultation teams.802, 803 Research school or community specific concerns • ngaging mental health and well- E indicates PBIS contributes to and the best strategies for addressing being stakeholders in state plan decreased classroom disruptions and them. CDC has defined key strategies development and implementation. office discipline referrals, increased that help improve positive protective academic achievement and l I nvesting in evidence-based social- factors through school connectedness performance, and improved school emotional learning, life and coping and parent engagement, including climate and safety.804 According to a skill programs. The benefits of social- promoting: adult support (school staff Washington State Institute for Public emotional learning programs are can dedicate their time, interest, Policy cost-benefit analysis, for every cross-sectoral — with clear long-term attention and emotional support to dollar spent on PBIS, there are benefits for the education, healthcare, students); belonging to a positive peer $13.49 in societal benefits.805 criminal justice and private sectors. group (a stable network of peers can Investments to seed and scale these improve student perceptions of school); Some local school districts have also programs, however, are often limited commitment to education (believing adopted trauma-informed practices to to the education sector. Aligning and that school is important to their future, encourage safe, supportive climates in coordinating funding streams from and perceiving that the adults in school schools and to manage behavior these other benefiting sectors — and are invested in their education can get concerns, acknowledging and reinvesting savings in promotion or students engaged in their own learning responding to the role of trauma prevention activities — would greatly and involved in school activities); and a (ranging from having been physically increase the opportunities to seed and positive school environment (the abused to living in adverse scale evidence-based mental health physical environment and psychosocial circumstances contributing to a program programming. Potential climate can set the stage for positive prolonged experience of “toxic funding streams could include: student perceptions of school).800 stress”) in the development of hospital community benefit dollars, Conversely, many traditional punitive- emotional, behavioral, educational leveraging Medicaid reimbursement centered approaches to school behavior and physical difficulties in the lives of in schools under CMS’ recent free concerns, such as suspensions and children and youth.806 care policy change, pay-for-success expulsions, have been shown not to ESSA also provides a number of new financing or the Community improve student behavior or school opportunities to support district and/or Development Financial Institutions climate. In fact, they are associated with school-wide health improvement Fund. Efforts should also be made negative student outcomes, including and to support more health-related to measure or leverage the benefits lower academic performance and professional development, including:807 of cross-sector investments in these engagement, chronic absenteeism, • ntegrating measures of mental health I programs. It is important to provide higher dropout rates, failure to and wellness in state accountability support so high-quality programs graduate on time and increased future systems and report cards; are implemented with fidelity — and disciplinary actions.801 results are evaluated. 132 TFAH • WBT • PaininTheNation.org l A dopting and supporting the wide 22 States Have Comprehensive Bullying Prevention Laws and sustained use of evidence-based WA substance misuse prevention programs MT ME ND in schools. In addition to the broader VT OR MN set of policies and programs aimed at ID SD WI NH NY MA preventing substance misuse, there WY MI CT RI IA PA NJ are specific approaches focused on NV NE OH DE IL IN school-based efforts. While there has CA UT CO MD WV KS MO VA DC been a long history of substance misuse KY prevention efforts in schools, many NC AZ TN OK of these have been underfunded and NM AR SC GA limited in duration, and have not been MS AL TX LA evidence-based. And many substance misuse, suicide and mental health FL AK programs are initiated in response to HI tragic events in a community, and are not sustained beyond an immediate States with comprehensive bullying prevention laws States with no comprehensive bullying prevention laws response period. It is important to Source: American Academy of Pediatrics provide more stable and sustained funding to support a long-term commitment to effective, ongoing l upport anti-bullying programs. In 2015, S bullying based on race, ethnicity, gender, evidence-based programs — which more than 20 percent of high school sexual orientation, gender identity, is a culture change from previous students reported being bullied on disability, religious beliefs and other practices of funding limited and short- school grounds, and 15.5 percent report personal attributes. Additionally, policies term campaigns or grant programs. being bullied through social media.808 should apply to students in all schools, It is also important to have an expert In addition to its pervasive nature, both on or off campus, or through the network to support schools in selecting bullying is associated with other forms use of technology (i.e., cyberbullying). which of a select menu of evidence- of violence.809, 810,811, 812, 813 Additionally, More than 160,000 students in the based programs best fit their needs, both youth who bully and those who are United States stay home from school starting and effectively maintaining a bullied report higher levels of suicidal every day out of fear of being bullied. new program, including training and ideation and suicides.814 Programs that It harms a student’s ability to learn, is ongoing technical support, providing help youth process their emotions, lower related to declines in grades and self- evaluations and advising on continuous their levels of aggression and develop worth, increases risk for depression quality improvement. School-based problem-solving skills have been shown and anxiety and can cause physical substance misuse programs are most to reduce incidents of bullying and symptoms such as head and stomach effective and should be developed delinquency and raise students’ levels of aches. According to AAP, student in context with other programs and academic success.815 AAP recommends education and support from adults is supports in a community. Schools and that pediatricians advocate for bullying particularly important, and more than school districts should work with multi- awareness by teachers, education 55 percent of bullying situations stop sector child and youth development administrators, parents and children, when a peer intervenes. coalitions and collaborations (such and supports adoption of evidence-based as Communities That Care) to help prevention programs. They recommend • ll states and Washington, D.C., Guam, A ensure that programs and efforts are that effective state policy clearly defines Puerto Rico and the U.S. Virgin Islands mutually reinforcing and the combined the role and the authority of the school have some form of bullying prevention efforts yield better overall results. officials, teachers and other school law or policy. However, according employees to address bullying and to AAP, only 22 have comprehensive would require a zero-tolerance policy for bullying prevention laws.816 TFAH • WBT • PaininTheNation.org 133 l xpand both the number of school E l ncrease school health services — I counselors and other mental including mental, behavioral and oral health personnel in schools, health — and improve coordination and professional development across education, health and other opportunities. There is a shortage social services. A number of models of trained professionals to support — including increased ability for social-emotional development and to Medicaid to pay for health services in address the behavioral and mental schools under the new free care policy health needs of U.S. students. For — are emerging to better support instance, the National Association children’s health needs in schools of School Psychologists (NASP) and/or to connect them to care.819 reported a shortage of more than Efforts range from increasing the 9,000 school psychologists in 2010, number and functions of school nurses with a projected shortage of 15,000 and full on-site school-based health by 2020. The national ratio was 457 centers to mobile health centers, students to one school psychologist. telehealth and designated caseworkers In some areas, the ratio is as high as for creating strong partnerships with 2,000 or 3,500 to one.817 Currently, local providers, such as hospitals, school psychologists, counselors community health centers, community and behavior specialists spend a mental health centers and social significant portion of their time service providers.820 In addition, there supporting the academic needs are increasing efforts to grow the of students and/or dedicated to availability and scope of mental health addressing the needs of around 13 and behavioral health professionals percent of U.S. students who receive employed by schools and/or referrals special education services. There to outside systems of support. is little time or resources to provide l equire school-based suicide prevention R support for additional mental plans, including prevention training health and/or social, behavioral and for teachers and other personnel who emotional problems. As a result, it regularly interact with students. In is important to increase the number 2015, suicide was the second-leading of trained professionals to provide cause of death among young people. support to the school community and Effective school-based prevention plans students.818 These professionals help and efforts have been shown to reduce students in academic achievement, suicides and suicidal thoughts among personal/social development and tweens and teens. Some best practices career development. Trained include: training teachers, administrators professionals can: provide support and staff to recognize warning signs and and intervention to students; how to connect students with specialized consult with families and teachers; supports; encouraging positive inclusive promote positive peer relationships, environments; routine mental health provide social problem solving and screening; implementing comprehensive conflict resolution; develop school- anti-bullying approaches; and having wide practices and approaches; “postvention” strategies to help and connect and collaborate with families, students, school staff and community providers for needed communities respond effectively to services. suicides or suicide attempts. 134 TFAH • WBT • PaininTheNation.org School Behavioral Health Services Framework Linking with Systems of Care Adequate Information Sharing Strong Communication Loop Warm Hand-Off Wraparound Services Youth-Driven and Family-Guided Services Tier 3 FEW Crisis Response Re-entry Plan Individual/Group Counseling/Therapy Tier 2 SOME Progress Monitoring Evidence-Based Interventions Tier 1 ALL Referral Process Behavioral Health Screening Social, Emotional Learning Opportunities Positive Behavior Supports FOUNDATION Family-School-Community Partnerships Mental Health Stigma Reduction Staff Professional Development Positive School Climate and Culture Accountability Systems Data-Based Decision Making District and School Teams Drive the Work Colorado Framework for School Behavioral Health Services | 9 Source: Colorado Education Initiative • he American Foundation for T • FSP also has recommendations A Suicide Prevention (AFSP) found for colleges and university policies as of 2016, only nine states required and programs to support suicide annual training for school personnel prevention — stressing gatekeeper on suicide prevention.821 Another training, providing information about 16 states require some training, crisis intervention services to students, though not annually, and 14 states online screening and support encouraged training, but did not programs, availability of mental health mandate it.822 In 2016, California services and other efforts. According became the first state to require all to their review, five states have laws middle and high school schools to related to college suicide prevention provide mandatory suicide prevention efforts (Ohio, Pennsylvania, Texas, educations (grades seven to 12).823 Washington and West Virginia).824 TFAH • WBT • PaininTheNation.org 135 EXAMPLES: SCHOOL-BEHAVIORAL HEALTH PROGRAMS Georgia Apex Program was Medicaid reimbursement rate.825 Billing rural counties with the lowest numbers created in the 2015 school year, for Medicaid services like individual, of mental health providers per capita. when 29 community mental group or family therapy allows Mary’s Among youth suicides, they found more health providers in Georgia con- Center to broaden its support within than half (52 percent) experienced a tracted with school partners to implement the school to other typically non-billable crisis in the two preceding weeks, 30.7 school-based mental health programs. school-wide mental health promotion and percent were experiencing problems School staff members and parents re- prevention services, such as lessons on related to school and 42.5 percent had ferred students to mental health providers, social-emotional wellness, workshops for a current mental illness. The project is with about one-third of students receiving parents on positive discipline and stress a collaboration among mental health, mental health services for the first time management, and