1. SUBSTANCE USE DISORDER TRENDS AND STATE EFFORTS TO ADDRESS ADDICTION CHILD WELFARE LEAGUE OF AMERICA NATIONAL ADVOCACY SUMMIT WASHINGTON, DC APRIL 20, 2016 Robert Morrison, Executive Director/Director of Legislative & Regulatory Affairs National Association of State Alcohol and Drug Abuse Directors (NASADAD)

2. Topics to Cover  Background on NASADAD – role of NASADAD members  Scope of substance use disorder problem  NASADAD Survey: State Actions on Opioids  Association initiatives of interest  Public policy priorities

3. Overview of NASADAD  Mission: promote effective and efficient State substance use disorder prevention, treatment and recovery systems.  Public Policy Department and Research/Program Applications Department  Governed by Board of Directors  Cassandra Price (GA), President

4. Role of State Substance Abuse Agencies  Placement in State government – varies by State  Develop annual State plans to provide prevention, treatment, and recovery services for safety net populations  Ensure service quality, accountability, service improvement, and service coordination  Substance Abuse Prevention and Treatment (SAPT) Block Grant  Includes 20% set-aside for prevention

5. Use of Illicit Drugs, Alcohol, and Tobacco  According to NSDUH 2014:  27.0 million people used an illicit drug in the past month  139.7 million past month alcohol drinkers 60.9 million who were binge users 16.3 million who were heavy users  66.9 million people were current users of a tobacco product

6. SUD Trends  Approximately 21.5 million people aged 12 or older had a substance use disorder (SUD) in the past year 17.0 million people with an alcohol use disorder 7.1 million with an illicit drug use disorder 2.6 million who had both

7. Opioid Crisis  5 million Americans used opioids during the past month  4.3 million misused prescription opioids  435,000 used heroin  Shift from prescription opioids to heroin

8. Inquiry on Prescription Drugs and Heroin  SSAs queried by NASADAD about recent public health initiatives  Original 2012 inquiry focused on SSA efforts on prescription drug abuse.  2014 inquiry was updated and expanded to include prescription drug abuse, heroin, and opioid overdose.

9. Inquiry Methods  Web-based survey was conducted March-April 2014.  Invited State Directors, Treatment Leads (NTNs), and Prevention Leads (NPNs) to participate.  2014 analysis includes 46 States and the District of Columbia (N= 47 States, 92% of States).

10. Inquiry Results: Prescription Drug Abuse

11. State Strategic Plan Addressing Prescription Drugs and Heroin Abuse 35 States reported that their strategic plan explicitly addresses prescription drug abuse. 12 of these States reported that their plan explicitly addresses heroin abuse. (All State prevention, treatment, and recovery systems include services for opioid and heroin abuse. However, during the past 2 years some States have identified prescription drug abuse and/or heroin abuse as requiring additional or reconfigured strategies in their State strategic plan.)

12. Educating the General Public on Prescription Drug Abuse In 2012, 39 States provided education on prescription drug abuse. In 2014, the number increased to 43 States.

13. Educational Activities for Physicians, Pharmacists, and Patients Physicians, Other Prescribers Pharmacists Patients, Families The number of States targeting their educational initiatives at each of the following populations increased from 2012 to 2014.

14. Evaluating Prevention Programs or Education Initiatives 21 States reported that they had (administered or funded) prescription drug abuse prevention programs or education initiatives with an evaluation component to assess their outcomes.

15. Usefulness of PDMP Data to SSAs (2012) 2012 Data 30 States said PDMP data is “very useful” or “useful.”

16. SSA Involvement with Prescription Drug Monitoring Program (PDMP) 2014 2012 As of 2014, most SSAs serve in an advisory capacity or have no involvement with the PDMP.

17. Inquiry Results: Heroin Abuse

18. State Trends for Heroin Abuse During the Past Two Years 37 States reported increases in treatment admissions for heroin. 27 States reported increases in fatal overdose rates for heroin.

19. Medication-Assisted Treatment (MAT) Expansions 26 States reported that they have expanded or made plans to expand MAT during the past 2 years. 49 States and DC have State opioid treatment programs (methadone maintenance). All 50 States and DC have physicians who are waivered to prescribe buprenorphine. All three FDA-approved opioid treatment medications (methadone, buprenorphine, and naltrexone) are covered under the Medicaid Drug Rebate Program. The associated co-pays and authorization requirements vary from State to State.