trainings for teachers public health and education agencies during the first year of this project. Com- on trauma-informed education. In the and advocates to reduce perceived monly delivered services, 88 percent of 2016-2017 school year, 57 percent stigma attached to mental illness and which were delivered in a school setting, of SBMH clients had an improvement accessing mental health services; train include individual therapy, community sup- of 10 points or greater during at least school-community teams; and increase ports/individual services and behavioral three months of treatment on the 30- the number of adults who recognize the health assessments. Trainings, such as point Child and Adolescent Functional signs of youth who are having trouble and youth mental health first aid and suicide Assessment Scale.826 know how to approach students and their prevention, community forums and weekly families to access appropriate services. Wisconsin School Mental coffee talks helped to fully integrate this Efforts also included focusing on means Health Project is a five-year project into the schools and allowed reduction, or access to lethal means. initiative launched in 2015 students and staff to receive guidance This included providing messages in 25 school districts as a partnership around the initiative. Providers were en- about safe storage of lethal means, created by Wisconsin’s Violent Death couraged to build infrastructure and create including storing firearms that are locked, Reporting System, Maternal Child Health lasting partnerships with the schools for unloaded and with ammunition stored program and Mental Health America of sustainability once the grant ended. After separately and using a best practice Wisconsin. It was developed in response just seven months of the program, the approach, CALM: Counseling on Access to data showing high risk for suicide number of students served increased from to Lethal Means, to provide counseling among youth in rural counties along with 234 at baseline to 1,487, with the total strategies to help youth and families at American Indians/Alaska Natives and number of students served increasing by risk for suicide. LGBT persons. The highest rates were in about 193 students each month. Mary’s Center, a federally qualified health center (FQHC) Recovery High Schools827 are system and delinquency, and a way to in Washington, D.C., operates intentionally designed for students reduce school violence while improving a school based mental recovering from a substance use disorder education attainment, by typically providing health (SBMH) program in 15 schools to as part of the continuum of recovery intensive therapeutic and peer-recovery decrease access barriers for students care. These schools offer programs support and academic curriculum with and families. By staffing mental health that uniquely meet the education and structured recovery-focused programming. professionals within the school building, therapeutic challenges faced by those A study found that complete avoidance of the program can operate and self- in recovery and who were struggling to alcohol or other drugs increased from 20 sustain through Medicaid billing — and succeed in traditional school settings. percent during the 90 days before entering as a FQHC, is eligible for an enhanced They provide an alternative to the justice the school to 56 percent after. 136 TFAH • WBT • PaininTheNation.org NIAAA RECOMMENDED SCHOOL-BASED ALCOHOL PREVENTION PROGRAMS828 According to a review of a broad range of l P roviding training and support for studies and programs, NIAAA has identified teachers and students; and key elements of the most effective school- l E nsuring efforts are culturally and based programs, which include:829 developmentally on target for the l C orrecting misperceptions that students they serve.830 everyone is drinking; For college students, some effective l T eaching youth ways to say no to alcohol; approaches include brief motivation intervention approaches, cognitive- l U sing interactive teaching techniques behavioral interventions (recognizing (e.g., small-group activities, role plays when or why an individual drinks and same-age leaders); and tools for changing behavior), l I nvolving parents and other segments challenging expectations or norm-beliefs of the community; about alcohol use and using trained counselors (including peer counselors) l R evisiting the topic over the years to and some tested web-based programs. reinforce prevention messages; PARTNERSHIP FOR DRUG-FREE KIDS: PARENTS’ ROLE IN HELPING THEIR KIDS The brains of teenagers and young starting at an early age; model adults are still maturing, and addiction appropriate use of prescriptions and often starts in the teen years. 831 The alcohol; safeguard prescription drugs; Partnership for Drug-Free Kids provides and do not provide alcohol to teens. advice and support for parents who l I dentifying problems early: Understand play an important role in helping their and look for warning signs of drug use, children grow up as healthy as possible, ongoing mental health issues, or crisis, from talking to kids from an early age and be prepared to take action.832 about drugs and alcohol to helping connect their young adult children with l C onnecting kids to care: Get emerging mental health issues with screenings from primary care appropriate healthcare. They raise the providers or psychologist for kids importance of providing resources for exhibiting concerning behavior; parent education and support efforts. help connect kids with appropriate Key roles of parents include: treatment and support them as much as possible, from health insurance l P revention: Have ongoing coverage to continuing care needs. conversations about drugs/alcohol TFAH • WBT • PaininTheNation.org 137 PROVISIONS UNDER ESSA TO ADDRESS MENTAL AND BEHAVIORAL HEALTH IN SCHOOLS ESSA presents several opportunities to an improvement plan to address the education needs assessments to promote and address mental health in findings. Under Title IV Part A, LEAs allow for easier data sharing and school settings. In the report, Framework must complete a needs assessment integration. The Colorado Department for Action: Addressing Mental Health and on safe and healthy learning of Education incorporates behavioral Well-being through ESSA Implementation, environments, access to well-rounded and mental health within their health the Alliance for a Healthier Generation, education and personalized learning and physical education academic Healthy Schools Campaign, Mental experiences supported by technology, standards through an emotional and Health America and TFAH identify key every three years. Stakeholders can social wellness (ESW) standard.834 And opportunities to promote mental health encourage LEAs to include measures Colorado’s comprehensive health and and well-being under ESSA, including: related to mental health and well-being physical education academic standards in these needs assessments and also include prevention and risk l I ntegrating measures of mental health resulting improvement plans. These management standards that include and wellness in state accountability measures should be aligned with competencies to apply knowledge and systems and report cards. States other existing needs assessments, skills that promote healthy, violence-free are required to include at least one particularly those conducted in other relationships; and to apply knowledge indicator of school quality or student sectors (such as hospital community and skills to make health-enhancing success in their state accountability health needs assessments) to decisions regarding the use of alcohol, system — creating an opportunity to facilitate greater collaboration and data tobacco and other drugs.835 integrate measures related to mental integration between sectors. health and well-being. Under Title I of l E ngaging mental health and ESSA, schools must also include chronic l T raining school personnel to address well-being stakeholders in state plan absenteeism in their state report cards. behavioral health and school climate development and implementation. As mental health issues are among the issues using ESSA professional ESSA requires meaningful stakeholder leading causes of chronic absenteeism, development funds. ESSA creates engagement in state plan development reporting on this metric could help opportunities to train staff, such as and implementation, which provides to catalyze actions to address the administrative staff, teachers and opportunities to engage a diverse underlying causes of these issues superintendents, to address key school set of cross-sector community-based in school settings. Other possible climate issues. ESSA’s professional organizations and institutions working accountability indicators include development funds could be used to on issues related to mental health measures of school climate.833 provide training on social-emotional and well-being. Schools may consider learning, build school personnel engaging stakeholders such as: l I ncorporating mental health and capacity to conduct screenings or behavioral health providers, health wellness into needs assessments treatment referrals, or other ways to insurers or hospitals, community mental and aligning metrics across other create a supportive and healthy school health centers, universities or colleges community needs assessments. environment. — especially those who train education ESSA includes two needs assessment or behavioral health professionals requirements. Under Title I, local l A lign measures across education and/or paraprofessionals — local education agencies (LEAs) must and health needs assessments and and state health departments and, complete a needs assessment to standards. Measures should be importantly, families and students. identify performance gaps and develop streamlined across healthcare and 138 TFAH • WBT • PaininTheNation.org EXAMPLES: SCHOOL-BASED SOCIAL-EMOTIONAL AND LIFE AND COPING SKILLS PROGRAMS Students who complete evidence-based ESTIMATES OF BENEFITS RELATIVE TO COSTS* social-emotional and life/coping skills Evidence-based Approach/Program Benefits per $1 of Cost development programs have lower rates Nurse-Family-Partnership® $1.61 of alcohol and drug misuse and suicidal ideation. These school-based programs The Incredible Years® – Parent $1.65 can begin as early as kindergarten and Strengthening Families 10–14 $5.00 are most effective if implemented in Early Childhood Education Programs (state and district) $5.05 early grade levels.836 Good Behavior Game $64.18 PAX Good Behavior Game (GBG) is Life Skills® Training $17.25 an approach to the management of classroom behaviors that rewards $14.85 (with volunteer cost) Mentoring (school-based) $23.86 (taxpayer only) children for displaying appropriate on- task behaviors during instructional Functional Family Therapy $6.51 times. The GBG presents an opportunity Multidimensional Treatment Foster Care $1.70 to improve students’ performance and Multisystemic Therapy® $1.74 allow teachers to teach more effectively. Source: CDC, A Comprehensive Technical Package for the Prevention of Youth Violence and New Mexico recently used this evidence- Associated Risk Behaviors based approach in an 1115 Waiver to *Dollar estimates by Washington State Institute for Public Policy are in 2015 dollars and are receive Medicaid reimbursement for specific to the state of Washington. Estimates are likely to vary across states and communities. The benefit-cost estimates are continually updated, and cost estimates presented are based on the program. Results from districts in information published by Washington State Institute for Public Policy as of September 2016. The New Mexico using this approach show latest information is available online at: http://www.wsipp.wa.gov. a 57 percent to 65 percent reduction in disruptive behaviors (compared to partnership with Columbus City Schools Life Skills Training (LST) Program is an initial 34 percent to 41 percent). (CCS), Nationwide Children’s Hospital focused on middle school students and Additionally, studies from across the supports behavioral health clinicians for includes a “booster” program for high nation show a 50 to 70 percent reduction first and second grade classrooms to school students.840 LST is designed in inattentive, unengaged learning, and help teachers implement GBG.838 to address a wide range of risk and disturbing, destructive, aggressive and protective factors by teaching general bullying behaviors. GBG also cut the Youth Aware of Mental Health (YAM) is personal and social skills, along with drug odds of suicide ideation and suicide a program which has shown 50 percent resistance skills and normative education. attempts in half when assessed 15 years reductions in attempted suicides and 49.6 The program has been extensively later (at ages 19 to 21) compared to percent reductions in suicidal thoughts tested over the past 20 years and has peers who were not in GBG.837 A cost- among teens ages 14 to 16 in 168 been found to reduce the prevalence benefit analysis of PAX GBG shows that schools in 10 European countries. The of tobacco, alcohol and illicit drug use the program returns $57.53 for every $1 program focuses on developing interactive relative to controls by 50 to 87 percent. invested. GBG has also been funded by dialogue and role-playing to teach about the When combined with booster sessions, hospitals, such as Nationwide Children’s risk and protective factors associated with LST was shown to reduce the prevalence Hospital as part of their community needs suicide (including depression and anxiety) of substance misuse long-term by as assessment implementation strategy and and how to enhance problem solving skills much as 66 percent, with benefits still in by health plans such as Trillium Health to deal with adverse life events, stress, place beyond the high school years. Plan. In Columbus, Ohio, through a school and other problems.839 TFAH • WBT • PaininTheNation.org 139 EXAMPLES: SCHOOL-BASED SOCIAL-EMOTIONAL AND LIFE AND COPING SKILLS PROGRAMS Al’s Pals is a comprehensive curriculum and teacher training program that develops social-emotional skills, self-control, problem-solving abilities and healthy decision- making in children ages 3- to 8-years old.841 The program is nationally recognized as an evidence-based model prevention program and received top rating by the National Center on Quality Teaching and Learning in their Social-Emotional Preschool Curriculum Consumer Report. Through fun lessons, engaging puppets, original music and effective teaching approaches, Al’s Pals: l H elps young children regulate their own feelings and behavior, allowing educators more time for creative teaching by reducing the need for discipline l C reates and maintains classroom environments of caring, cooperation, respect, and responsibility l T eaches conflict resolution and peaceful problem-solving l P romotes appreciation of differences and positive social relationships l P revents and addresses bullying behavior l onveys clear messages about the harms of alcohol, tobacco C and other drugs l B uilds children’s abilities to make healthy choices and cope with life’s difficulties Source: Al’s Pals 140 TFAH • WBT • PaininTheNation.org Family Opportunities — Addressing Core Needs and Promoting Stability CDC’s review of the most effective strategies for preventing suicides include: 1) strengthening household security (unemployment benefits, other forms of temporary assistance, livable wages, medical benefits, retirement and disability insurance and similar programs); and 2) housing stabilization policies (housing assistance, eviction and foreclosure laws, loan modification programs, move-out planning and financial counseling services).842 Across many measures, there is a l A study found that higher state clear link between a lack of financial spending on income support and stability and the drug, alcohol and medical benefits had lower rates of suicide crises: suicide (estimated spending $45 more per capita would lead to 3,000 l R egions with the most economic fewer suicides per year).845 distress also have the highest death rates from drug, alcohol and l U nemployment, periods of recession, suicide deaths. 843 lower income and lower educational levels have been associated with l F inancial factors were reported in 37.5 higher drug and alcohol misuse in a percent of suicide deaths in 2010.844 number of studies.846, 847 TFAH • WBT • PaininTheNation.org 141 Key Policies Some of the most effective policies that help provide support to families to meet their basic needs and better well-being include: Income Assistance l arned Income Tax Credit (EITC) and Child Tax Credit E (CTC). Two of the most effective and targeted federal anti- poverty programs are the EITC, which is fully refundable, and the CTC, which is partially refundable. The EITC and CTC provide money to low-income individuals who are working (EITC) and who have children (CTC). In 2016, more than 27 million workers and their families received an average EITC of $2,455.848 The program boosted 9.4 million people, including 5 million children, over the poverty limit in 2013.849 Studies show the higher amount of refundable tax credits a child’s family receives, the more likely that child is to have better school performance, attend college, earn more as Source: Center on Budget and Policy Priorities an adult and avoid the early onset of disabilities and other illnesses associated with child poverty.850, 851, 852, 853 States can also offer EITC programs that help leverage federal support and help for working families. As of 2016, 26 states and Washington, D.C. had enacted EITCs, with 23 states making it refundable — including the state of Washington, which does not have a state income tax.854 l emporary Assistance for Needy Families. Established in T 1996, TANF provides block grants to states to supplement state spending in support of low-income families. In FY 2014, over 1.5 million families and nearly 2.7 million children received TANF assistance.855 TANF has been subject to several short-term extensions in recent years but is overdue for full reauthorization. The basic TANF amount has not changed since 1996, causing its real value to decline by more than 30 percent. In order to be eligible for TANF assistance, recipients must be working and cannot be immigrants; they also cannot be assisted by the program for more than five years. While the number of Americans in poverty and extreme poverty has increased, the number of people receiving TANF assistance has declined. In 1996, 68 out of 100 poor families received TANF benefits; by 2013, that number had dropped to 26 out of 100.856 In 1995, TANF’s predecessor, Aid to Families with Dependent Children (AFDC), lifted out of deep poverty 62 percent (2 million) of the children who otherwise would have been below half of the poverty line; by 2010, this figure for TANF was just 24 percent (629,000).857 Source: Center on Budget and Policy Priorities 142 TFAH • WBT • PaininTheNation.org l inimum Wage. The federal minimum M Recession, unemployment insurance wage is currently $7.25 an hour, and it helped keep 3.5 million Americans is not indexed for inflation. A recent above the poverty line in 2011, study found that if minimum wage had including nearly 1 million children.865 kept pace with productivity over recent An analysis found that suicide rates decades, it would be more than $18 were lower in states that provided an hour.858 A worker employed full higher than average benefits (mean: time in a minimum wage job earns just $7,990 per person) and for a duration $14,500, which is more than $4,000 that could go longer than 26 weeks.866 below the poverty line for a mother with two children and not enough Housing Assistance to afford a one-bedroom apartment l ousing Choice Vouchers, Section 8 H in any state.859 Thirty-one states and Project-Based Rental Assistance and Washington, D.C. have minimum Public Housing: There are three major wages above the federal limit.860 federal rental assistance programs that are administered at the local and l amily and Medical Leave. Only about F state level and help make housing 12 percent of the U.S. workforce has affordable for more than 10 million access to paid family leave benefits to people, including 4 million children.867 support time off after a child is born A recent study found that housing or during his or her first year of life.861 vouchers reduced the number of Nearly half of U.S. employees do not families living in shelters or the streets work for a company that is required to by three-fourths; reduced the number offer leave under the federal Family of families who lacked their own home and Medical Leave Act, and more or residence by nearly 80 percent; than half of those who do cannot reduced the share of families living afford to take the unpaid leave that in crowded conditions by more than the law provides.862, 863 This can make half; and reduced the number of times it more difficult to breastfeed, causes families moved over a five-year period stress for the parent and child and by close to 40 percent.868 However, due makes it more difficult for parent and to funding limitations, only around children to establish positive, nurturing one in four families eligible for federal relationships. Past the first year of life, assistance receives it. A 2015 report more than half of working mothers do by the Department of Housing and not have paid sick days to either care for Urban Development found that six out themselves or their children.864 While of 10 extremely low-income renters some states excuse workers from TANF and three out of 10 very low-income work requirements during the first six renters do not have access to affordable months of a child’s life, only three states and available rental units, and three- have created insurance programs that quarters of renters eligible for low- provide paid leave for workers. income rental assistance do not receive l nemployment Insurance. Federal- U it.869 870 The federal government spends state unemployment insurance three times as much on tax subsidies programs support states in providing for homeownership — more than half short-term assistance for many families of which benefits households with to fill a gap between jobs — states can incomes above $100,000 — as on rental define the maximum amount and assistance for low-income families.871 duration of benefits. During the Great TFAH • WBT • PaininTheNation.org 143 l ortgage/Foreclosure Assistance: M parks and strong community activities, nutrition.878 WIC helps provide Between April 2009 and May 2016, the reduce stress and help improve mental approved nutritious foods, nutrition federal government also worked with health and well-being. education (including breastfeeding public and private entities to provide promotion and support) and referrals relief on 10.5 million mortgages — Food Assistance to health and other social services to for those with high interest loans and l upplemental Nutrition Assistance S participants at no charge. The federal owed more than the home’s value or Program: SNAP is the largest nutrition grant-based program provided benefits were unemployed — through a Making assistance program in the United to 7.7 million individuals each month Homes Affordable (MHA) program States, providing benefits equaling in 2016 (1.9 million infants, 4 million following the housing crisis in 2008.872 around $1.40 per meal to nearly 45 children and 1.8 million women) at The program expired in May 2016. million low-income Americans in an average cost of $42.62 per person FY 2016.873 In 2016, 44.2 million a month.879 Every $1 spent to support l tate and Local Housing Trusts: At the S Americans were enrolled in the good nutrition and early health for state and local community level, there Supplemental Nutrition Assistance infants in the two months after birth are also a range of housing programs, Program and several million more through WIC has been shown to lead loans and grants — including 47 states were SNAP-eligible.874 According to to a reduction in healthcare costs of and Washington, D.C. and hundreds of an analysis by the Center on Budget $1.77 to $3.13 in the two months after communities have housing trusts, but and Policy Priorities (CBPP), SNAP birth (a 2:1 to 3:1 ROI).880 the amount for these programs varies kept an estimated 8.4 million people significantly from area to area. l chool Meal Programs: The National S out of poverty, including 3.8 million School Meal Programs provides a free l ocal, State and Federal Place- L children — and 2.1 million children or reduced-cost meal to students from Based Community/Neighborhood out of deep poverty (50 percent of the families earning below 185 percent Development Initiatives: Local, state poverty line) in 2014.875 The average of the federal poverty guidelines. In and federal place-based initiatives amount of per-person SNAP benefits 2016, more than 30 million children focus on how to improve the overall has decreased since the height of received lunch and 14.5 million quality of neighborhoods and areas, the fiscal crisis.876 Mothers in food received breakfast each day through supporting housing, equal education insecure households that receive SNAP the programs.881 2016 was the ninth and job opportunities, crime reduction, benefits are less likely to experience straight year enrollment in the active living and quality healthcare. symptoms of maternal depression than program increased.882 School meal For instance, the Neighborhood mothers in food insecure households programs are widely credited with Revitalization Initiative, including not receiving SNAP benefits.877 reducing levels of student truancy Choice Neighborhoods, Promise Zones l pecial Supplemental Nutrition S and behavioral issues and raising and Strong Cities, Strong Communities Program for Women, Infants, and levels of student concentration (SC2), focus on improving housing, Children: WIC is a federal grant-based and achievement.883 There is also schools, transportation, healthcare, program that provides nutrition some evidence they may play a role community design and development support to low-income pregnant, in reducing the risk of developing and other efforts to be more effective postpartum and breastfeeding chronic diseases later in life.884 and coordinated. Residing in areas women, infants and children up to that offer lots of opportunities, such as age 5 who are at risk for inadequate high-performing schools, high-quality 144 TFAH • WBT • PaininTheNation.org CREATING ECONOMIC OPPORTUNITY There have been marked shifts in the U.S. percent of earners increased by 0.03 economy and labor markets — and it has percent since 1980 while the income for impacted the vitality and job opportunities the top 0.01 percent of earners increased within many communities around the country. by more than 300 percent over the same time period) remain critical issues in the While the U.S. economy has improved greatly United States. Moreover, insufficient since the financial crisis and recession of the investment in children’s health, education late 2000s (with the economy growing each and economic security, which particularly year since 2010 and unemployment falling hurts lower-income families, and higher under 5 percent in 2016), there are still unemployment in rural areas continue to areas and populations in the country that are contribute to the nation’s challenges.887 888 lagging and significant barriers to economic opportunity for many Americans.885 886 l S tudies show recessions and unemployment cause significant l H igh levels of income inequality (in 2015, psychological distress and more of those half of all income in the United States went affected turn to alcohol and drugs to to 10 percent of earners) and stagnant cope, which creates additional health wages for the vast majority of Americans issues and further hurts families and (the average income for the lower 90 communities that are already struggling.889 2016 USDA Rural Development Grants TFAH • WBT • PaininTheNation.org 145 To address many of these ongoing (e.g., SNAP) in the short term; and issues and ensure there is economic polices that reduce economic inequality, opportunity for all Americans, experts call boost income and wage stagnation, for additional investment in infrastructure bolster affordable housing, improve public and the workforce (such as direct job health and healthcare, reform criminal creation, adult education, job training justice and education systems, and and apprenticeship programs) and continue to support programs that bolster maintenance of current education grants low and moderate income families in the (e.g., Pell grants) and safety net programs long-term.890, 891, 892, 893 U.S. Employment, metro and non-metro areas, 2007-2016 (quarterly) 146 TFAH • WBT • PaininTheNation.org OPIOID USE AND THE LABOR MARKET A 2017 analysis by Brookings found that Labor Force Participation Rates by Age & Gender opioid use is having a negative impact Percent(Seasonally Adjusted) on labor force participation rates — 90 estimating that the increase in opioid 85 prescriptions could account for around Men (25 Years 80 & Over) 20 percent of the labor force decline 75 among men and 25 percent among 16 -24 Years women between 1999 and 2015.894 The 70 connection between opioid use and the 65 labor market is clear, but the study cannot 60 determine which causes which. 