20. Educating the General Public on the Transition from Prescription Drugs to Heroin Abuse How? 21 States reported that they have taken steps to educate the general public on the transition from prescription drugs to heroin abuse.

21. Remaining Challenges/ TA Needs on Prescription Opioids and Heroin: Themes Across States  Lack of funding.  Need for greater treatment capacity to meet the increasing need.  Challenges with data (lack of data, data that doesn’t capture the entire story).  Stigma associated with heroin abuse.  Collaboration with primary care for referrals and prescriber education.

22. Legislative action related to SUDs  Opioid use disorders continue to gain traction in Congress  Comprehensive Addiction and Recovery Act (S. 524/ H.R. 953) Passed the Senate in March  Sen. Shaheen’s (D-NH) Emergency Funding Bill to Address Opioid and Heroin Abuse Epidemic  Mental Health Reform Act of 2016  Various hearings in House and Senate on opioids  Criminal justice reform  Interest in parental substance use in families involved with child welfare system

23. Substance Abuse Prevention & Treatment (SAPT) Block Grant  $1.8 billion formula grant administered by SAMHSA.  Provided treatment for 2.5 million Americans in 2015.  20% prevention set-aside represents 68 percent of prevention funds for State substance abuse agencies.  Priority populations:  Pregnant and Parenting Women  Intravenous Drug Users  Individuals with HIV/AIDS  Individuals with Tuberculosis  SAPT Block Grant funding has not kept up with costs of inflation over the past decade (2006-2016)  The result is a 26% decrease in actual funding when adjusted for inflation over the past 10 years ($483 million)

24. Services for Pregnant & Postpartum Women  Improving Treatment for Pregnant and Postpartum Women Act (H.R. 3691; S. 2226)  Reauthorizes SAMHSA’s Grant Program for Residential Treatment for Pregnant and Postpartum Women (PPW)  Family-based services Children can enter treatment with mother  Creates pilot program to give States the flexibility to implement family-based services for PPW at various levels of care, not only residential settings Would help State substance abuse agencies address gaps in services for PPW across the continuum of care

25. Comprehensive Addiction & Recovery Act  After clearing Senate Judiciary Committee in February, the Comprehensive Addiction and Recovery Act (CARA) of 2016 moved to the Senate floor for consideration on February 29th First time a standalone addictions bill had been on the floor since the 1980s.  CARA passed the Senate on March 10th with a vote of 94-1.  Provisions address: Prevention Treatment (including for PPW) Recovery support Law enforcement Criminal justice reform

26. Funding for SUD Programs  In February the Administration proposed $1.1 billion in new funding over two years to address the opioid crisis: $920 million to support cooperative agreements with States to expand access to medication-assisted treatment for opioid use disorders. $50 million in National Health Service Corps funding to expand access to substance use treatment providers. $30 million to evaluate the effectiveness of treatment programs employing medication-assisted treatment under real-world conditions and help identify opportunities to improve treatment for patients with opioid use disorders.  Additionally, Sen. Shaheen (D-NH) proposed $600 million in supplemental emergency funding for the opioid crisis Initially introduced in December to provide additional funding for programs within DOJ (COPS, Byrne/JAG) and HHS (SAMHSA, CDC, NIH, Office of the Secretary)  Would add $225,000,000 to SAPT Block Grant In February the bill was introduced in the House by Rep. Courtney (D-CT) Offered as amendment to CARA

27. Reauthorization of RPG  Regional Partnership Grants (RPG) support interagency collaborations to improve the permanency and the safety of children who are in, or at risk of, out-of-home placements as a result of a parental substance abuse.  Varied evidence-based, trauma-informed interventions:  family drug courts  comprehensive substance abuse treatment  in-home parenting support  child safety support for families  On February 23 rd Senators Grassley (IA) and McConnell (KY) introduced legislation (S. 2565) that would reauthorize the RPG program and include language requiring the State child welfare agency to “coordinate to a reasonable degree” with the SSA in administering the grants

28. NASADAD Resources  Guidance to States: Treatment Standards for Women With Substance Use Disorders  Therapeutic Services for Children Whose Parents Receive Substance Use Disorder Treatment  State Adolescent Substance Use and Recovery Practice Guide

29. Thank you  Questions/Comments?  Contact: Robert Morrison NASADAD 202 293 0090 rmorrison@nasadad.org www.nasadad.org