55 Jul-17 The research also found that much of 50 Women the variation of opioid prescription rates 45 (25 Years & Over) between counties comes from differences 40 in prescribing practices separate from 35 the underlying health and demographics 30 that also affected prescribing rates. This 25 shows that prescribing practices alone 1948 1958 1968 1978 1988 1998 2008 2018 have played an important role in how many people take opioids and that the Source: Brookings, 2017. connections between opioids and labor force is more than a proxy for underlying health or demographic differences. TFAH • WBT • PaininTheNation.org 147 S EC T I ON 4 : Pain in the SECTION 4: RECOMMENDATIONS FOR A NATIONAL RESILIENCE STRATEGY Recommendations for a National Nation: Resilience Strategy — and Public Health Reducing Alcohol and Drug Report Misuse and Suicide series The nation needs much stronger action to counter the rising opioid, alcohol and suicide death trends — and address the underlying pain, prolonged stress, hopelessness, financial insecurity and other factors that contribute to these crises. This report shows that without a more However, the overarching concerted effort, the problems will recommendation of the report is the continue to get worse — and that limited need to bring policies and programs attention on preventing problems in the together in a more comprehensive and first place perpetuates a negative cycle. effective way — to develop a National Resilience Strategy to improve the lives It also reviews a broad range of of Americans across the country. evidence-based and promising policies and programs that are available to tackle In addition, there is a need to continue the drug, alcohol and suicide death to support research and development crises — and the factors contributing into effective strategies to reduce to these trends, including ways to substance misuse and suicides and modernize and expand the behavioral improve well-being — along with a health system to focus more broadly on need to continue to adapt, evaluate “whole health” and to support improved and improve strategies, particularly as well-being in communities and raise a aspects of the crises change over time. healthier generation of children. NOVEMBER 2017 SUMMARY OF POLICIES AND PROGRAMS TO REDUCE SUBSTANCE MISUSE AND IMPROVE WELL-BEING A. Reducing Drug and Alcohol Misuse and Suicide 1. Opioid Response: Much of the every state, with a focus on using data • terile syringe access to reduce the S response to date has been focused to help inform and improve pain risk and spread of HIV, hepatitis C on reacting to the acute emergencies treatment for patients and avoiding and vein infections; and of overdoses, insufficient treatment and treating addiction; • iversion strategies to provide D availability and options and limiting • ublic education, safe storage, P support and treatment to individuals the supply of opioids available for disposal and Take Back programs to with substance use disorders that misuse. Some key efforts include: inform patients about safe use and focus on treating addiction as a l Surveillance — to be able to track storage and risk of dependence — health and not a criminal issue. problems — and inform and target and reduce the availability of unused l reatment as prevention — T response activities — including drug medicines in the community — and expanding the availability and quality use patterns, such as identifying trends support tamper-resistant formulations; of substance misuse services available in prescription drug misuse, heroin, • trengthen the “public benefit” S that meet recommended, modern fentanyl and carfentanil increases in considerations of FDA approval standards of care. communities — and related harms practices and support tamper-resistant such as hepatitis C and HIV. and non-addictive formulations; and 2. reventing Excessive Drinking which P l E vidence-based community prevention can increase risk for developing • Anti-drug trafficking and stopping programs to be scaled and expanded alcohol use disorders, as well as the supply-chain of heroin, fentanyl to benefit local areas throughout the injuries, suicide and other forms of and other illicit, synthetic opioids country — supporting best-practice, violence and a number of chronic efforts must be a top priority. multi-sector partnerships that leverage diseases. Some top evidence-based the leadership, expertise and resources l R educing the harms caused by policies for reducing excessive within a community to support a overdoses and misuse and treating drinking include: comprehensive strategy — and expert substance use disorders as public l ricing, access and availability — P networks to provide advice and technical health issues first — and the need for increases in prices, limiting hours and assistance so effective programs are community-based, stigma-free harm limiting the density of outlets and implemented for maximum impact. reduction services that provide people restaurants/stores/bars selling alcohol; the support and help they need when l I mproving pain treatment and and where they need them by: l educing underage drinking through R management practices, including minimum legal age compliance checks, responsible prescribing of • xpanding naloxone availability E zero tolerance for underage drunk prescription opioids: and Good Samaritan laws and other driving laws and penalties for hosting policies that make the rescue drug • ncreased education and training I parties with underage drinking; and more widely available and able to be for providers — including guidance prescribed to individuals and families l educing drinking and driving — R for improving pain management at risk and community institutions which reduces risks for crashes while and treatment; (workplaces, libraries, community also identifying individuals who may • esponsible prescribing of R centers, airports/train and metro need treatment or support — through prescription opioids and Prescription stations, universities and schools, etc.) drunk driving limit laws, mandatory Drug Monitoring Programs — to be able to respond to overdoses and ignition interlocks even for first time including continued study and use limit liability for helping. Ensuring offenses, increases in sobriety check of best practices for PDMPs, and accessibility and affordability of points and increasing driving under ensuring they receive sufficient naloxone is also essential; the influence penalties. support to be fully operational in TFAH • WBT • PaininTheNation.org 149 3. reventing Suicides by supporting P help identify those at risk — and crisis a cultural shift that focuses on services for those in need. Special focus providing help to individuals, should be dedicated to school-based especially when experiencing trauma, efforts and support veterans, Native distress or severe circumstances. American/Alaska Native, LGBT and Preventing excessive drinking, alcohol other higher risk communities; use disorders and opioid misuse are l S uicide risk identification training also important strategies for reducing for medical professionals — and the number of suicides. In addition, improving access to mental health leading strategies include: services; and l N ational Violent Death Report System l L imiting access to “hotspots” and should be expanded to every state to lethal means for suicide since most allow for better tracking of suicide suicides are carried out within a short patterns and risks to develop stronger, time of having suicidal thoughts targeted prevention strategies; and risk goes down if means are not l tatewide suicide prevention plans that S available, including promoting safety focus on building effective support within communities (bridges, building systems within key institutions, training access, etc.) and firearm safety policies, “gatekeepers” or people in positions that especially for those at risk, including have high contact with tweens, teens safe storage, child access prevention, and adults (educators, community and gun violence protective orders and faith leaders, human resource and social background reporting/checks for service providers, etc.) with training to mental illness and other risks. B. Improving Behavioral Health Services to Address Whole Health l E xpanding and modernizing • olstering the behavioral workforce B • aximize Medicare and Medicaid to M behavioral health services — with only and expanding access to services follow and support state use of best around one in 10 people receiving the in underserved communities — practices to treat opioid use disorder recommended treatment for mental expanding the availability of coverage and to broadly modernize the health and substance use disorders requires also increasing the behavioral delivery and coverage of behavioral — there is an urgent need to expand health workforce — including with health services. This should include the availability of behavioral health incentivized workforce development continuing to support and expand services. The gaps are particularly initiatives and expanded training and integrated/aligned healthcare and acute in rural and lower-income areas. use of community health workers behavioral health service models — In addition, there is a need to expand and peer counselor support — and ensuring guidelines and coverage the use of modern best practices for models such as telehealth in many for the scope and duration and treatment in line with the research communities and other service multiple forms of recommended about what is most effective (including delivery models. standards of care that meet patient being able to provide different forms needs and conditions. In addition, • edication-Assisted Treatment M of treatment, durations and scopes continued support should be should be available for patients as that match the needs and conditions provided for innovative Medicaid recommended/appropriate — which of individual patients). Parity laws models that support connecting will require expanding the workforce must be implemented and enforced. healthcare and social services — trained and credentialed to support including Accountable Health its delivery. 150 TFAH • WBT • PaininTheNation.org Communities and expanding screenings for early childhood, teen C. Prioritize Prevention and family risks and connections to Supporting Healthier Communities transition from early childhood services and supports. and Raising a Mentally and Physically programs to elementary school; l A lign and integrate behavioral health Healthier Generation of Kids — with a l odernizing child welfare system — M with healthcare — where the “whole strategy of preventing problems before and need for multi-generational care health” of patients is addressed — they start — supporting evidence-based — including meeting the increased including physical and mental health policies and programs that reduce risks needs related to the opioid epidemic needs. This will require changes for substance misuse, suicide and other — prioritizing services and support that help align systems, payments harms, and promote protective factors to parents and children — to help and incentives for more coordinated like: safe, secure families, homes and keep families together and reduce the and integrated care. Some models communities; life and coping skills; and trauma of separation when possible include expanding training for types of social-emotional development, including: and appropriate; supporting the ability professionals, referral systems and/or l M ulti-sector collaborative partnerships of grandparents and other relatives to co-location of services. Systems should that provide support and leadership provide care for children when possible be trauma-informed to be accessible for comprehensive approaches to and appropriate; and comprehensive and supportive of patients and patients problems, like the opioid, alcohol supports and case manager approaches should be able to be referred to and suicide crises, which impact the for children in foster care system; appropriate services and supports no whole community. These partnerships matter where they start in the system, l S chool-aged tween/teen strategies, provide the infrastructure to leverage so there is “no wrong door” for entry including prioritizing healthy, positive the expertise, resources, leadership to support; school climates for all individuals in and capabilities of a broad range of the school; investing in evidence-based l F ocusing on early identification of partners — healthcare and hospitals, social-emotional learning and life and issues and connections to care — universities and schools, businesses, coping skill programs; widespread use there also needs to be increased community and faith groups, and of modern evidence-based substance focus on identifying issues early other organizations — across a misuse prevention programs; anti- — and connecting individuals and community — for stronger collective bullying programs; expanding families to the care and support impact. These partnerships are key for availability for school counselors and they need. There are numerous being able to scale and sustain policies mental health personnel and increasing models and tools for screening for and programs to address the opioid, school services and coordination across trauma, adverse childhood and family alcohol and suicide epidemics — and health, education and social services; experiences, risk for mental illness, to also focus on promoting prevention- and school-based suicide prevention risk for and misuse of drugs and focused efforts on an ongoing basis. plans including training for personnel; alcohol and risk of suicide; and l xpert networks to provide guidance E l amily opportunity programs, including F l C oordination across healthcare, on evidence-based approaches that best income assistance programs, housing behavioral health and social services fit a local area’s needs and technical assistance and transportation, food is also important, since many factors assistance for effective implementation assistance and healthcare — that address influence health, including social and evaluation of the effort. core needs and promote stability; services. Systems must support l arly childhood strategies, including E connections to services and case l E conomic opportunity initiatives high-quality home visiting programs; management to ensure people that promote job opportunities and evidence-based parent education and receive the support that is needed training in targeted areas — and support initiatives; high-quality child and available. improve infrastructure and community care and early childhood education; amenities and services. services that provide support to TFAH • WBT • PaininTheNation.org 151 Appendices: Pain in the APPENDICES APPENDIX A: Nation: PREVENTION POLICY INDICATORS Substance Use Mental Health Public Health Indicator Newborn Screening for Substance Use Exposure - state requires reporting if newborn has been exposed to drugs, State Mental Health Budget (Increased/Decreased/ Remained Level) Report Year Alabama alcohol or other controlled substances as of April 2015 FY 2015-2016 Maintain series Alaska Arizona √ √ Decrease Increase Arkansas √ Decrease California √ Maintain Colorado Increase Connecticut Increase Delaware Increase D.C. √ Decrease Florida Increase Georgia Increase Hawaii Maintain Idaho Increase Illinois √ Pending Indiana Increase Iowa √ Decrease Kansas Decrease Kentucky √ Decrease Louisiana √ Maintain Maine √ Increase Maryland √ Maintain Massachusetts √ Increase Michigan √ Maintain Minnesota √ Increase Mississippi Maintain Missouri √ Maintain Montana √ Increase Nebraska Increase Nevada √ Decrease New Hampshire Increase New Jersey Increase New Mexico Increase New York Increase North Carolina Decrease North Dakota Decrease Ohio Decrease Oklahoma √ Maintain Oregon Increase Pennsylvania √ Pending Rhode Island Maintain South Carolina Increase South Dakota Increase Tennessee Maintain Texas Increase Utah √ Maintain Vermont Maintain NOVEMBER 2017 Virginia √ Increase Washington Increase West Virginia Increase Wisconsin Maintain Wyoming Decrease U.S. N/A N/A State Statutes Search. In Child Welfare Information Gateway. https://www.childwelfare.gov/systemwide/laws_policies/state/ National Alliance on Mental Illness. State Mental Health Legislation 2014. Trends, Themes & Effective Practices. Arlington, VA: National Alliance on Mental Illness. http://www2.nami.org/Template.cfm?-Section=Policy_Reports&Template=/ContentManagement/ ContentDisplay.cfm&ContentID=172851” PREVENTION POLICY INDICATORS Childhood Healthcare Indicators — Access and Utilization EPSDT Participation Rate EPSDT Participation Rate Newborn Screening - out Income Eligibility Levels of Children (1- to 2-year- of Children (3- to 5-year- Medicaid/CHIP Income Children (ages 1 to 18) of 34 Conditions listed Indicator for Children in Medicaid/ olds) Receiving at Least olds) Receiving at Least Eligibility Levels for Enrolled in Medicaid on the Recommended CHIP One Initial or Periodic One Initial or Periodic Pregnant Women Uniform Screening Panel Screen Screen Year FY 2014 as of January 2017 FY 2015 FY 2015 2017 as of January 2017 Alabama 50% ≥300%FPL 1.00 0.66 30 138% up to 200%FPL Alaska 57% 200% up to 300%FPL 0.65 0.62 31 200% up to 250%FPL Arizona 49% 200% up to 300%FPL 1.00 0.68 30 138% up to 200%FPL Arkansas 44% 200% up to 300%FPL 1.00 0.59 31 200% up to 250%FPL California 32% 200% up to 300%FPL 1.00 1.00 32 ≥250%FPL Colorado 40% 200% up to 300%FPL 0.94 0.66 31 ≥250%FPL Connecticut 37% ≥300%FPL 1.00 0.89 32 ≥250%FPL Delaware 40% 200% up to 300%FPL 1.00 0.83 31 200% up to 250%FPL D.C. 34% ≥300%FPL 0.95 0.99 30 ≥250%FPL Florida 50% 200% up to 300%FPL 0.89 0.82 31 138% up to 200%FPL Georgia 58% 200% up to 300%FPL 0.89 0.76 31 200% up to 250%FPL Hawaii 39% ≥300%FPL 1.00 0.83 31 138% up to 200%FPL Idaho 61% <200% FPL 0.79 0.63 30 138% up to 200%FPL Illinois 40% ≥300%FPL 0.84 0.92 33 200% up to 250%FPL Indiana 56% 200% up to 300%FPL 0.88 0.81 30 200% up to 250%FPL Iowa 43% ≥300%FPL 1.00 0.78 31 ≥250%FPL Kansas 60% 200% up to 300%FPL 0.84 0.80 30 138% up to 200%FPL Kentucky 38% 200% up to 300%FPL 1.00 0.83 33 200% up to 250%FPL Louisiana 50% 200% up to 300%FPL 1.00 0.86 30 200% up to 250%FPL Maine 36% 200% up to 300%FPL 1.00 0.96 31 200% up to 250%FPL Maryland 40% ≥300%FPL 1.00 1.00 31 ≥250%FPL Massachusetts 25% ≥300%FPL 1.00 1.00 28 200% up to 250%FPL Michigan 44% 200% up to 300%FPL 1.00 0.60 31 200% up to 250%FPL Minnesota 39% 200% up to 300%FPL 1.00 0.71 32 ≥250%FPL Mississippi 50% 200% up to 300%FPL 0.88 0.58 31 138% up to 200%FPL Missouri 53% ≥300%FPL 1.00 1.00 33 ≥250%FPL Montana 58% 200% up to 300%FPL 0.79 0.69 31 138% up to 200%FPL Nebraska 59% 200% up to 300%FPL 0.87 0.72 31 200% up to 250%FPL Nevada 40% 200% up to 300%FPL 1.00 0.77 30 138% up to 200%FPL New Hampshire 40% ≥300%FPL 1.00 0.77 28 200% up to 250%FPL New Jersey 41% ≥300%FPL 1.00 0.91 31 200% up to 250%FPL New Mexico 40% ≥300%FPL 1.00 0.85 31 ≥250%FPL New York 35% ≥300%FPL 1.00 1.00 33 200% up to 250%FPL North Carolina 54% 200% up to 300%FPL 1.00 0.79 31 200% up to 250%FPL North Dakota 40% <200% FPL 0.95 0.64 31 138% up to 200%FPL Ohio 41% 200% up to 300%FPL 0.64 0.66 31 200% up to 250%FPL Oklahoma 55% 200% up to 300%FPL 1.00 0.63 31 200% up to 250%FPL Oregon 36% ≥300%FPL 0.70 0.58 31 138% up to 200%FPL Pennsylvania 42% ≥300%FPL 1.00 0.90 34 200% up to 250%FPL Rhode Island 40% 200% up to 300%FPL 1.00 0.85 31 ≥250%FPL South Carolina 53% 200% up to 300%FPL 1.00 0.56 31 138% up to 200%FPL South Dakota 59% 200% up to 300%FPL 0.79 0.48 31 138% up to 200%FPL Tennessee 51% 200% up to 300%FPL 0.83 0.82 31 ≥250%FPL Texas 64% 200% up to 300%FPL 0.98 0.96 31 200% up to 250%FPL Utah 60% 200% up to 300%FPL 1.00 0.68 31 138% up to 200%FPL Vermont 32% ≥300%FPL 1.00 0.89 31 200% up to 250%FPL Virginia 52% 200% up to 300%FPL 0.90 0.85 31 200% up to 250%FPL Washington 45% ≥300%FPL 1.00 0.68 30 138% up to 200%FPL West Virginia 36% ≥300%FPL 1.00 1.00 31 138% up to 200%FPL Wisconsin 40% ≥300%FPL 1.00 0.80 31 ≥250%FPL Wyoming 64% 200% up to 300%FPL 0.90 0.54 30 138% up to 200%FPL U.S. 43% N/A N/A N/A N/A N/A Medicaid enrollment by age. In Kaiser Family Foundation, 2015. http://kff.org/medicaid/state-indicator/medicaid-enrollment-by-age/#(accessed October 2015). Income Eligibility Levels for Children in Medicaid/CHIP January 2015. In Kaiser Family Foundation, 2015. http://kff.org/medicaid/slide/income-eligibility-levels-for-children-in-medicaidchip-january-2015/ Early and Periodic Screening, Diagnostic, and Treatment. In Medicaid.gov. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and- Treatment.html (accessed July 2015) State profile information. In NewSTEPs. https://data.newsteps.org/newstepsweb/stateProfile/input.action (accessed October 2015). Where are States Today? Medicaid and CHIP Eligibility Levels for Adults, Children and Pregnant Women. April 13, 2015. In The Henry J. Kaiser Family Foundation. http://kff.org/medicaid/fact-sheet/where-are- states-today-medicaid-and-chip/ (accessed August 2015).” TFAH • WBT • PaininTheNation.org 153 PREVENTION POLICY INDICATORS Early Childhood General Welfare/Well-being Early Childhood Early Childhood Education Early Childhood Early Childhood Percent of Education Hours Needed at Enrollment Education Education Homeless Number of Comprehensive Minimum Wage Child Maltreatment Indicator (Enrollment in Funding ($ per Comprehensive People Who Are Children Entering NEW Quality to Afford a One- Rates per 1,000 Head Start or child enrolled in Quality Standards Unaccompanied Foster Care State Supported Standards Bedroom Unit preschool) (out of 10) Children and Youth Pre-K) Checklist Year 2015-2016 School Year 2017 2015 2015 2015 Alabama 29.1% $7,299 10 10 61 5.7% 7.7 3,605 Alaska 17.6% $6,270 7 6 79 7.9% 15.6 1,513 Arizona 17.5% $3,444 3 1 67 6.3% 7.4 12,722 Arkansas 44.8% $7,773 9 7 54 7.3% 13.0 4,065 California 38.0% $6,639 4* 4* 92 9.0% 7.9 32,205 Colorado 30.3% $4,001 6 5 75 5.7% 8.0 4,926 Connecticut 28.6% $10,419 5.3* 4.7* 84 3.1% 9.1 1,765 Delaware 18.0% $7,295 8 6 89 6.0% 7.5 397 D.C. 76.1% $17,875 4 3 100 2.7% 11.4 437 Florida 77.5% $2,353 3 3 77 6.6% 10.7 17,672 Georgia 56.3% $3,934 8 6 72 4.2% 10.8 8,581 Hawaii 11.8% $7,467 8 7 125 4.0% 4.8 1,189 Idaho 10.9% No program No program No program 59 6.6% 3.7 1,201 Illinois 35.8% $3,854 8 7 75 6.3% 10.1 4,929 Indiana 13.7% $6,594 3 1 62 6.4% 16.7 11,175 Iowa 61.7% $3,386 6.5* 6.5* 58 5.8% 10.8 4,011 Kansas 29.1% $2,328 7.5* 7.5* 62 3.4% 2.8 3,984 Kentucky 32.6% $8,110 9 8 57 5.5% 18.7 5,383 Louisiana 38.2% $4,617 9* 8* 69 9.5% 11.3 4,099 Maine 44.8% $8,371 9 9 71 6.2% 13.2 902 Maryland 36.3% $7,533 8 7 101 5.7% 5.0 2,114 Massachusetts 16.5% $3,309 7* 6.5* 87 2.0% 22.4 6,245 Michigan 33.3% $6,291 9 9 58 9.3% 15.7 6,982 Minnesota 12.5% $7,924 9 7 68 9.7% 4.0 6,911 Mississippi 33.2% $4,031 10 8 61 4.7% 12 3,082 Missouri 15.1% $4,722 8 8 59 7.3% 4.1 6,906 Montana 18.6% No program No program No program 54 10.0% 8.3 1,940 Nebraska 28.9% $5,695 6 7 54 8.7% 7.4 2,421 Nevada 12.9% $4,512 7 6 71 26.4% 7.4 3,486 New Hampshire 12.5% No program No program No program 89 6.3% 2.8 620 New Jersey 34.1% $12,664 8.3* 8.3* 100 6.4% 4.8 4,594 New Mexico 43.5% $5,233 8 8 64 7.3% 17.5 1,795 New York 51.8% $6,716 7 7 98 3.0% 15.8 8,980 North Carolina 25.0% $7,855 10 9 66 5.9% 3.4 5,597 North Dakota 16.6% No program No program No program 62 10.9% 10.1 1,037 Ohio 20.8% $4,000 4 5 54 6.9% 8.8 10,360 Oklahoma 73.7% $7,479 9 6 59 12.2% 15.0 5,467 Oregon 13.4% $8,929 9 7 58 10.2% 12.1 3,752 Pennsylvania 22.2% $6,580 6.25* 4.5* 78 5.6% 1.4 11,259 Rhode Island 20.4% $10,506 10 10 67 4.2% 15.1 1,215 South Carolina 43.6% $3,367 6 4.5* 66 3.6% 13.6 3,644 South Dakota 19.6% No program No program No program 49 10.4% 5.1 1,039 Tennessee 29.3% $7,037 9 5 65 7.4% 7.6 5,878 Texas 49.5% $4,127 4 4 73 6.0% 8.8 17,319 Utah 11.1% No program No program No program 69 4.4% 10.5 2,270 Vermont 65.9% $7,879 6 5 70 6.6% 7.7 958 Virginia 24.6% $5,964 5 4 97 4.7% 3.3 2,879 Washington 16.9% $8,305 9 7 73 6.9% 3.7 5,704 West Virginia 58.7% $9,898 10 9 53 7.9% 12.8 3,947 Wisconsin 68.2% $5,791 6 4.5* 67 5.5% 3.7 4,700 Wyoming 22.1% No program No program No program 64 4.6% 7.0 1,141 U.S. 35.9% $5,696 N/A N/A N/A 6.5% 9.2 N/A Out of Reach 2015. 2015 Hours at Minimum Wage Needed to Afford Rent. In, National Low Income Housing Coalition, 2015. http://nlihc.org/sites/default/files/oor/OOR2015_Min-Wage-Map.pdf (accessed October 2015). America’s Youngest Outcasts. A Report Card on Child Homelessness. In, The National Center on Family Homelessness at American Institutes for Research, 2014. http://new.homelesschildrenamerica.org/ mediadocs/280.pdf. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2013. Washington, D.C.: U.S. Department of Health and Human Services, 2015. http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment. Numbers of children entering foster care by State. FY 2004 –FY 2013. In, U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2014. http://www.acf.hhs.gov/sites/default/files/cb/entering_foster_care2013.pdf (accessed October 2015). 154 TFAH • WBT • PaininTheNation.org PREVENTION POLICY INDICATORS General Government Assistance Changes in Real Supplemental Consumer (inflation-adjusted) Work-Oriented Nutrition United Enacted Earned Protection Family and TANF Benefits Child Support Indicator Assistance States WIC Income Tax Minimum Wage Levels from Medical Paid Comparing Current Programs by Program (SNAP) Participation Credits (EITCs) Predatory Leave Participation Levels with Levels in State Payday Loans 1996 as of March as of Feb enacted as of Year 2014 2016 2016 as of Jan 1, 2017 2016 2017 2014 July 2017 Alabama 16.5% 1.50% -14.0% none √ Alaska 11.8% 0.23% -34.4% $9.80 Arizona 13.2% 1.87% -47.5% $10.00 √ Arkansas 12.9% 1.01% -34.4% $8.50 √ √ California 10.5% 16.46% R -22.5% $10.50 √ √ Colorado 8.4% 1.08% R -14.9% $9.30 √ √ Connecticut 11.0% 0.64% R -28.0% $10.10 √ Delaware 15.5% 0.25% NR -34.4% $8.25 D.C. 17.7% 0.18% R -30.3% $11.50  √ √ √ Florida 15.4% 6.13% R -34.4% $8.10 √ Georgia 13.8% 3.39% -34.4% $5.15 √ √ Hawaii 11.8% 0.42% -43.8% $9.25 Idaho 10.4% 0.47% -36.1% $7.25 Illinois 14.7% 3.23% R -24.9% $8.25 √ Indiana 10.2% 1.84% R -34.4% $7.25 √ Iowa 11.7% 0.81% -34.4% $7.25 √ Kansas 8.0% 0.81% R -34.4% $7.25 √ Kentucky 14.6% 1.56% -34.4% $7.25 √ Louisiana 19.5% 1.55% R -17.2% none Maine 13.6% 0.27% R -23.9% $9.00 √ Maryland 11.3% 1.64% R 11.8% $8.75 √ √ Massachusetts 11.2% 1.43% R -28.3% $11.00  √ Michigan 13.9% 3.10% R -29.7% $8.90 √ Minnesota 8.3% 1.42% R -34.4% $9.50 (lower for small employers) √ Mississippi 17.9% 0.91% -7.1% none Missouri 12.5% 1.58% -34.4% $7.70 (exempts small employers) √ Montana 11.7% 0.23% -12.0% $8.15 (lower for very small employersI) √ Nebraska 9.3% 0.44% R -21.5% $9.00 Nevada 14.9% 0.83% -27.8% $8.25 (lower with health benefitsI) New Hampshire 7.0% 0.18% -19.5% none √ New Jersey 9.2% 1.77% R -34.4% $8.44 √ √ √ New Mexico 21.9% 0.67% R -31.1% $7.50 New York 14.8% 6.13% R -10.3% $9.70 √ √ North Carolina 14.3% 3.08% -34.4% $7.25 √ √ North Dakota 7.1% 0.15% -26.1% $7.25 √ Ohio 13.1% 2.81% NR -9.0% $8.15 (less for smaller employers) √ Oklahoma 15.3% 1.11% NR -37.6% $7.25 ($2 for smaller employers) √ Oregon 16.8% 1.16% R -27.9% $10.25 √ Pennsylvania 14.4% 2.81% -34.4% $7.25 √ √ Rhode Island 14.5% 0.27% R -34.4% $9.60 √ √ South Carolina 14.5% 1.34% -7.5% none √ South Dakota 10.8% 0.23% -6.2% $8.65 Tennessee 15.9% 1.98% -34.4% none √ Texas 13.5% 11.36% -0.6% $7.25 Utah 6.9% 0.76% -21.5% $7.25 Vermont 12.4% 0.16% R -29.7% $10.00 √ √ Virginia 9.2% 1.77% NR -24.2% $7.25 √ Washington 12.9% 2.17% R -37.4% $11.00 √ √ West Virginia 18.6% 0.52% -11.9% $8.75 √ √ Wisconsin 12.1% 1.27% R -17.2% $7.25 √ Wyoming 5.8% 0.12% 19.7% $5.15 U.S. 13.0% Note: R=state with refundable EITC, NR = state with nonrefundable EITC Supplemental Nutrition Assistance Program: Share of Population Participating. In Food Research & Action Center, 2015. http://frac.org/wp-content/uploads/2011/01/snapdata2015_jun.pdf (accessed October 2015) U.S. Department of Agriculture. WIC Participation and Program Characteristics, 2012 Final Report. Alexandria, VA: Office of Policy Support, U.S. Department of Agriculture, 2013 Tax Credits for Working Families: Earned Income Tax Credit. In National Conference of State Legislators. http://www.ncsl.org/ research/labor-and-employment/earnedincome-tax-credits-for-working-families.aspx (accessed October 2014). Policy Basics: State Earned Income Tax Credits. In Center on Budget and Policy Priorities. http://www.cbpp.org/cms/index.cfm?-fa=view&id=2506 (accessed March 2015). TANF Cash Benefits Have Fallen by More than 20 Percent in Most States and Continue to Erode. In Center on Budget and Policy Priorities, 2014 http://www.cbpp.org/research/tanf-cash-benefits-have-fallen- bymore-than-20-percent-in-most-states-andcontinue-to-erode (accessed July 2015). State Minimum Wages: 2015 Minimum Wage by State. In National Conference of State Legislatures. http://www.ncsl.org/research/ labor-and-employment/state-minimumwage-chart.aspx (accessed July 2015). 560 Wage and Hour Division. Minimum Wage Laws in the States — January 1, 2015. In, U.S. Department of Labor, 2015. http:// www.dol.gov/whd/minwage/america.htm (accessed October 2015). 561 Predatory Short-Term Lending Protections. In Assets & Opportunity Scorecard, 2015. http://scorecard.assetsandopportunity.org/latest/measure/predatory-short-term-lending-protection (accessed October 2015). 562 Payday Loans. In, Center for Responsible Lending, 2015. http://www.responsiblelending.org/payday-lending/ (accessed October 2015). https://www.acf.hhs.gov/css/work-oriented-programs-for-noncustodial-parents-with-active-child-support Paid Leave is Crucial for Women and Families. Fact Sheet: Employment. In, National Women’s Law Center, 2013. http://www.nwlc.org/sites/default/files/pdfs/family_act_fact_sheet.pdf (accessed October 2015). TFAH • WBT • PaininTheNation.org 155 PREVENTION POLICY INDICATORS Schools Mandate Training in Suicide Require Annual Training for Have Laws that Encourage Meet the Requirements of Meet the Requirements for Prevention for School Indicator School Personnel on Suicide Suicide Prevention Training for IDEA Part B IDEA Part C Personnel but Do Not Specify Prevention School Personnel it be Annual Year 2017 2017 2016 2016 2016 Alabama √ √ √ Alaska √ Arizona √ Arkansas √ California √ Colorado √ Connecticut √ √ √ Delaware √ √ D.C. √ Florida √ Georgia √ √ Hawaii Idaho Illinois √ Indiana √ √ Iowa √ √ Kansas √ Kentucky √ √ √ Louisiana √ Maine √ Maryland √ √ Massachusetts √ √ Michigan √ √ Minnesota √ √ √ Mississippi √ √ Missouri √ √ Montana √ √ Nebraska √ √ Nevada √ √ New Hampshire √ √ New Jersey √ √ New Mexico √ New York √ √ North Carolina √ √ North Dakota √ √ √ Ohio √ √ Oklahoma √ √ Oregon √ Pennsylvania √ √ √ Rhode Island √ √ South Carolina √ South Dakota √ Tennessee √ √ Texas √ √ Utah √ √ Vermont Virginia √ √ √ Washington √ √ West Virginia √ √ Wisconsin √ √ √ Wyoming √ √ √ 2017 Determination Letters on State Implementation of IDEA. Washington, DC: U.S. Department of Education, 2017. https://sites.ed.gov/idea/files/ideafactsheet-determinations-2017.pdf (accessed September 2017). 2017 Determination Letters on State Implementation of IDEA. Washington, DC: U.S. Department of Education, 2017. https://sites.ed.gov/idea/files/ideafactsheet-determinations-2017.pdf (accessed September 2017). https://www.congressweb.com/assets/BackgroundDocuments/70147535-0C42-B1F3-E3DB3ED529C97A80/School%20Personnel%20Training%20Overview_6.pdf 156 TFAH • WBT • PaininTheNation.org STATE ALCOHOL AND DRUG POLICIES Alcohol Mandatory Excise Tax per Excise Tax per Excise Tax per Ban on Sunday Ban on Sunday Ban on Sunday Dram Shop Social Host Ignition Interlock Gallon for 5% Gallon for 12% Gallon for 40% Sales of Distilled Sales of Beer Sales of Wine Liability Laws Liability Laws for Alcohol- Beer Wine Distilled Spirits Spirits related Offenses Alabama $1.05 $1.70 $18.25 X* X* X* X X Alaska $1.07 $2.50 $12.80 X X X Arizona $0.16 $0.84 $3.00 X X X Arkansas $0.35 $1.35 $6.88 X* X* X* X X X California $0.20 $0.20 $3.30 X Colorado $0.08 $0.32 $2.28 X Connecticut $0.23 $0.72 $5.40 X X Delaware $0.16 $0.97 $3.75 X D.C. $0.68 $1.79 $5.69 X X Florida $0.48 $2.25 $6.50 X X Georgia $1.01 $1.51 $3.79 X* X* X* X Hawaii $0.93 $1.38 $5.98 X X Idaho $0.15 $0.45 $10.98 X Illinois $0.23 $1.39 $8.55 X X X Indiana $0.12 $0.47 $2.68 X** X** X** X X Iowa $0.19 $1.75 $12.52 X X 2015-2016 School Year Kansas $0.18 $0.30 $2.50 X X Kentucky $0.83 $3.17 $7.74 Louisiana $0.40 $0.76 $3.03 X* X* X* X Maine $0.35 $0.60 $5.86 X X X Maryland $0.52 $1.40 $4.85 X* X* X* X X Massachusetts $0.11 $0.55 $4.05 X X Michigan $0.20 $0.51 $11.97 X X Minnesota $0.49 $1.21 $8.80 X Mississippi $0.43 $7.98 X X X X X Missouri $0.06 $0.42 $2.00 X X Montana $0.14 $1.06 $9.84 X X Nebraska $0.31 $0.95 $3.75 X X Nevada $0.16 $0.70 $3.60 New Hampshire $0.30 X X X New Jersey $0.12 $0.88 $5.50 X X New Mexico $0.41 $1.70 $6.06 X* X* X* X X New York $0.14 $0.30 $6.44 X X North Carolina $0.62 $1.00 $14.66 X X North Dakota $0.39 $1.06 $4.66 X Ohio $0.18 $0.32 $9.90 X X Oklahoma $0.40 $0.72 $5.56 X X X X Oregon $0.08 $0.67 $22.78 X X X Pennsylvania $0.08 $7.27 X X X Rhode Island $0.12 $1.40 $5.40 X X South Carolina $0.77 $1.08 $5.42 X* X* X X South Dakota $0.27 $1.29 $4.68 X Tennessee $1.29 $1.27 $4.46 X X X X Texas $0.20 $0.20 $2.40 X X X Utah $0.41 $13.11 X X X X X Vermont $0.27 $0.55 $7.75 X Virginia $0.26 $1.51 $19.90 X Washington $0.76 $0.87 $31.48 X X X West Virginia $0.18 $1.00 $5.05 X X Wisconsin $0.06 $0.25 $3.25 X X Wyoming $0.02 X X Source: taxfounda- Source: taxfoundation. Source: taxfoundation. Source: http://www. Source: http://www. Source: http://www. Source: [reflects Source: https:// Source: http://www. tion.org/beer-taxes- org/high-wine-taxes- org/states-spirits- stateliquorlaws.com/ stateliquorlaws. stateliquorlaws.com/ 2015 TFAH report alcoholpolicy. ncsl.org/research/ state state taxes-2017 statelist com/statelist statelist -- update per CDC niaaa.nih.gov/ transportation/ * Laws vary by and NOLO] Prohibitions_ state-ignition-inter- jurisdiction Against_Hosting_ lock-laws.aspx Underage_Drink- ** Restaurants and ing_Parties.html wineries permitted TFAH • WBT • PaininTheNation.org 157 STATE ALCOHOL AND DRUG POLICIES Drugs Naloxone Access - Immunity to Naloxone Access - No Criminal Naloxone Access - Third Party Naloxone Access - Immunity to Good Samaritan Laws Medical Prescribers and/or Liability for Possession without or Standing Order Prescribing Lay Administrators Dispensers a Prescription Permitted Alabama X X X X Alaska X X X X Arizona X X X Arkansas X X X X California X X X X Colorado X X X X Connecticut X X X X Delaware X X X D.C. X X X X X Florida X X X X Georgia X X X X Hawaii X X X X X Idaho X X X Illinois X X X X Indiana X X X Iowa X X X X Kansas X X X Kentucky X X X X Louisiana X X X X X Maine X X X Maryland X X X X Massachusetts X X X X Michigan X X X X X Minnesota X X X X Mississippi X X X X Missouri X X X X Montana X X X X Nebraska X X X X Nevada X X X X X New Hampshire X X X X New Jersey X X X X New Mexico X X X X X New York X X X North Carolina X X X X North Dakota X X X X X Ohio X X X X Oklahoma X Oregon X X X Pennsylvania X X X X Rhode Island X X X X X South Carolina X X X South Dakota X X X Tennessee X X X X Texas X X X X Utah X X X X Vermont X X X X X Virginia X X X Washington X X X X West Virginia X X X X X Wisconsin X X X X X Wyoming X X X Source: https://www.networkforphl. Source: https://www.networkforphl. Source: https://www.networkforphl. Source: https://www.networkforphl. Source: https://www.networkforphl. org/_asset/qz5pvn/network-nalox- org/_asset/qz5pvn/network-nalox- org/_asset/qz5pvn/network-nalox- org/_asset/qz5pvn/network-nalox- org/_asset/qz5pvn/network-nalox- one-10-4.pdf one-10-4.pdf one-10-4.pdf one-10-4.pdf one-10-4.pdf 158 TFAH • WBT • PaininTheNation.org STATE ALCOHOL AND DRUG POLICIES Drugs PDMP - Mandatory PDMP - Mandatory Query PDMP - Data Uploaded PDMP - Engaged in PDMP - Implementing Laws Supporting Syringe Query by Prescribers and by Prescribers Only within 24 Hours Interstate Data Sharing Data Sharing Exchange Programs* Dispensers Alabama X X X Alaska X X X Arizona X X X Arkansas X X X California X X X Colorado X X X Connecticut X X X X Delaware X X X X D.C. X X X Florida X X X X Georgia X X X Hawaii X Idaho X X Illinois X X X Indiana X X X X Iowa X Kansas X X Kentucky X X X X Louisiana X X X Maine X X X X Maryland X X X X Massachusetts X X X X Michigan X X X Minnesota X X X Mississippi X X X Missouri X* X Montana X X Nebraska X X Nevada X X X X New Hampshire X X X X New Jersey X X X X New Mexico X X X X New York X X X X North Carolina X X X X North Dakota X X X Ohio X X X Oklahoma X X** X Oregon Pennsylvania X X Rhode Island X X*** X X South Carolina X X X South Dakota X X Tennessee X X X Texas X X Utah X X**** X X Vermont X X X X Virginia X X X X Washington X X X X West Virginia X X X Wisconsin X X X Wyoming X X Source: http://www.pdmpassist. Source: http://www.pdm- Source: http://www.pdmpassist. Source: http://www.pdmpassist. Source: http://www.pdmpassist. Source: http://knowledgecenter. org/pdf/Mandatory_ passist.org/pdf/Mandatory_ org/pdf/PDMP_Data_Collection_ org/pdf/Interstate_Data_Shar- org/pdf/Interstate_Data_Shar- csg.org/kc/content/four-states- Query_20170824.pdf Query_20170824.pdf Frequency_20171001.pdf ing_20170920.pdf ing_20170920.pdf passed-needle-exchange- *Missouri does not have a state- legislation-2015-two-more-2016 wide PDMP, only district *does not reflect other states that **Oklahoma requires point of may have removed legal barriers sale reporting to syringe programs but do not directly authorize them ***Rhode Island requires daily transmission only for opioid prescriptions ****Utah reqyures point of sale/24 hours reporting TFAH • WBT • PaininTheNation.org 159 APPENDIX B: Methodology for Drug, Alcohol and Suicide (DAS) Deaths Drug-Induced Deaths • nder an extreme worst case scenario, U National Center for Health Statistics. l T here were 434,000 total drug- annual alcohol-related deaths would (CDC, accessed on July 11, 2017.) induced deaths from 2006 to 2015 reach 71,000 in 2025 alone. https://wonder.cdc.gov/wonder/ (based on CDC WONDER.). help/mcd.html#Population 2015) l T he alcohol-related death rate under l A baseline-scenario projects that the baseline scenario would increase l ational and State Population: BGR used N this total could increase to 770,000 by 26 percent from 2015 to 2025 the CDC WONDER tool for our state between 2016 and 2025. (from 10.3 deaths per 100,000 in 2015 population numbers from 1999 to 2015. to 13.0 deaths per 100,000 by 2025). • nder best case and worst case U l lcohol-Induced Deaths and Drug- A Under an extreme worst case scenario, scenarios, it would be 725,000 and Induced Deaths: BGR used the CDC the rate would nearly double to 20.5 830,000, respectively. WONDER tool for data by underlying deaths per 100,000 in the same time. • nder an extreme worst case U cause of death (UCD), isolating scenario, drug-related deaths would Suicide Deaths alcohol-induced deaths and drug- be about 1,050,000, or about double induced deaths, by year and by state. l T here were 387,492 total suicide the number from the previous 10 deaths, from 2006 to 2015 (based on • lcohol-induced deaths and A years. Annual drug-related deaths CDC WONDER). drug-induced deaths are mutually- would reach 163,000 in the year 2025. exclusive. However, these deaths may l A baseline-scenario projects that this also be considered suicide deaths. l T he drug-related death rate under the figure could increase to 510,000 between baseline scenario would increase by 65 • The methodology used by CDC 2016 and 2025. Under best case and percent from 2015 to 2025 (from 17.2 does not rely exclusively on ICD worst case scenarios, it would be about deaths per 100,000 in 2015 to 28.4 codes published in the International 500,000 or 520,000, respectively. deaths per 100,000 by 2025). Under Classification of Diseases, but an extreme worst case scenario, the • he annual growth trend in suicide T instead applies some of their own rate would increase by 170 percent to deaths has been fairly consistent analysis and judgment for these 47.0 deaths per 100,000 by 2025. — the population adjusted annual classifications. (CDC, accessed on growth rate was between 0.5 percent July 11, 2017. https://wonder.cdc. Alcohol-Induced Deaths and 3.2 percent, from 2006 to 2015. gov/wonder/help/mcd.html#Drug/ l T here were 267,000 total alcohol- Alcohol Induced Causes) • he suicide death rate under the T induced deaths from 2006 to 2015 baseline scenario would increase by l uicide Deaths: BGR used the CDC S (based on CDC WONDER. “Induced” nearly 20 percent from 2015 to 2025 WONDER tool for data by underlying deaths are as coded by cause of (from 13.8 deaths per 100,000 in 2015 cause of death (UCD) and Injury death and are not the same as some to 16.4 deaths per 100,000 by 2025). Intent and Mechanism, isolating definitions used for all alcohol suicide, by year and by state. “attributable” deaths, where alcohol Drug, Alcohol and Suicide Historical may be a related factor in a death). • Suicide deaths are not necessarily Analysis mutually exclusive from drug- l T he baseline scenario projects that For the historical analysis, BGR used induced or alcohol-induced deaths. this total could increase to nearly death data from the CDC Wide- • The methodology used by CDC 400,000 between 2016 and 2025. ranging Online Data for Epidemiologic does not rely exclusively on ICD • nder best case and worst case U Research (CDC WONDER). codes published in the International scenarios, it would be about 370,000 l ata Source: BGR used the CDC D Classification of Diseases, and does not or 430,000, respectively. WONDER online tool for Multiple include a detailed methodology. (CDC, • nder an extreme worst case scenario, U Cause of Death data from 1999 to accessed on July 11, 2017. https:// alcohol-related deaths would be nearly 2015. Note: The CDC WONDER wonder.cdc.gov/wonder/help/mcd. 520,000, or about double the number tool uses information from the html#Drug/Alcohol Induced Causes) from the previous 10 years. Census Bureau, and is released by the 160 TFAH • WBT • PaininTheNation.org l otal DAS Deaths: For total drug, T l T o account for year-over-year slower rate), BGR chose the 10-year alcohol, or suicide (DAS) deaths, BGR anomalies, BGR examined trends CAGR with the lowest growth rate. avoided double-counting by subtracting over 10-year periods, the same as our • For alcohol-related deaths, this was out suicides that were drug-related or period of analysis. the time period from 1999-2009. alcohol-related, by state and by year. • GR calculated the compound annual B • For drug-related deaths, this was • GR then queried the CDC WONDER B growth rates (CAGR) over 10-year the time period from 2003-2013. data for deaths that were determined periods for each type of DAS death rate. • For suicide deaths, this was the to be drug-induced suicides or alcohol- • GR used CAGR rather than the B time period from 1999-2009. induced suicides, by state and by year. average of annual growth rates over • GR also developed a very pessimistic B • round 11 percent to 14 percent A the 10-year period, as it dampens scenario based on recent experience. of suicide deaths each year were the impact of large annual changes Feedback from experts and initial data also classified as drug-related, while in a given year. suggest that we could see a 10-year very few (less than 1 percent) were • AGR is the annualized average rate C period of unprecedented DAS deaths. classified as alcohol-related. of growth between two different years: For our very pessimistic scenario, BGR l AS Death Rate per 100,000: For our D • he CAGR is calculated where T used the DAS death per 100,000 growth DAS death rate per 100,000, BGR used Z — X = N, is the number of years from 2014 to 2015 (the most recent total DAS deaths and divided by total between the two given years, is year of data available from CDC). population, by state and by year. calculated as follows: • ote: BGR did not create state- N l AS Death Rate per 100,000 Annual D • AGR, year X to year Z = [(value in C specific scenarios, due to the volatility Increase: The DAS Death Rate per year Z/value in year X) ^ (1/N)-1] in year-to-year trends at the state level. 100,000 in a given year divided by the • or example, the national alcohol- F l F or national population growth DAS Death Rate per 100,000 in the related death rates per 100,000 projections from 2016 to 2025, BGR preceding year. in 1999 and 2009 were 6.85 and used the most recent data from the • his metric shows the change in DAS T 12.76, respectively. Census Bureau. (Census Bureau, deaths while controlling for overall • he CAGR is [12.76/6.85^ (1/10)- T accessed as of July 18, 2017, https:// population changes 1] = 6.4 percent www.census.gov/data/datasets/2014/ demo/popproj/2014-popproj.html) Assumptions Used to Calculate the l F or the three DAS metrics over DAS Growth Trends and Population the time period 1999-2015, BGR l F or state population growth, Trends for 2016-2025 calculated 10-year CAGRs for 7 years BGR used the most recent 2025 (e.g., 1999-2009, 2000-2010, etc.). population projections from state BGR used historical DAS death trends • or our baseline growth rate, BGR took F government officials. from 1999-2015 to inform our projected DAS growth trends for 2016 to 2025. the average of these 10-year CAGRs. • GR pulled the data from publicly B • or our pessimistic bound (a period F available data (see Appendix C for links l B GR examined each cause of death to sources). where DAS deaths would grow at a separately (alcohol-related, drug- faster rate), BGR chose the 10-year • eorgia and Michigan’s state G related, and suicide deaths). CAGR with the highest growth rate. government offices supplied us l B GR analyzed the changes in annual data after a request. l F or alcohol-related deaths, this was the death rate per 100,000 from 1999-2015. • or several states, there were no 2025 F time period from 2005-2015. • The annual changes fluctuated data, so BGR used data from the significantly over the period, l F or drug-related deaths, this was the closest year available particularly those for drug- time period from 1999-2009. • BGR used the CAGR method to induced deaths. l F or suicide deaths, this was the time develop an annual growth rate, and • t the state level, the fluctuations A period from 2005-2015. applied this to come up with the were far more pronounced, • or our optimistic bound (a period F 2025 state population figures particularly in less populated states. where DAS deaths would grow at a TFAH • WBT • PaininTheNation.org 161 • he Census Bureau has not updated T 2016-2025 National and State Death We used the most recent final data their state projections since the 2000 Projections available. Although CDC has released census, and refers people to states l B GR examined each cause of death preliminary 2016 data, we know that for more recent estimates. separately (alcohol-related, drug- these number are subject to change, • he difference in data sources leads to T related, and suicide deaths). and as a result, wanted to use final a small difference in totals (less than numbers. Note: we plan to update this l B GR used the death rate per 100,000 report annually to account for more 1 percent nationally, after taking into in 2015 for each of the DAS categories, recent CDC data. account population in territories). and applied this population-controlled l B GR did not account for demographic annual growth rate for the different To account for year-over-year anomalies, changes in population over the time scenarios (baseline, optimistic, the analysis examined trends over 10-year period due to data limitations. At pessimistic, and very pessimistic) from periods [(using a common technique for the state level, death rates for any of 2016 through 2025. smoothing over periods of time called the DAS categories by demographic CAGR — or compounded average rate l B GR then applied the death rate per of growth). There were 7 10-year CAGRS segment have small data cell 100,000 for each DAS category to the (1999-2009; 2000-2010; etc)] sizes, particularly in less populous population estimate by year. states. Some states do not have l T he pessimistic scenario used the highest reported population projections by l T o calculate the sum of projected DAS (worst) growth rate over the observed demographic segment. Those states deaths, BGR considered potential 10-year period that has been observed that do report these projections do not double-counting. As noted above, (for each of the DAS categories). This necessarily report consistent measures. suicide deaths could also count as drug- represents the worst 10-year period, related deaths or alcohol-related deaths. based on hard data to date. • deally, the projections would I account for expected demographic • For our 2016 to 2025 projections, l T he optimistic scenario used the lowest changes. DAS death rates differ by BGR assumed that 12 percent of (relatively best) growth rate over the demographic group. suicide deaths were also either drug- observed 10-year period (for each DAS related deaths or alcohol-related • owever, BGR’s analysis supported H category). This represents the best 10- deaths. This is the same percentage that any attempts at greater year period, based on hard data to date. as 2015, and within the bound from modeling precision is not advisable historical experience. l T he baseline scenario uses the average due to the data limitations. growth rate of 7 different 10-year l F or the state death projections, BGR • urther, the changes in the F periods. The average of all the 10-year usedthe state-specific death rate per demographic makeup of the United periods, based on hard data to date. 100,000 for each DAS category. States should not be overstated. For l T he very pessimistic scenario uses • GR usedthe national projected B example, the aging of Baby Boomers the sharp growth rate seen in the annual growth rate scenarios per will lead to some changes over the most recent data year (2014-2015), 100,000 from 2016 to 2025. next 10 years, but the Census Bureau to assume the average annual growth estimates that those 65 and older • GR usedthe projected enrollment B rate for 2016-2025. As noted, the will only go from 15 percent of the for 2025 by state, as described above. preliminary data for 2016 and 2017 country in 2015 to 19 percent by • BGR calculated annual population has suggested growth rates may 2025. (Census Bureau data, accessed change from 2015 to 2025 using actually be exceeding what has on July 19, 2017. Link: https://www. the CAGR method described above. happened historically — so our very census.gov/data/datasets/2014/ • GR applied the growth rate to come B pessimistic scenario may actually not demo/popproj/2014-popproj.html) up with annual population estimates. be pessimistic enough. Historically, • he expected changes are likely T there have been years with higher The projected scenarios are based on more pronounced at the state level, than typical increases — and the historical experience from 1999-2015 but we do not have data to make baseline longer term analyses help from the CDC WONDER tool for data these adjustments. “average out” changes. by underlying cause of death (UCD). 162 TFAH • WBT • PaininTheNation.org APPENDIX C: State Populations Estimate Sources (for 2010 data) State Link to data source Accessed Alabama hƩp://cber.cba.ua.edu/edata/est_prj.html 6/9/2017 Alaska hƩp://live.laborstats.alaska.gov/pop/projecƟons.cfm 6/9/2017 Arizona hƩps://populaƟon.az.gov/populaƟon-projecƟons 6/9/2017 Arkansas hƩp://iea.ualr.edu/populaƟon-esƟmates-a-projecƟons.html#proj 6/9/2017 California hƩp://www.dof.ca.gov/ForecasƟng/Demographics/projecƟons/ 6/9/2017 Colorado hƩps://demography.dola.colorado.gov/populaƟon/populaƟon-totals-colorado-substate/#populaƟon-totals-for-colorado- 6/9/2017 ConnecƟcut hƩp://web2.uconn.edu/ctsdc/projecƟons.html 6/9/2017 Delaware hƩp://stateplanning.delaware.gov/informaƟon/dpc_projecƟons.shtml 6/9/2017 District of Columbia hƩps://www.mwcog.org/documents/2016/11/16/growth-trends-cooperaƟve-forecasƟng-in-metropolitan-washington-coo 6/9/2017 Florida hƩp://edr.state.fl.us/Content/populaƟon-demographics/data/MediumProjecƟons_2015.pdf 6/9/2017 Georgia Requested Data 6/9/2017 Hawaii hƩp://dbedt.hawaii.gov/economic/databook/2012-individual/_01/ 6/9/2017 Idaho hƩps://lmi.idaho.gov/populaƟon-projecƟons 6/9/2017 Illinois hƩps://www.illinois.gov/sites/hfsrb/InventoriesData/Documents/PopulaƟon_ProjecƟons_Report_Final_2014.pdf 6/9/2017 Indiana hƩp://www.stats.indiana.edu/pop_proj/ 6/9/2017 Iowa hƩp://www.iowadatacenter.org/datatables/CountyAll/co2010populaƟonprojecƟons20002040.pdf 6/9/2017 Kansas hƩp://www.cedbr.org/populaƟon-projecƟons-4 6/9/2017 Kentucky hƩp://www.e-archives.ky.gov/pubs/Economic_Dev/2005desk/PopProjecƟon.pdf 6/9/2017 Louisiana hƩp://louisiana.gov/Explore/PopulaƟon_ProjecƟons/ 6/9/2017 Maine hƩp://www.maine.gov/economist/projecƟons/index.shtml 6/9/2017 Maryland hƩp://www.mdp.state.md.us/msdc/S3_ProjecƟon.shtml 6/9/2017 MassachuseƩs hƩp://pep.donahue-insƟtute.org/downloads/2015/new/UMDI_LongTermPopulaƟonProjecƟonsReport_SECTION_2.pdf 6/9/2017 Minnesota hƩps://mn.gov/admin/demography/data-by-topic/populaƟon-data/our-projecƟons/ 6/9/2017 Mississippi hƩp://www.mississippi.edu/urc/downloads/PopProjecƟons/PopulaƟonProjecƟons.pdf 6/9/2017 Missouri hƩp://archive.oa.mo.gov/bp/projecƟons/MFCombined.pdf 6/9/2017 Montana hƩp://ceic.mt.gov/PopulaƟon/PopProjecƟons_StateTotalsPage.aspx 6/9/2017 Nebraska hƩps://www.unomaha.edu/college-of-public-affairs-and-community-service/center-for-public-affairs-research/documen 6/9/2017 Nevada hƩp://nvdemography.org/wp-content/uploads/2014/10/Nevada-PopulaƟon-ProjecƟons-2014-Full-Document.pdf 6/9/2017 New Hampshire hƩp://www.nh.gov/oep/data-center/documents/2016-state-county-projecƟons-final-report.pdf 6/9/2017 New Jersey hƩp://lwd.dol.state.nj.us/labor/lpa/dmograph/lfproj/lfproj_index.html 6/9/2017 New Mexico hƩp://gps.unm.edu/data/PopulaƟon%20ProjecƟons.html 6/9/2017 New York hƩps://pad.human.cornell.edu/counƟes/projecƟons.cfm 6/9/2017 North Carolina hƩps://ncosbm.s3.amazonaws.com/s3fs-public/demog/countytotals_populaƟonoverview.html 6/9/2017 North Dakota hƩps://www.commerce.nd.gov/census/ 6/9/2017 Ohio hƩps://development.ohio.gov/files/research/P6001.pdf 6/9/2017 Oklahoma hƩp://okcommerce.gov/wp-content/uploads/2015/06/PopulaƟon_ProjecƟons_Report-2012.pdf 6/9/2017 Oregon hƩp://www.oregon.gov/das/OEA/Documents/appendixc.pdf 6/9/2017 Pennslyvania hƩp://www.rural.palegislature.us/documents/reports/PopulaƟon_ProjecƟons_Report.pdf 6/9/2017 Rhode Island hƩp://www.planning.ri.gov/documents/census/tp162.pdf 6/9/2017 South Carolina hƩp://abstract.sc.gov/chapter14/pop5.html 6/9/2017 South Dakota hƩp://dlr.sd.gov/lmic/menu_demographics.aspx 6/9/2017 Tennessee hƩp://cber.haslam.utk.edu/popproj.htm 6/9/2017 Texas hƩp://txsdc.utsa.edu/Data/TPEPP/ProjecƟons/Index 6/9/2017 Utah hƩps://gomb.utah.gov/budget-policy/demographic-economic-analysis/ 6/9/2017 Vermont hƩps://addisoncountyedc.org/uploads/documents/VermontPopulaƟonProjecƟons2010_2030%201.pdf 6/9/2017 Virginia hƩp://demographics.coopercenter.org/virginia-populaƟon-projecƟons/ 6/9/2017 Washington hƩp://www.ofm.wa.gov/pop/sƞc/sƞc2016/sƞc_2016.pdf 6/9/2017 West Virginia hƩp://busecon.wvu.edu/bber/pdfs/BBER-2014-04.pdf 6/9/2017 Wisconsin hƩp://www.doa.state.wi.us/Documents/DIR/Demographic%20Services%20Center/ProjecƟons/FinalProjs2040_PublicaƟon 6/9/2017 Wyoming hƩps://www.census.gov/prod/2/pop/p25/p25-1131.pdf 6/9/2017 TFAH • WBT • PaininTheNation.org 163 APPENDIX D: Cost Estimates for Patients with Alcohol, Drug or Suicide Diagnoses For healthcare cost estimates for those • We also used CMS NHE data to codes rather than 5. As a result, it may with ADS diagnoses, two data sources estimate per capita health spending capture some unrelated diagnoses. were used: Medical Expenditure Survey at the national and state levels. We • For example, code ‘305’ or (MEPS) data Agency for Healthcare used the “Expenditures by state of “Nondependent abuse of drugs” Research and Quality (AHRQ) to residence: summary tables, 1991- includes both nondependent identify those with an alcohol, drug, or 2014”.896 alcohol use, and several suicide diagnosis code. This data was nondependent drug use sub-codes l lcohol-Chronic or Alcohol- A used to calculate healthcare costs for (including for opioids, cocaine, Contributable Conditions: To identify those with these diagnoses. In addition, and hallucinogens). people with alcohol-related events or per capita National Health Expenditure conditions in a given year, the analysis l uicide Conditions: To identify people S (NHE) data from the Office of the used the following codes: ‘291’, ‘303’, with suicide events or conditions in Actuaries (OACT) from the Centers for ‘305’, ‘357’,’425’,’535’,’571’,’655’, a given year, we used the following Medicare and Medicaid Services (CMS) ‘760’, ‘790’, ‘980’, ‘E86’ code: ‘E95’ were used for overall and per capita healthcare spending. • his study did not include high T • There were not any health events in causation codes, such as those for MEPS with suicide-related diagnoses. l ata Sources: MEPS and NHE data D cirrhosis, or any other conditions • e used MEPS household W that have been shown to have a Healthcare Costs for Those with an expenditure data from 2000-2014.895 causal relationship with alcohol use. ADS Diagnoses • EPS is a household survey M • ome of these codes include S l alculating prevalence for individuals C that represents the healthcare conditions other than alcohol, which with an ADS diagnoses: Using MEPS experience for the U.S. population. can lead to an overrepresentation of data, we grouped all of the 3-digit • EPS includes detailed M prevalence. As noted above, MEPS diagnoses codes for alcohol, drugs, information on spending by public only includes 3 digits of the ICD-9 and suicide. and private programs, as well as codes rather than 5. As a result, it may • For our numerator, we identified out-of-pocket spending. capture some unrelated diagnoses. any individual with one or more • he data includes medical events T • or example, code ‘305’ or F healthcare events that have one or and self-reported conditions by “Nondependent abuse of drugs” more ADS diagnosis codes in a given individual. includes both nondependent alcohol calendar year. use, and several nondependent drug • For our denominator, we used the • he data do not include state T use sub-codes (including for opioids, total population. residence information for cocaine, and hallucinogens). individuals. • We ran the analysis for MEPS data • EPS data includes diagnosis codes - M l rug-Chronic or Drug-Contributable D for the years 2001 to 2014. International Statistical Classification Conditions: To identify people with • he prevalence was at its lowest point T of Diseases and Related Health drug-related events or conditions in of 2.4 percent in 2001, and reached its Problems — version ICD-9. a given year, we used the following highest mark of 3.8 percent in 2014. codes: ‘292’,’304’,’305’, ‘648’, ‘655’, • hese codes allow researchers to T • While the prevalence rates fluctuate ‘760’, ‘779’, ‘790’, ‘965’, ‘969’, ‘968’, identify persons with specific events over the 14 years, they are relatively ‘977’, ‘E85’, ‘V65’ or conditions. tightly bound. • ome of these codes include S • he publicly-available versions of T • They also have an upward trend, conditions other than alcohol, which MEPS data only include partial similar to the trend seen in the ADS can lead to an overrepresentation of diagnosis code information, or mortality data over the same time prevalence. As noted above, MEPS truncated information, with 3 digits period. only includes 3 digits of the ICD-9 instead of all 5 ICD-9 digits. 164 TFAH • WBT • PaininTheNation.org l alculating average healthcare costs C • ational per capita average N using MEPS: BRG used the TotXX healthcare spending was $8,045 payment field in MEPS for healthcare annually in 2014. spend by individual. • RG applied the ADS diagnosis B • RG calculated the average B average spend multiplier of 2.5X healthcare spend amount for those from 2011-2014, based on the with at least one ADS diagnoses. results from MEPS. • e included all costs, not just events W • he estimated national per capita T that included the diagnosis code. average heath care spending for • RG calculated the average healthcare B those with an ADS diagnosis was spend amount for all individuals. $20,113 annually in 2014. • RG ran the analysis for MEPS data B • RG also applied the same ADS B years 2001 to 2014. multiplier to the NHE state averages. • or example, the per capital F l alculating average spend for those C healthcare costs in Alabama were with ADS diagnoses to overall average $7,281 annually in 2014, while in spend: BRG calculated the average Alaska they were $11,064. spend for those with ADS diagnoses relative to the national average by • RG estimated that the costs for B simply taking the ADS average and those with an ADS diagnosis in dividing it by the overall average spend. each state in 2014 were $18,203 and $27,660, respectively. • RG ran the analysis for MEPS data B years 2001 to 2014. • RG did not attempt to control for B any state differences due to data • pending for those with ADS S limitations. diagnoses 240 percent (2.4 times) higher, on average, than the national l stimated Total Healthcare Spend for E average from 2001 to 2014. Those with ADS Diagnoses, National: • pending for those with ADS S • RG used national per capita B diagnoses was 250 percent (2.5 times) estimates for those with ADS higher, on average, from 2011 to 2014. diagnoses for 2014: $20,113. l stimated Average Healthcare Spend E • RG then used the Census Bureau B for Those with ADS Diagnoses, national population number for National and State: National health 2014: 318,857,056. expenditure data is considered the • e multiplied the population W most reliable source for overall and estimates by the ADS prevalence per capita health spend. It is well- in 2014, using MEPS data (the documented that the per capita NHE methodology is above): 3.8 percent numbers are much higher than those • t is estimated that the total health I from MEPS.897, 898 Researchers have costs for the 3.8 percent of the typically used findings from MEPS, population with least one ADS and then applied them to NHE data diagnoses during the year was $249B (basically, inflating the numbers to in 2014, or roughly 9.5 percent of match those reported in NHE). all total health expenditures in the • RG used the “US_PER_CAPITA14” B United States. from the NHE health expenditures by place of residence tables. TFAH • WBT • PaininTheNation.org 165 APPENDIX E: APPROPRIATIONS AND REQUESTS FOR SELECT FEDERAL PROGRAMS (IN MILLIONS) Total, Health and Human Services 2016 2017 2018 Budget Authority (New Discretionary Spending) 1,119,166 1,126,789 1,112,883 The President’s 2018 Budget requests Also cuts $610 billion over 10 years $69.0 billion for HHS, a $15.1 billion from Medicaid (and another $6 billion or 17.9 percent decrease from the 2017 from CHIP). annualized CR level. This funding level (https://www.whitehouse.gov/sites/ excludes certain mandatory spending whitehouse.gov/files/omb/budget/ changes but includes additional funds for fy2018/budget.pdf) program integrity and implementing the 21st Century CURES Act.” (https://www.whitehouse.gov/sites/ whitehouse.gov/files/omb/budget/ fy2018/2018_blueprint.pdf) APPROPRIATIONS AND REQUESTS FOR SELECT FEDERAL PROGRAMS (IN MILLIONS) 2018, 2018 +/- Program 2016 2017 (CR) Requested 2017 HHS: Head Start 9,168 9,151 9,168 +17 Administration for Children Child Care and Development Block Grant (discretionary) 2,761 2,756 2,761 +5 and Families (ACF) Child Abuse Prevention 98 98 98 -- Child Welfare Programs 326 325 316 -9 Refugees; Unaccompanied Alien Children 948 1,396 948 -448 Low Income Home Energy Assistance Program 3,390 3,384 -- -3,384 Community Services Block Grant 715 714 -- -714 Other Community Services Programs 55 55 -- -55 Promoting Safe and Stable Families (mandatory only) 472 461 495 +34 Social Services Block Grant 1,669 1,662 85 -1,577 TANF 16,737 16,737 15,117 -1,620 TANF Contingency Fund 583 608 -- -608 HHS: Chronic Disease Prevention and Health Promotion 1,177 1,175 952 -222 Centers for Disease Control Birth Defects, Developmental Disabilities, Disability and Health 136 135 100 -35 and Prevention (CDC) Environmental Health 182 217 157 -60 Injury Prevention and Control 236 236 216 -19 Public Health Scientific Services 491 491 460 -31 Occupational Safety & Health 339 338 200 -138 Public Health Preparedness and Response 1,413 1,402 1,266 -136 166 TFAH • WBT • PaininTheNation.org APPROPRIATIONS AND REQUESTS FOR SELECT FEDERAL PROGRAMS (IN MILLIONS) 2018, 2018 +/- Program 2016 2017 (CR) Requested 2017 HHS: National Health Service Corps [Mandatory] 310 289 310 +21 Health Resources and Training for Diversity 83 83 -- -83 Services Administration Training in Primary Care Medicine 39 39 -- -39 (HRSA) Area Health Education Centers 30 30 -- -30 Health Care Workforce Assessment 5 5 5 -- Public Health and Preventive Medicine Programs 21 21 -- -21 Nursing Workforce Development 229 229 83 -146 Other Workforce Programs 49 48 -- -48 Rural Outreach Grants 64 63 51 -13 Rural Hospital Flexibility Grants 42 42 -- -42 Telehealth 17 17 10 -7 Rural Health Policy Development 9 9 5 -4 State Offices of Rural Health 10 9 -- -9 HHS: National Institute of General Medical Sciences 2,509 2,509 2,186 -323 National Institutes of Health Eunice K. Shriver Natl. Inst. of Child Health & Human Development 1,338 1,337 1,032 -305 (NIH) National Institute of Mental Health 1,517 1,545 1,245 -301 National Institute on Drug Abuse 1,049 1,075 865 -210 National Institute on Alcohol Abuse and Alcoholism 467 467 361 -105 National Institute of Nursing Research 146 146 114 -33 Natl. Institute on Minority Health and Health Disparities 280 279 215 -64 Natl. Center for Complementary and Integrative Health 130 131 102 -29 HHS: Substance Abuse and Mental Health 1,167 1,165 912 -252 Mental Health Services Substance Abuse Prevention 211 223 150 -73 Administration (SAMHSA) Substance Abuse Treatment 2,195 2,696 2,696 -- Office of National Drug Office of National Drug Control Policy 380 379 369 -10 Control Policy (ONDCP, or High Intensity Drug Trafficking Areas (HIDTAs) 250 249.5 246.5 -3 Drug Czar) Drug-Free Communities Support Program 95 95 92 -3 Department of Housing and Tenant-Based Rental Assistance 19,629 20,292 19,318 -974 Urban Development Programs Choice Neighborhoods Initiative 125 138 0 -138 Community Development Block Grants 3,000 3,000 0 -3,000 Housing for Persons with Disabilities (811) 151 146 121 -25 TFAH • WBT • PaininTheNation.org 167 Endnotes 1 ohmann J. “The Daily 202: Trump over H 10 tahre M, Roeber J, Kanny D, Brewer RD, S 21 Bonnie RJ, Ford MA, and Phillips JK. Pain performed the most in counties with the and Zhang X. 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